Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic.

In this review, we examine the evidence behind nonopioid medication alternatives, peripheral nerve blocks, surgical techniques, and postoperative recovery protocols that can help minimize and effectively treat postoperative pain after minimally invasive gynecologic surgery (MIGS). Because of the depth and heterogeneity of the data, a narrative review was performed of reported interventions. A comprehensive review was performed of PubMed, Embase, and the Cochrane Database with a focus on randomized controlled trials. In the absence of literature specific to benign gynecology, similar specialty or procedural data were reviewed. A variety of nonopioid medications, surgical techniques, and postoperative recovery protocols have shown significant improvements in postoperative pain after gynecologic surgery. Nonopioid medication options that are beneficial include acetaminophen, nonsteroidal anti-inflammatories, and antiepileptics. Incision infiltration with local anesthesia also significantly reduces pain. Surgically, minimally invasive approaches, reducing the laparoscopic trocar size to <10 mm, and evacuating the pneumoperitoneum at the end of the case all have significant benefits. Lastly, enhanced recovery pathways show promise in reducing pain after MIGS. By using a multimodal approach, minimally invasive gynecologic surgeons can help to minimize and manage postoperative pain with less reliance on opioid pain medications.

Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair.

BACKGROUND: A rarely used technique for enabling closure of large ventral hernias with loss of domain is preoperative progressive pneumoperitoneum (PPP), which uses intermittent insufflation to gradually stretch the contracted abdominal wall muscles, increasing the capacity of the abdominal cavity. This allows the re-introduction of herniated viscera into the abdominal cavity and assists in closure of giant hernias which may otherwise be considered inoperable. METHODS: This was a prospective study assessing 16 patients between 2013 and 2015 with multi-recurrent ventral hernia. All patients were treated preoperatively with both Botulinum Toxin A (BTA) injections to the lateral abdominal wall muscles to confer flaccid paralysis, and short-term PPP to passively expand the abdominal cavity. All patients underwent serial abdominal CT imaging, with pre- and post-treatment circumference measurements of the peritoneal cavity and hernia sac, prior to undergoing operative mesh repair of their hernia. RESULTS: The mean hernia defect size was 236 cm2, with mean 28 % loss of domain. The mean overall duration of PPP was 6.2 days. The mean gain in abdominal circumference was 4.9 cm (5.6 %) (p 0.002) after BTA and PPP. Fascial closure and mesh hernia repair were performed in all 16 patients, with no patients suffering from postoperative abdominal hypertension, ventilatory impairment, or wound dehiscence. There are no hernia recurrences to date. Eight patients (50 %) experienced PPP-related complications, consisting of subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumocardium, and metabolic acidosis. No complication required intervention. CONCLUSIONS: PPP is a useful adjunct in the repair of complex ventral hernia. It passively expands the abdominal cavity, allowing viscera to re-establish right of domain. At the same time, it helps to minimize the risks of postoperative abdominal compartment syndrome and the sequelae of fascial closure under tension. However, its benefits must be carefully weighed with the risk of serious complications, such as infection, perforation, pneumothorax, and pneumomediastinum.

Warmed, humidified CO2 insufflation benefits intraoperative core temperature during laparoscopic surgery: A meta-analysis.

BACKGROUND: Intraoperative hypothermia is linked to postoperative adverse events. The use of warmed, humidified CO2 to establish pneumoperitoneum during laparoscopy has been associated with reduced incidence of intraoperative hypothermia. However, the small number and variable quality of published studies have caused uncertainty about the potential benefit of this therapy. This meta-analysis was conducted to specifically evaluate the effects of warmed, humidified CO2 during laparoscopy. METHODS: An electronic database search identified randomized controlled trials performed on adults who underwent laparoscopic abdominal surgery under general anesthesia with either warmed, humidified CO2 or cold, dry CO2 . The main outcome measure of interest was change in intraoperative core body temperature. RESULTS: The database search identified 320 studies as potentially relevant, and of these, 13 met the inclusion criteria and were included in the analysis. During laparoscopic surgery, use of warmed, humidified CO2 is associated with a significant increase in intraoperative core temperature (mean temperature change, 0.3°C), when compared with cold, dry CO2 insufflation. CONCLUSION: Warmed, humidified CO2 insufflation during laparoscopic abdominal surgery has been demonstrated to improve intraoperative maintenance of normothermia when compared with cold, dry CO2.

