Laparoscopically assisted reversal of Hartmann's procedure.

BACKGROUND: Restoration of bowel continuity after Hartmann's procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann's procedure (LARH) to assess difficulties and potential advantages associated with this procedure. METHODS: A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. RESULTS: A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann's procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. CONCLUSIONS: Laparoscopically assisted reversal of Hartmann's procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial.

BACKGROUND: Preoperative mechanical bowel preparation is aimed to reduce the risk of infectious complications, and its utility is a dogma in left-sided large bowel anastomosis. The aim of this study was to specifically assess whether colocolonic and colorectal anastomoses may be safely performed without preoperative mechanical bowel preparation. METHODS: Patients undergoing elective colon and rectal surgery with primary colocolonic or colorectal anastomosis were prospectively randomized into two groups. The "prep" group had mechanical bowel preparation prior to surgery, while the "non-prep" group had surgery without pre-operative mechanical bowel preparation. RESULTS: Two hundred forty-nine patients were included in the study, 120 in the prep group and 129 in the nonprep group. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups. Overall infectious complication rate was 12.5% in the prep group and 13.2% in the non-prep group. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.6%, 4.2%, and 1.6% of patients in the prep group and in 10.0%, 2.3%, and 0.7% of patients in the nonprep group, respectively (p=NS). CONCLUSIONS: These results suggest that elective left-sided anastomosis may be safely performed without mechanical preparation. Multicenter studies to test the reproducibility of these results are required, to support a change in this time-honored practice.

Preperitoneal bupivacaine attenuates pain following laparoscopic inguinal hernia repair.

BACKGROUND: Laparoscopic preperitoneal inguinal hernia repair is associated with a short hospital stay and an early return to normal activity. Therefore, early postoperative pain control is important. The aim of this study was to evaluate the effect of preperitoneal Bupivacaine instilled into the preperitoneal cavity on pain following laparoscopic mesh repair of inguinal hernia. METHODS: After institutional review board approval, 44 patients undergoing elective laparoscopic inguinal hernia repair were prospectively randomized into two groups. Upon completion of the Prolene mesh repair, group A received 80 mg of Bupivacaine in 25 cc of saline installed into the preperitoneal space, whereas group B received normal saline installed into the preperitoneal space. Pain was assessed using a visual analog scale at fixed time intervals; the amount of analgesics required was also recorded. RESULTS: Twenty-two patients were included in each group. The demographic characteristics and type of surgery (unilateral vs bilateral) did not significantly differ between the two groups. The average pain levels were significantly attenuated in group A compared to group B at 1 (4.0 vs 5.0, respectively; p = 0.0038), 2 (4.0 vs 5.9, respectively; p = 0.0015), and 4 (4.3 vs 5.8, respectively; p = 0.0038) h after surgery. Furthermore, the analgesic intake was significantly decreased in group A compared to group B. CONCLUSION: Preperitoneal Bupivacaine attenuates pain following laparoscopic inguinal hernia repair and should be considered in these cases.

Laparoscopic management of surgical complications after a recent laparotomy.

BACKGROUND: The use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures. METHODS: Fourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically. RESULTS: Eleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space. CONCLUSIONS: We conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.

Laparoscopic approach to small-bowel obstruction.

BACKGROUND: Small-bowel obstruction poses both a diagnostic and a therapeutic challenge. The laparoscopic approach may assist in determining the cause of the obstruction and in many cases to treat the obstructing lesion. METHODS: For the last 2 years, we have been approaching patients with small-bowel obstruction laparoscopically. RESULTS: We have found this technique to be successful as the definitive treatment in more than half of the cases. CONCLUSION: The laparoscopic approach should be the modality of choice for most, if not all, cases of small-bowel obstruction in which there is an indication for exploration.

Intraperitoneal bupivacaine does not attenuate pain following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is characterized by a short hospital stay. Hence, pain control on the day of surgery is increasingly important. The aim of this study was to evaluate the effect of intraperitoneal bupivacaine on pain relief following laparoscopic cholecystectomy. METHODS: Sixty patients undergoing elective laparoscopic cholecystectomy were prospectively randomized into 2 groups. Following removal of the gallbladder, group A received 100 mg of bupivacaine in 50 cc of saline, installed into the gallbladder bed and right subphrenic space. Group B received saline without bupivacaine. Pain was assessed using a visual/analog scale at fixed-time intervals. RESULTS: No significant difference occurred in the average pain levels between the groups at 1, 2, 4, and 14 hours postsurgery. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance. CONCLUSION: Application of intraperitoneal bupivacaine did not attenuate pain following laparoscopic cholecystectomy, and no role exists for its routine use.