Index of Consciousness monitoring may effectively predict and prevent circulatory stress induced by endotracheal intubation under general anesthesia: a prospective randomized controlled trial.

BACKGROUND: The primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA). METHODS: We enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups. RESULTS: The mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05). CONCLUSION: This promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management. TRAIL REGISTRATION:  Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022).

[The role of magnesium sulfate in providing hemodynamic stability in patients undergoing laparoscopic surgery: a prospective randomized controlled study]. / Intérêt du sulfate de magnésium pour la stabilitée hémodynamique en cœliochirurgie: étude prospective contrôlée randomisée.

Introduction: during laparoscopic surgery, carbon dioxide (CO2) insufflation to create pneumoperitoneum increases blood pressure, heart rate and systemic vascular resistance. The purpose of our study was to investigate the efficacy of magnesium sulfate in preventing adverse hemodynamic reactions associated with pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. Methods: we conducted a prospective, randomized, double-blind, controlled clinical study of patients scheduled for laparoscopic cholecystectomy and divided into two equal groups: the Mg2+ group received slow intravenous magnesium sulfate 50 mg/kg injection prior to pneumoperitoneum insufflation while the S group received the same volume of 0.9 % saline. Our primary endpoint was intraoperative changes in systolic blood pressure (SBP) related to pneumoperitoneum, in particular at 1 minute after insufflation. The secondary endpoints were the haemodynamic effects of pneumoperitoneum in terms of systolic blood pressure (SP), diastolic blood pressure (DP), mean arterial pressure (MAP) and heart rate (HR) from 2 minutes after insufflation to extubation and postoperatively, and the presence of possible adverse reactions related to the administration of magnesium sulphate. Results: we included 70 patients divided into two groups of 35. SP was significantly higher in the S group at insufflation (T0), 3 min, 4 min and 5 min post-operative, and at 60 min after surgery. HR was significantly higher in patients in the S group compared to the Mg2+ group at 7 min and 8 min after insufflation. No significant differences in DP and MAP measurements were observed between the 2 groups. No adverse reactions related to magnesium administration were reported. Conclusion: magnesium sulfate administered prior to pneumoperitoneum insufflation provided improved intraoperative hemodynamic stability during laparoscopic surgery.

[Experience of indocyanine green use in acute calculous cholecystitis]. / Opyt primeneniya indotsianina zelenogo pri ostrom kal'kuleznom kholetsistite.

OBJECTIVE: To assess the safety and effectiveness of the indocyanine green use in acute cholecystitis for identification of anatomical variants of the biliary tree; prevention and timely detection of intraoperative complications. MATERIAL AND METHODS: The medication of indocyanine green made by OOO «Ferment¼ domestic manufacturer was used. The drug dose from 2.5 mg to 10 mg was applied according to studied materials (8). Time of the surgery beginning was from 2 to 6 hours after intravenous injection of aqueous solution, respectively. In addition, it has been established that the optimal drug dose is 5 mg. The surgery should be performed not earlier than 3 hours after, but no later than 6 hours. This allows to achieve the most comfortable fluorescence of the extrahepatic biliary tract. The drug concentration in the liver cells decreases by this time and increases in the biliary tract. It is not always possible to perform the operation strictly within the specified time limit considering the urgency of the surgical intervention. In this connection, the surgery was carried out not earlier than 3 hours after the drug injection, but not later than 6 hours. Endoscopic equipment with the ability to display near-infrared fluorescence was used. A laser light source with a wavelength of 820 nm in the Arthrex imaging system with 4K resolution as well as the Olympus imaging system with HD resolution were used for fluorescence excitation. RESULTS: The implementation of intraoperative fluorescent navigation with indocyanine green contributes to the improvement of safety and effectiveness of surgical treatment through visualization of topography and identification of anatomical variants of the biliary tree; possibilities of prevention and timely detection of intraoperative complications. The use of indocyanine green allows to intraoperatively reveal atypical location and different variations of the extrahepatic biliary tract.

Surgical Management of the Horrible Gallbladder.

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Shoeshine maneuver for cystic duct dissection: a simple technique to make Calot-triangle dissection smooth.