Hyperthermic carbon dioxide pneumoperitoneum reinforces the inhibition of 5-FU on the proliferation and invasion of colon cancer.

The effect of hyperthermic carbon dioxide (CO2) pneumoperitoneum in combination with 5-fluorouracil (5-FU) on the proliferation and invasion of colon cancer was explored. Colon cancer cell line SW-480 was sealed into the urine collection bag to simulate pneumoperitoneum with 100% CO2 under a pressure of 12 mmHg. The cells were divided into group A, CO2 at 37˚C; group B, CO2 at 43˚C; group C, 5-FU; group D, CO2 at 37˚C+5-FU; group E, CO2 at 43˚C+5-FU; and control groups under normal culture conditions. The cell proliferation was assessed by CCK-8 test; the cell apoptosis was tested by FACS analysis; the cell invasion was examined by Transwell assay; the expression of HSP-70, caspase-3, HIF-1α and MMP-9 proteins and genes were detected by western blot analysis and RT-PCR. The SW-480 cells were injected into nude mouse cecum subserosal to establish a colon cancer model. We applied 43˚C CO2 pneumoperitoneum or 5-FU intraperitoneal chemotherapy to intervene, detected the transplantation tumor growth and metastasis. The cell proliferation was inhibited in groups B, C, D and E, apoptosis was induced in groups B, C, D and E, the Transwell cell number decreased in groups B, C, D and E, the transplantation tumor weight and metastasis rate were inhibited in groups B, C, D and E, but all not in group A. The most significant change was observed in group E. Hyperthermic CO2 pneumoperitoneum was able to reinforce the inhibition of 5-FU on proliferation and invasion of colon cancer.

Study on the inhibition of hyperthermic CO2 pneumoperitoneum on the proliferation and migration of colon cancer cells and its mechanism.

The present study explored the inhibitory effect of hyperthermic CO2 pneumoperitoneum on the proliferation and migration of colon cancer cells, and its mechanism. Colon cancer cell line SW-480 was sealed into a urine collection bag to simulate pneumoperitoneum with 100% CO2 under a pressure of 14 mmHg. The growth and morphology of cells were observed under a microscope, the inhibition on cell proliferation was measured using WST-8 test, cell apoptosis and the cell cycle were monitored using fluorescence-activated cell sorting analysis, the migration of cells was tested using the scratch assay, and the expression of HSP-70, caspase-3, hypoxia-inducible factor-1α (HIF-1α) and matrix metalloproteinase-9 (MMP-9) proteins and genes was investigated using western blotting and reverse transcription polymerase chain reaction. Compared with the control group, there was no significant difference in the CO2 group (P>0.05), while the apoptosis and necrosis rates in the hyperthermo-CO2 group was significantly increased (P<0.05). Compared with the control group, the number of cells at G0/G1 phase significantly increased and the number of cells at S phase significantly decreased in the hyperthermo-CO2 group (P<0.05), indicating that hyperthermo-CO2 could arrest the cell cycle. It was suggested by the results of the scratch assay that cell migration ability enhanced in the CO2 group, but decreased in the hyperthermo-CO2 group compared with the control. CO2 pneumoperitoneum promoted cell migration by upregulating HIF-1α and MMP-9 expression. However, the CO2 pneumoperitoneum with hyperthermia enhanced apoptosis and inhibited migration by upregulating the expression of HSP-70, HIF-1α and caspase-3, but downregulating the expression of MMP-9.

