A randomized, double-blinded, placebo-controlled trial of the effects of infusing local analgesia on post-operative pain during laparoscopic inguinal hernia repair.

PURPOSE: While it is widely accepted that laparoscopic total extraperitoneal (TEP) inguinal herniorrhaphy has decreased post-operative pain, there are conflicting data as to whether instillation of local anesthetic into the preperitoneal space improves post-operative pain in these patients. We designed a prospective study to evaluate this. Secondary outcomes include time spent in the PACU, need for narcotic pain medication, and total amount of narcotics required postoperatively. METHODS: Prospective, randomized, double-blind, placebo-controlled study which enrolled 70 patients with unilateral non-recurrent inguinal hernia from 09/2013 to 03/2019 and included immediate and 2-week post-operative follow-up. All patients received unilateral laparoscopic TEP inguinal hernia repair with control patients receiving 10 ml of 0.9% saline instilled into preperitoneal space while treatment group received 10-ml 0.5% bupivacaine without epinephrine. RESULTS: A total of 70 patients [67 (96%) men and 3 women; mean age (SD), 57 years (13.8)] were enrolled, 35 randomized into each group. Demographics between the two groups were similar. No differences were found in post-operative pain between the control and test groups at 1 h [mean (SD) of 3.15(2.5) vs 3.21(2.9); P = 0.92], 2 h [3.39 (1.55) vs 2.74 (1.85) P = 0.18], or 1 day [4.79 (2.19) vs 4.39 (2.37); P = 0.13] postoperatively. Likewise, no significant differences were observed in usage of narcotic pain medication postoperatively, as 17 control patients (50%) and 16 (46%) study patients required narcotics within 2 h of surgery (P = 0.72). CONCLUSION: Instilling local anesthetic into the preperitoneal space during laparoscopic TEP inguinal hernia repair did not result in statistically significant difference in post-operative pain (Rade et al. in NESS Annual Meeting, 2021). Trial registry ClinicalTrials.gov Identifier: NCT02055053.

Per-oral endoscopic myotomy for the treatment of non-achalasia esophageal dysmotility disorders: experience from a single high-volume center.

BACKGROUND: Achalasia is a rare disorder of esophageal motility that induces progressive intolerance to oral intake. Other esophageal dysmotility disorders include esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypercontractile esophagus (HE), and other minor disorders of peristalsis (MDP) and can present similarly to achalasia despite different pathophysiologies. Prior studies have demonstrated the safety and efficacy of POEM in the treatment of achalasia, but little is reported regarding POEM's role in treating non-achalasia esophageal dysmotility disorders (NAEDD). This study aims to assess the safety and efficacy of POEM in the treatment of NAEDD. STUDY DESIGN: This is a retrospective review of consecutive POEM cases from June 1, 2011, to February 1, 2021. NAEDD were characterized according to the Chicago classification. Primary outcome measure was the resolution of preoperative symptoms. Secondary outcomes include preoperative diagnosis, myotomy length, conversion to laparoscopic or open procedure, operative time, and length of stay (LOS). Technical success was defined as the completion of an 8 cm myotomy including the esophagogastric junction (EGJ) and extending 2 cm distal to the EGJ. Clinical success was defined as a postoperative Eckardt score ≤ 3. RESULTS: Of 124 cases of POEM performed during the study period, 17 were performed for NAEDD. Technical success was achieved in all 17 patients (100%). Of the fifteen patients that had documented postoperative Eckardt scores, 13 were ≤ 3, achieving a clinical success rate of 87%. Subgroup analysis (HE/MDP/DES vs. EGJOO) showed no significant differences in the preoperative or postoperative Eckardt scores between groups, and both groups demonstrated a significant decrease in Eckardt scores after POEM. No cases were aborted for technical or clinical reasons, and there were no adverse outcomes. CONCLUSION: POEM is a safe and efficacious treatment modality for NAEDD. Further work is needed to develop optimal treatment strategies for this complex group of diseases.

Evaluation of a stand-alone robotic camera holding system: technology that improves laparoscopy.

INTRODUCTION: In order to perform laparoscopic procedures, a surgeon requires an assistant to hold the camera. Problems with this approach include table crowding leading to poor ergonomics, and miscommunication leading to poor images. AutoLap is a novel FDA-approved camera navigation system. We present our experience with this device and compare it to human camera holders. MATERIALS AND METHODS: The study design included an initial training period followed by a non-randomized allocation between robotic and human camera holder cohort. Data included set up time, ergonomics and usability (via nurse, surgeon and camera holder questionnaire) and image stability recorded via the Inertial Measurement Unit (IMU), describing linear acceleration (in unit gravity [g]) and horizontal acceleration (Angular Velocity in rad/s). RESULTS: Twenty-six patients were equally divided between human and robotic camera holders. Image stability were significantly better for the robotic camera holder. Median angular velocity was 0.029 and 0.005 rad/s for human and the AutoLap system, respectively (p-value <.001). Linear acceleration was 0.011 and 0.007 [g] (p-value .015). Positive feedback for the robotic system included greater surgeon comfort (92%) and improved nurse - surgeon interaction (100%). CONCLUSIONS: The AutoLap system provides improved image stability, team-work, and ergonomic comfort for the surgical team with minimum set-up time.

Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial.

