Ischiorectal fossa block decreases posthemorrhoidectomy pain: randomized, prospective, double-blind clinical trial.

PURPOSE: Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to assess the efficacy of a preemptive local anesthetic, ischiorectal fossa block, in the reduction of pain and analgesic requirements after hemorrhoidectomy. METHODS: All patients were suitable for an established day surgery hemorrhoidectomy protocol. Immediately before surgery patients were randomly assigned either to receive (Group 1) or not receive (Group 2) the local anesthetic block. All other aspects of surgery and anesthesia were standardized. Nursing staff assessed pain at 30 minutes and 2, 4, and 24 hours postoperatively using a visual analog scale (1-10, where 1 represented no pain and 10 represented the worst pain imaginable). Analgesic requirements also were recorded at these times. Both the patients and the nursing staff were blinded to which local anesthetic protocol had been used. RESULTS: Twenty patients were enrolled in the trial. Ten patients were randomly assigned to Group I and ten to Group 2. Mean pain scores for Group 1 (anal block) at 0.5, 2, 4, and 24 hours were 1.5, 1.8, 2.1, and 2.5, respectively, compared with Group 2, with mean pain scores of 3.4, 3.4, 3.9, and 5.1. These differences were statistically significant. Patients in Group 1 used less analgesia in the first 24 hours postoperatively than those in Group 2. CONCLUSION: The use of a preemptive local anesthetic, ischiorectal fossa block, is associated with a significant decrease in pain and analgesia requirements after hemorrhoidectomy.

Core temperature changes during open and laparoscopic colorectal surgery.

BACKGROUND: Perioperative hypothermia increases the morbidity of surgery. However, the true incidence of hypothermia during prolonged laparoscopic surgery is still unknown. To investigate this issue, we compared the temperature change between patients undergoing open and laparoscopic colorectal surgery. METHODS: Sixty consecutive patients who were undergoing laparoscopic (33) or open (27) colorectal surgery had a transesophageal temperature probe placed after induction of anesthesia. Core temperature values were measured at 15-min intervals. RESULTS: The groups were not statistically different with respect to age, sex, body surface area, or initial transesophageal temperature. The type of surgical access (open or laparoscopic) caused no difference in the incidence of hypothermia. The use of a forced-air warming device produced significantly less hypothermia during laparoscopic surgery. Men showed significantly less variability in temperature change than women. CONCLUSIONS: The incidence of hypothermia in open and laparoscopic colorectal surgery is similar. Forced-air warming devices are of value in prolonged laparoscopic surgery. A gender difference in the response to a hypothermic situation has not been previously reported. This finding warrants further investigation.

Localization of the nonpalpable colonic lesion with intraoperative ultrasound.

Localization of an nonpalpable colonic lesion at the time of colectomy usually requires intraoperative colonoscopy. The use of ultrasound to locate the lesion has not been described. A soft bowel clamp is placed above the expected location of the lesion and a catheter placed in the anus. Saline is then instilled into the colon and rectum. The lesion is located by ultrasound scan of the fluid filled colon with the probe placed on the serosal surface. Refinement of the technique was performed on resected colonic specimens. An in vivo trial was then performed with rapid and accurate localization of the lesion for resection. Intraoperative ultrasound of the colon can accurately localize nonpalpable colonic lesions and is an alternative to currently available techniques of localization.

Day-case haemorrhoidectomy.

BACKGROUND: Ligation excision haemorrhoidectomy is usually performed on an inpatient basis. This study was designed to assess the feasibility of day-case haemorrhoidectomy. METHODS: Patients fulfilling criteria for day surgery underwent ligation excision haemorrhoidectomy with the intention of a same-day discharge from hospital. A standardized protocol for anaesthesia, perioperative analgesia and antiemesis was followed. Patients received daily home nursing visits until they felt both comfortable and confident. Staff recorded pain and nausea scores on a visual analogue scale (range 1-10) until the first bowel action. Patient satisfaction was assessed independently after operation. RESULTS: Fifty-one patients underwent planned day-case haemorrhoidectomy. Forty-two (82 per cent) were discharged on the day of surgery. All patients were discharged within 26 h of surgery. Four patients required readmission, two with reactive bleeding, one with urinary retention and one for pain control. Pain and nausea were well controlled. Forty-four patients (86 per cent) were totally or very satisfied with their overall care. CONCLUSION: Ligation excision haemorrhoidectomy can be performed successfully as a day-case procedure.

Laparoscopic-assisted colonoscopic polypectomy: technique and preliminary experience.

BACKGROUND: The majority of colonic polyps found at endoscopy are suitable for diathermy snare excision via colonoscope. Due to location or size, some are deemed unsafe to treat in this manner and therefore require colectomy. This study describes the technique and early results of a laparoscopic-assisted colonoscopic polypectomy technique that can be used to manage such polyps and thereby avoid laparotomy and colectomy. METHODS: Colonoscopy with simultaneous laparoscopy was utilized to locate the site of the polyp. The colon was mobilized, if required, and the polyp resected by electrosurgical snare via the colonoscope while the serosal aspect of the colon was monitored laparoscopically. RESULTS: The technique has been tried successfully in six patients. Three polyps were in the cecum and three were within the left colon. The size of the polyps ranged from 3 to 7 cm. All polyps were benign on histological examination. The patients were discharged on the day following the procedure. There were no complications. CONCLUSIONS: The combination of laparoscopy with colonoscopic resection of a select group of large polyps represents a safe alternative to colonic resection.

Intraoperative abdominal ultrasonography.

BACKGROUND: Ultrasonography during abdominal surgery has been reported since the 1960s, but its use did not become widespread until the recent availability of high-frequency, high-resolution transducers. This review discusses the application of intraoperative ultrasonography to open and laparoscopic abdominal surgery. METHODS: A literature search (Medline) was undertaken. All papers pertaining to the subject matter that were located were included in the review. RESULTS: Intraoperative ultrasonography influences surgical strategy in up to 50 per cent of liver resections for malignancy. It is the single most sensitive technique for the detection of occult hepatic metastases at the time of primary colorectal resection. In pancreatic surgery, intraoperative ultrasonography is of value in the localization of islet cell tumours and in the assessment of resectability of adenocarcinoma. The technique may also have a role in staging laparoscopy, and in the operative management of kidney and gastrointestinal diseases. CONCLUSION: Ultrasonography is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. It should be regarded as an essential component of major hepatobiliary and pancreatic procedures. The recent availability of flexible laparoscopic probes is likely to lead to a similar impact on minimal access surgery.

Laparoscopic cholecystectomy for acute inflammation of the gallbladder.

OBJECTIVE: The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach. METHODS: All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema. RESULTS: The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation. CONCLUSIONS: Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.