PURPOSE: Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy. METHODS: This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage. RESULTS: The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks. CONCLUSION: The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

Cystic Duct Exploration in Laparoscopic Cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is a severe complication following cholecystectomy and is therefore a particularly concerning surgical predicament for hepatobiliary surgeons. Owing to very high medical compensation awarded to patients suffering from BDI, surgeons need to exercise caution during surgery to avoid BDI. Herein, we explored a novel method to identify cystic duct during laparoscopic cholecystectomy (LC), expanding the applicability of this surgical approach. METHODS: Patients receiving LC between April 2021 and October 2022 at the Gaoyou People's Hospital were included in this retrospective clinical study and divided into two groups according to whether the cystic duct was incised (one group with LC alone, while another with laparoscopic cholecystectomy and cystic duct exploration [LCCDE]). Clinical and baseline characteristics of patients were collected, and the preoperative and postoperative biochemical parameters were compared. The surgical outcomes of LCCDE were observed. RESULTS: A total of 114 patients had undergone LC, while 162 patients had received LCCDE as treatment. There were no significant differences in age, gender, common bile duct diameter, preoperative and postoperative biochemical parameters between the two groups. No significant difference in the mean operation time between the LC and LCCDE groups was noted (p = 0.409). In the LCCDE group, white secretions in the cystic duct were observed in 92 patients (56.8%). CONCLUSIONS: The presence of intraoperative white secretions in the cystic duct may further confirm the presence of cystic duct, thereby enabling earlier detection of BDI. Importantly, LCCDE, as the new surgical method explored in this study, does not extend the operation time.

Robotic, laparoscopic and open surgery for gallbladder cancer: a systematic review and network meta-analysis.

INTRODUCTION: Minimally invasive oncological resections have become increasingly widespread in the surgical management of cancers. However, the role of minimally invasive surgery (MIS) for gallbladder cancer (GBC) remains unclear. We aim to perform a systematic review and network meta-analysis of existing literature to evaluate the safety and feasibility of laparoscopic and robotic surgery in the management of GBC compared to open surgery (OS) by comparing outcomes. METHODS: A literature search of the PubMed/MEDLINE (2000 to December 2021) and EMBASE (2000 to December 2021) databases was conducted. The primary outcome studied was overall survival, and secondary outcomes studied were postoperative morbidity, severe complications, incidence of bile leak, length of hospital stay, operation time, R0 resection rate, local recurrence and lymph node yield. RESULTS: Thirty-two full-text articles met the eligibility criteria and were included in the final analysis with a total of 5883 patients undergoing either OS or MIS (laparoscopic or robotic) for GBC. 1- and 2-stage meta-analyses did not reveal any significant differences between OS, laparoscopic and robotic surgery in terms of overall survival, R0 resection, lymph node harvest, local recurrence and post-operative complications. Patients who underwent OS had significantly longer hospitalization stay and intra-operative blood loss compared to those who underwent laparoscopic or robotic surgery. Network meta-analysis did not reveal any significant differences between post-operative and survival outcomes of laparoscopic vs robotic surgery groups. CONCLUSION: This network meta-analysis suggests that both laparoscopic and robotic surgery are safe and effective approaches in the surgical management of GBC, with post-operative and survival outcomes comparable to OS. An MIS approach may also lead to shorter hospitalization stay, less intraoperative blood loss and post-operative complications compared to OS. There was no obvious benefit of either MIS approach (laparoscopic versus robotic) over the other.

A case of H-type double gallbladder anomaly: A case report.