BACKGROUND: Hip arthroscopy causes moderate to severe postoperative pain. We hypothesized that performance of a lumbar plexus block (LPB) would reduce postoperative pain in the postanesthesia care unit (PACU) for patients discharged home on the day of surgery. METHODS: Patients received a combined spinal epidural with IV sedation, ondansetron, and ketorolac. Half of the patients (n = 42) also underwent a single-injection bupivacaine LPB. Postoperative analgesia (PACU and after discharge) was provided with oral hydrocodone/acetaminophen (5/500 mg) and an oral nonsteroidal antiinflammatory drug. IV hydromorphone was given as needed in the PACU. RESULTS: The LPB reduced pain at rest in the PACU (GEE: ß estimate of the mean on a 0 to 10 scale = -0.9; 95% confidence interval = -1.7 to -0.1; P = 0.037). Mean PACU pain scores at rest were reduced by the LPB from 4.2 to 3.3 (P = 0.048, 95% confidence interval for difference = 0.007-1.8; uncorrected for multiple values per patient, using independent samples t test for preliminary evaluation comparing pain between the groups). There were no statistically significant differences in PACU analgesic usage, PACU pain with movement, and patient satisfaction. No permanent adverse events occurred, but 2 LPB patients fell in the PACU bathroom, without injury. Three unplanned admissions occurred; one LPB patient was admitted for epidural spread and urinary retention. Two control patients were admitted, one for oxygen desaturation and one for pain and nausea. CONCLUSION: LPB resulted in statistically significant reductions in PACU resting pain after hip arthroscopy, but the absence of improvement in most secondary outcomes suggests that assessment of risks and benefits of LPB should be individualized.

Performance characteristics and validation of the Opioid-Related Symptom Distress Scale for evaluation of analgesic side effects after orthopedic surgery.

BACKGROUND: The Opioid-Related Symptom Distress Scale (ORSDS) is a 4-point scale that evaluates 3 symptom distress dimensions (frequency, severity, bothersomeness) for 12 symptoms. The symptom-specific ORSDS is the average of the 3 symptom distress dimensions. The composite ORSDS is the average of 12 symptom-specific scores. The ORSDS was validated for outpatient laparoscopic cholecystectomy (under general anesthesia) by assessment of internal consistency, content validity, construct validity, principal components analysis, known group validity, responsiveness, and opioid dose dependency. Additional validation studies were suggested. We investigated performance characteristics and validity of the ORSDS for postoperative analgesia after 4 types of anesthetic and analgesic regimens. METHODS: The ORSDS and validation questions were administered to 4 groups of 50 orthopedic patients. Peripheral nerve blockade (Peripheral) was performed for distal upper extremity surgery; neuraxial anesthesia (Neuraxial) was performed for anterior cruciate ligament reconstruction; combined spinal-epidural anesthesia/femoral nerve block/epidural analgesia (Regional) was performed for total knee arthroplasty; and general anesthesia/IV opioids (GA) was performed for posterior lumbar spine fusion. All patients also received oral opioid analgesics. RESULTS: Median composite ORSDS scores on postoperative day 1 were 0.19 (Peripheral), 0.52 (Neuraxial), 0.51 (Regional), and 0.94 (GA). The following symptoms had median symptom-specific ORSDS scores >0: Neuraxial = drowsiness, dry mouth; Regional = dizziness, dry mouth; GA = nausea, fatigue, dizziness, drowsiness, dry mouth. Problematic symptoms (symptoms for which at least 25%of patients reported symptom-specific ORSDS scores >1) were: all groups = drowsiness, dry mouth, fatigue; Neuraxial = nausea, dizziness, itchiness; Regional = nausea, dizziness, itchiness; GA = difficulty concentrating, headache, nausea, dizziness, itchiness. High symptom-specific ORSDS scores were associated with clinically meaningful adverse events. In some cases, relevant ORSDS scores were related to activity level, patient satisfaction, and nausea and vomiting measures. Many components occurred in correlated clusters. Responsiveness statistics (the ability of an instrument to detect changes once they have occurred) were high for nausea and vomiting. Linear regression analysis indicated that opioid use was associated with composite ORSDS scores for Peripheral, Regional, and GA. CONCLUSIONS: Validity of the ORSDS was supported by predetermined validation criteria, including measures of internal consistency, content validity, construct validity, principal components analysis, known group validity, responsiveness, and correlation with opioid intake. The ORSDS is a valid tool for assessment of opioid side effects after orthopedic surgery, and can be used in clinical trials involving a wide variety of anesthetic and analgesic regimens.

Postoperative delirium in elderly patients after elective hip or knee arthroplasty performed under regional anesthesia.

Delirium is a major adverse postoperative event in elderly patients. Incidence rates of postoperative delirium are difficult to determine. Because of the accuracy, brevity, and ease of use by clinical interviewers, the Confusion Assessment Method (CAM) has become widely used. This study used the CAM to determine the rate of postoperative delirium in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures under regional anesthesia. Following Institutional Review Board approval, a prospective study of 20 patients per group ages 70 and above undergoing unilateral THA or TKA was initiated. Both groups received a combined spinal-epidural, postoperative patient-controlled epidural anesthesia, and postoperative oral opioids. Patient interviews occurred five times: once preoperatively and two times each on postoperative days 1 and 2. Only two patients were assessed as delirious according to the CAM method (one in each group; 5%). Patient assessment by other clinicians indicated that five additional patients experienced acute change in mental status; however, these patients were not delirious at the times of the study interviews. The rate of delirium in the elderly after arthroplasty performed under regional anesthesia is very low. Reasons for this include patient selection criteria and anesthesia type. The study excluded patients with several proposed risk factors for postoperative delirium: prior history of dementia, history of mental illness, and use of benzodiazepines. The use of regional anesthesia may have also reduced the occurrence of postoperative delirium.