Lethal effect of a hyperthermic CO2 pneumoperitoneum on gastric cancer cells.

OBJECTIVES: We investigated the lethal effect of a hyperthermic CO2 pneumoperitoneum on gastric cancer cells. This could form the theoretical basis for further studies of the feasibility and safety of inflating hyperthermic CO2 in the abdominal cavity of gastric cancer patients during laparoscopy. METHODS: An in vitro hyperthermic CO2 pneumoperitoneum experimental model was built, where gastric cancer cell line SGC-7901 cells were grouped according to temperature. Cytotoxicity was detected using a cell counting kit; apoptosis was detected by Annexin V-FITC/PI flow cytometry and Hoechst 33342/PI fluorescent microscopy. Morphological alterations were observed by transmission electron microscopy. Invasion and migration were detected by a scratch test and by transwell migration, respectively. RESULTS: Cytotoxicity assays showed that a hyperthermic CO2 pneumoperitoneum significantly inhibited the proliferation of SGC-7901 cells (P<0.05); it also significantly induced apoptosis of SGC-7901 cells (P<0.05). Morphological observations showed that the cell membrane and nucleus had an apoptotic phenotype. The invasiveness and migration ability of the gastric cancer cells subjected to hyperthermic CO2 were significantly reduced. CONCLUSIONS: A hyperthermic CO2 pneumoperitoneum had a lethal effect on gastric cancer SGC-7901 cells by inhibiting their invasion and migration, and by inducing apoptosis.

Caffeic acid phenethyl ester (CAPE) protects against acute urogenital injury following pneumoperitoneum in the rat.

PURPOSE: Our aim is to determine the biochemical and histologic changes induced in the kidneys, testis and prostate on possible ischemia and reperfusion (I/R) injury caused by pneumoperitoneum (PNP) in a rat model and to evaluate the ability of protective effects of caffeic acid phenethyl ester (CAPE). METHODS: Twenty-eight adult male Wistar albino rats were randomly divided to one of three treatment groups, with seven animals in each group. Sham, laparoscopy (L), and laparoscopy plus CAPE (L + C) group were subjected to 60 min of PNP with 15 mmHg one hour before the desufflation period. Total oxidant status (TOS) and total antioxidant status (TAS) levels were determined in kidney, testis, and prostate. Kidney and testis tissues were removed to obtain a histologic score. Also, Johnsen scoring system was used for testicular tissue analysis. RESULTS: L group had significantly higher TOS and lower TAS levels on kidney and testis compared to the other groups. In prostate biochemical analysis, there was not any difference between groups. No difference was found between groups according to kidney and testis tissues' histologic evaluation. In evaluation of Johnsen scoring, L group showed significant lower score compared to the other two groups. CONCLUSIONS: Increased intraabdominal pressure (IAP) had an oxidative effect on kidney and testis but not on prostate in rats. Moreover, it could affect the testicular Johnsen score. All these adverse effects of IAP on both kidney and testis could be prevented by CAPE administration.

Protective effects of dexmedetomidine in pneumoperitoneum-related ischaemia-reperfusion injury in rat ovarian tissue.

OBJECTIVES: To determine the effects of dexmedetomidine on pneuomoperitoneum-related ischaemia-reperfusion (I/R) injury in rat ovarian tissue. STUDY DESIGN: Animals were randomized into three groups: Group S (n=8), no pneumoperitoneum; Group C (n=8), pneumoperitoneum; and Group D (n=8), 100µg intraperitoneal dexmedetomidine 30min before pneumoperitoneum. Ovarian tissue was collected from all rats 30min after desufflation, and fresh frozen for histological and biochemical evaluation. RESULTS: Body weight was similar in all three groups (202.62±28.86, 211.00±14.45 and 212.87±15.71g in Groups S, D and C, respectively). The mean malondialdehyde level was higher in Group C than the other groups (p<0.03). When the histological samples of ovarian tissue were compared, vascular congestion, haemorrhage, follicular cell degeneration and infiltrative cell infiltration scores were higher in Group C compared with the other groups (p<0.05). Significantly lower scores for the histological parameters were found in Group D compared with Group C (p<0.05). Similar scores for follicular cell degeneration and inflammatory cell infiltration were found in Group D and Group S (p>0.05). Although vascular congestion and haemorrhage scores were significantly lower compared with Group C, higher scores were found for Group D compared with Group S (p<0.05). CONCLUSION: Pneumoperitoneum caused oxidative injury in rat ovarian tissue. Dexmedetomidine reduced oxidative stress and histological injury related to I/R.