RATIONALE: Biliary system anomalies, such as duplicated gallbladders, are rare congenital conditions that present significant diagnostic challenges. Dr. Boyden's classification system, especially the H-type anomaly, offers vital insight into these variations. Failure to detect these anomalies preoperatively can increase the risk of surgical complications, making early identification crucial for surgical planning. PATIENT CONCERN: A 42-year-old male, asymptomatic, was incidentally found to have a gallbladder mass during routine imaging. An upper abdominal magnetic resonance imaging showed gallbladder wall thickening, gallstones, and a liver lesion. Despite the absence of symptoms, a laparoscopic cholecystectomy revealed an atrophied gallbladder with a cystic duct cyst, which was identified as an H-type double gallbladder anomaly. The surgery was completed without complications, and pathology confirmed the presence of gallstones and inflammation. DIAGNOSES: The patient was diagnosed with a duplicated gallbladder, classified as an H-type anomaly, following laparoscopic cholecystectomy. Preoperative imaging identified gallbladder wall thickening and gallstones, and further investigation during surgery confirmed the congenital anomaly. INTERVENTIONS: The patient underwent laparoscopic cholecystectomy for the removal of the gallbladder, and during the procedure, an H-type double gallbladder anomaly was discovered. The surgery proceeded without incident, ensuring the complete excision of the gallbladders. OUTCOMES: The case highlights the diagnostic difficulty of identifying duplicated gallbladders and the importance of advanced imaging techniques in detecting atypical anatomical variations. The successful laparoscopic removal of both gallbladders illustrates the current capabilities of minimally invasive surgery. Postoperative recovery was uneventful, and the pathology confirmed gallstones and inflammation. LESSONS: This case emphasizes the importance of recognizing biliary anomalies such as duplicated gallbladders to avoid complications during surgery. Preoperative identification, aided by imaging, and careful surgical planning are key to managing these rare conditions. The case contributes to the growing body of knowledge about biliary system anomalies and reinforces the need for comprehensive management strategies to ensure optimal patient outcomes.

Modified thoracoabdominal nerve block via perichondral approach: an alternative for perioperative pain management in laparoscopic cholecystectomy in a middle-income country.

BACKGROUND: Laparoscopic cholecystectomy is known for its minimally invasive nature, but postoperative pain management remains challenging. Despite the enhanced recovery after surgery (ERAS) protocol, regional analgesic techniques like modified perichondral approach to thoracoabdominal nerve block (M-TAPA) show promise. Our retrospective study evaluates M-TAPA's efficacy in postoperative pain control for laparoscopic cholecystectomy in a middle-income country. METHODS: This was a retrospective case-control study of laparoscopic cholecystectomy patients at Hospital General de Mexico in which patients were allocated to the M-TAPA or control group. The data included demographic information, intraoperative variables, and postoperative pain scores. M-TAPA blocks were administered presurgery. OUTCOMES: opioid consumption, pain intensity, adverse effects, and time to rescue analgesia. Analysis of variance (ANOVA) compared total opioid consumption between groups, while Student's t test compared pain intensity and time until the first request for rescue analgesia. RESULTS: Among the 56 patients, those in the M-TAPA group had longer surgical and anesthetic times (p < 0.001), higher ASA 3 scores (25% vs. 3.12%, p = 0.010), and reduced opioid consumption (p < 0.001). The M-TAPA group exhibited lower postoperative pain scores (p < 0.001), a lower need for rescue analgesia (p = 0.010), and a lower incidence of nausea/vomiting (p = 0.010). CONCLUSION: Bilateral M-TAPA offers effective postoperative pain control after laparoscopic cholecystectomy, especially in middle-income countries, by reducing opioid use and enhancing recovery.

Minimally invasive approach in a rare emergency surgery, gallbladder perforation.

BACKGROUND: Gallbladder perforations are challenging to manage for surgeons due to their high morbidity and mortality, rarity, and surgical approach. Laparoscopic cholecystectomy (LC) is now included with open cholecystectomy in surgical managing gallbladder perforations. This study aimed to evaluate the factors affecting conversion from laparoscopic to open cholecystectomy in cases of type I gallbladder perforation according to the Modified Niemeier classification. METHODS: Patients who met the inclusion criteria were divided into two groups: LC and conversion to open cholecystectomy (COC). Demographic, clinical, radiologic, intraoperative, and postoperative factors were compared between groups. RESULTS: This study included 42 patients who met the inclusion criteria, of which 28 were in the LC group and 14 were in the COC group. Their median age was 68 (55-85) years. Age did not differ significantly between groups (p = 0.218). However, the sex distribution did differ significantly between groups (p = 0.025). The location of the perforation differed significantly between groups (p < 0.001). In the LC group, 22 patients were perforated from the fundus, four from the trunk, and two from the neck. In the COC group, two patients were perforated from the fundus, four from the trunk, and eight from the neck. Surgical procedure times differed significantly between the LC (105.0 min [60-225]) and COC (125.0 min [110-180]) groups (p = 0.035). The age of the primary surgeons also differed significantly between the LC (42 years [34-63]) and COC (55 years [36-59]) groups (p = 0.001). CONCLUSIONS: LC can be safely performed for modified Niemeier type I gallbladder perforations. The proximity of the perforation site to Calot's triangle, Charlson comorbidity index (CCI), and Tokyo classification are factors affecting conversion from laparoscopic to open surgery of gallbladder perforations.