ALPPS procedure with the use of pneumoperitoneum.

BACKGROUND: A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. We present a video of an ALPPS procedure with the use of pneumoperitoneum. METHODS: A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant. RESULTS: The first operation began with 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for additional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectionectomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver. CONCLUSIONS: The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis. The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.

Evaluation of the effects of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats undergoing segmental resection and anastomosis of the left colon / Avaliação dos efeitos do pneumoperitônio com dióxido de carbono na cicatrização da parede abdominal de ratos submetidos à ressecção segmentar e anastomose no cólon esquerdo

PURPOSE: To evaluate the influence of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats. METHODS: Eighty rats underwent laparotomy, segmental left colon resection, and anastomosis. The animals were divided into three experimental groups and one control group: EI = pneumoperitoneum for 30 minutes before laparotomy (n=20); EII = pneumoperitoneum for 30 minutes after abdominal closure (n=20); EIII = pneumoperitoneum for 30 minutes before laparotomy and 30 minutes after abdominal closure (n=20); C = control group, without pneumoperitoneum (n=20). In each group, 10 animals were killed 7 days and 10 animals 14 days postoperatively. A segment of the abdominal wall was resected and subjected to tensile strength testing. Another segment of abdominal muscle was used for histopathological analysis; the specimens were fixed in formalin and stained with hematoxylin and eosin. RESULTS: There were no differences in histopathology and tensile strength values among animals in the experimental and control groups 7 or 14 days after surgery. CONCLUSION: Under the present experimental conditions, carbon dioxide pneumoperitoneum did not interfere with abdominal wall wound healing.

OBJETIVO: Avaliar a influência do pneumoperitônio com dióxido de carbono na cicatrização da ferida operatória na parede abdominal de ratos. MÉTODOS: Oitenta ratos foram submetidos à laparotomia, ressecção de segmento do cólon esquerdo e anastomose. Os animais foram distribuídos em quatro grupos de 20 ratos, três experimentais e um controle: Grupo EI = pneumoperitônio por 30 minutos antes da laparotomia. Grupo EII = pneumoperitônio por 30 minutos após a laparorrafia. Grupo EIII = pneumoperitônio por 30 minutos antes da laparotomia e 30 após a laparorrafia. Grupo C = controle, sem pneumoperitônio. Realizou-se, em cada grupo, a eutanásia de 10 animais no 7° e no 14° dia pós-operatório. Um segmento da parede abdominal foi ressecado e submetido à medida da resistência. Outro segmento muscular abdominal foi destinado à análise histopatológica, as peças foram fixadas em formol e as lâminas coradas com hematoxilina e eosina. RESULTADOS: Não houve diferença, à histopatologia e na força de ruptura, entre os animais dos grupos experimentais e do controle no 7° ou 14° dia pós-operatório. CONCLUSÃO: Nas condições em que o experimento foi realizado, o pneumoperitônio com dióxido de carbono não interferiu na cicatrização da parede abdominal.

Evaluation of the effects of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats undergoing segmental resection and anastomosis of the left colon.

PURPOSE: To evaluate the influence of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats. METHODS: Eighty rats underwent laparotomy, segmental left colon resection, and anastomosis. The animals were divided into three experimental groups and one control group: EI = pneumoperitoneum for 30 minutes before laparotomy (n=20); EII = pneumoperitoneum for 30 minutes after abdominal closure (n=20); EIII = pneumoperitoneum for 30 minutes before laparotomy and 30 minutes after abdominal closure (n=20); C = control group, without pneumoperitoneum (n=20). In each group, 10 animals were killed 7 days and 10 animals 14 days postoperatively. A segment of the abdominal wall was resected and subjected to tensile strength testing. Another segment of abdominal muscle was used for histopathological analysis; the specimens were fixed in formalin and stained with hematoxylin and eosin. RESULTS: There were no differences in histopathology and tensile strength values among animals in the experimental and control groups 7 or 14 days after surgery. CONCLUSION: Under the present experimental conditions, carbon dioxide pneumoperitoneum did not interfere with abdominal wall wound healing.

Nitrous oxide for pneumoperitoneum: no laughing matter this! A prospective single blind case controlled study.

BACKGROUND: The search for the perfect insufflating gas has been elusive. Even though Carbon dioxide (CO(2)) is the most commonly used gas, it has numerous cardiovascular, respiratory and hemodynamic side effects, which have often been taken for granted. In the current scenario of ever expanding and complex indications for Laparoscopic Surgery these changes have an increasing implication of placing the patient at risk. Nitrous Oxide (N(2)O) has now made a comeback and shown by recent studies to be as safe as CO(2) for creating pneumoperitoneum (PP). The purpose of our study is to determine whether benefits of N(2)O (PP) outweigh those of CO(2) PP in Laparoscopic Surgery. MATERIAL AND METHODS: All patients undergoing Laparoscopic Surgery over an 8 week period were divided into two groups. Data were collected prospectively for Group I {N(2)O(n = 38)} and Group II {CO(2) PP(n = 39)}. Heart rate, Mean Arterial Blood Pressure, End-Tidal CO(2), Arterial pH, Peak Airway Pressure, Minute Ventilation and O(2) Saturation were recorded before PP, 15 minutes after PP and 10 minutes after exsufflation. Intraoperative anesthetic agent and postoperative pain medication use was recorded. Pain was assessed by means of visual analog scale (VAS) at postoperative hours 2 and 4 and on day 1. Results tabulated and analyzed statistically. RESULTS: There was no statistical difference in age, sex, weight, complexity of surgery (type of procedure and duration of PP), Anesthetic risk, and duration of hospitalization between the two groups. Mean End-Tidal CO(2) increase was greater despite a greater mean intraoperative increase in Minute Ventilation in group II, Heart Rate, Arterial pH, Mean Arterial Pressure under anesthesia were significantly higher in group II. The quantum of intraoperative anesthetic agent and postoperative pain (as assessed by Visual Analog Scale) was less in group I. CONCLUSION: This is an initial study assessing the use of N(2)O for insufflation; the results of our study suggest N(2)O PP has a definitive advantage over CO(2) PP. Further multicentric randomized trials are necessary before N(2)O becomes the standard insufflating agent.

Management of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.

The common and distressing complications of postoperative nausea and vomiting (PONV) are the main concern of 40-70% of patients undergoing laparoscopic cholecystectomy (LC). The first step in preventing PONV after LC is to reduce the risk factors involving patient characteristics, surgical procedure, anesthetic technique, and postoperative care. Particularly, the use of propofol-based anesthesia can reduce the incidence of PONV after LC. Second, prophylactic antiemetics including antihistamines (dimenhydrinate), phenothiazines (perphenazine), butyrophenones (droperidol), benzamides (metoclopramide), dexamethasone, and serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron) are available for preventing PONV after LC. Third, antiemetic therapy combined with a serotonin receptor antagonist (ondansetron, granisetron) and droperidol or dexamethasone is highly effective in the prevention of PONV after LC. Fourth, acupressure at the P6 point is a nonpharmacologic technique that is as effective as ondansetron for preventing PONV after LC. Knowledge regarding the risk factors for PONV and antiemetics is needed for the management of PONV after LC.

Postoperative strategies to treat permanent air leaks.

Air leakage after pulmonary resections is considered the most prevalent postoperative problem, and it is often the only morbidity identified. Ideally, treatment begins with prevention; the onset of this complication should be anticipated and recognized during surgery, and intraoperative strategies should be attempted to avoid it and reduce the impact on the clinical course. Once an air leak develops, in most of the cases it seals spontaneously within 2 or 3 days of operation. When it persists, it might elicit the onset of other complications and increase costs and length of hospitalization. The postoperative approaches to a prolonged air leak include management of the pleural drainage and residual space, pleurodesis, pneumoperitoneum, endobronchial one-way valve placement, and potential reoperation.

Management of residual pleural space and air leaks after major pulmonary resection.

Postoperative air leaks associated with residual pleural space is a well known complication contributing to prolong hospitalization. Many techniques have been proposed for the treatment of this complication. Between 1999 and 2009, 39 patients with air leaks associated with residual pleural space (>3 cm at chest X-ray) persisting over three days after major lung resection were enrolled in this study. All patients were treated with combined pneumoperitoneum and autologus blood patch. Pneumoperitoneum is obtained by the injection of 30 ml/kg of air under the diaphragm, using a Verres needle through the periumbilical area. The blood patch is obtained by instillating 100 ml of autologus blood through the chest tubes. No patients experienced complications related to the procedure. Obliteration of pleural space was obtained in all the patients at a maximum of 96 h postoperatively. Air leaks stopped in all the cases at a maximum of 144 h from surgery. Chest tube was removed 24 h after the air leakage disappearance. Our 10-year experience supports the early, combined use of pneumoperitoneum and blood patch whenever pleural space and air leaks present after major pulmonary resection. This approach may be recommended because of its easiness, safety, effectiveness, and the low costs.

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation.

BACKGROUND: Laparoscopic implantation of peritoneal dialysis catheters has many advantages over conventional methods. The ability to perform laparoscopy with the patient under local anesthesia allows renal failure patients, who ordinarily might not be considered candidates for general anesthesia, an opportunity to undergo this procedure. METHODS: Using local anesthesia and nitrous oxide pneumoperitoneum, 175 catheters were implanted in long musculofascial tunnels under laparoscopic guidance to minimize the risk of catheter migration and flow dysfunction. RESULTS: Nitrous oxide pneumoperitoneum was well tolerated, allowing all procedures to be safely completed with the patients under local anesthesia. The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Temporary pericatheter leak occurred in 7.4% of cases. CONCLUSIONS: Nitrous oxide insufflation enables safe performance of laparoscopic surgery with the patient under local anesthesia. Patients benefit from a minimally invasive technique with the assurance of obtaining successful long-term catheter function.

[Comparative assessment of extraperitoneoscopic and laparoscopic methods of varicocele treatment].

The article presents a comparative analysis of the results of extraperitoneoscopic and laparoscopic methods of internal seminal vein ligation in 90 varicocele patients (40 and 50 patients, respectively); describes insufficiently known method--extraperitoneoscopic operations. The working space in the prevesical space is created by direct introduction of trocars with optics into the prevesical space without any additional tools. The operations took the same time. Laparoscopic operations required more postoperative analgetic drugs than extraperitoneoscopic ones. By pain intensity and physical activity scales, varicocele patients' quality of life was higher after extraperitoneoscopic operations than after laparoscopic and open operations. Thus, extraperitoneal ligation of the seminal veins by direct introduction of endoscope into the preperitoneal space with CO2 insufflation without prior creation of working space is simple for use, low invasive, has low risk of visceral injury and can be applied as an alternative to laparoscopy.