Who should perform pediatric laparoscopic cholecystectomies? A systematic review of the literature.

Laparoscopic cholecystectomy (LC) is an increasingly common operation in the pediatric population, although numbers remain significantly lower than in adults. Currently, this operation is performed by both adult and pediatric surgeons and there is no consensus as to whether specialist low-volume or adult high-volume surgeons should be performing this operation. A literature search was performed to compare the outcomes following pediatric LC when performed by adult or pediatric surgeons. 19,993 patients were included in this analysis. Overall, post-operative complications were reduced when LC was performed by high-volume adult surgeons, along with reduced length of stay and associated cost. Overall morbidity following LC in children is comparable to adults. When performed by higher volume adult surgeons, there was a statically significant reduction in post-operative complications and re-admission rates. Morbidity was also reduced in patients with simple cholelithiasis. Initial results show that in pediatric patients presenting with cholelithiasis, LC performed by a high-volume adult general surgeon is safer. In more complex children with needs from other specialist pediatricians, surgery performed by a pediatric surgeon is recommended. Further research with direct comparisons is still required.

Comparison of the therapeutic effects of three minimally invasive approaches for laparoscopic cholecystectomy combined with common bile duct exploration-- a 5-year retrospective analysis.

OBJECTIVE: The aim of this retrospective study was to explore the indications for three minimally invasive approaches-T-tube external drainage, double J-tube internal drainage, and primary closure-in laparoscopic cholecystectomy combined with common bile duct exploration. METHODS: Three hundred eighty-nine patients with common bile duct stones who were treated at the Second People's Hospital of Hefei between February 2018 and January 2023 were retrospectively included. Patients were divided into three groups based on the surgical approach used: the T-tube drainage group, the double J-tube internal drainage group, and the primary closure group. General data, including sex, age, and BMI, were compared among the three groups preoperatively. Surgical time, length of hospital stay, pain scores, and other aspects were compared among the three groups. Differences in liver function, inflammatory factors, and postoperative complications were also compared among the three groups. RESULTS: There were no significant differences among the three groups in terms of sex, age, BMI, or other general data preoperatively (P > 0.05). There were significant differences between the primary closure group and the T-tube drainage group in terms of surgical time and pain scores (P < 0.05). The primary closure group and double J-tube drainage group differed from the T-tube drainage group in terms of length of hospital stay, hospitalization expenses, and time to passage of gas (P <0.05). Among the three groups, there were no statistically significant differences in inflammatory factors or liver function, TBIL, AST, ALP, ALT, GGT, CRP, or IL-6, before surgery or on the third day after surgery (P > 0.05). However, on the third day after surgery, liver function in all three groups was significantly lower than that before surgery (P<0.05). In all three groups, the levels of CRP and IL-6 were significantly lower than their preoperative levels. The primary closure group had significantly lower CRP and IL-6 levels than did the T-tube drainage group (P < 0.05). The primary closure group differed from the T-tube drainage group in terms of the incidences of bile leakage and electrolyte imbalance (P < 0.05). The double J-tube drainage group differed from the T-tube drainage group in terms of the tube dislodgement rate (P < 0.05). CONCLUSION: Although primary closure of the bile ducts has clear advantages in terms of length of hospital stay and hospitalization expenses, it is associated with a higher incidence of postoperative complications, particularly bile leakage. T-tube drainage and double J-tube internal drainage also have their own advantages. The specific surgical approach should be selected based on the preoperative assessment, indications, and other factors to reduce the occurrence of postoperative complications.

Cholecystectomy in Mild and Moderate Acute Pancreatitis: A Retrospective Study.

Background: Cholecystectomy has been a subject of debate regarding its timing and utility in cases of mild and moderately severe acute pancreatitis (AP). We aimed to critically evaluate the role of early cholecystectomy in the management of mild and moderate AP, considering patient's characteristics, associated procedures, and overall impact on patient outcomes. Methods: The study compared the outcomes between patients admitted in a tertiary care surgical center undergoing early ( 96h) versus delayed ( 96h) laparoscopic cholecystectomy (LC) for mild and moderately severe acute gallstone pancreatitis between January 2019 and December 2022. Results: The study included 54 cases [mean (standard deviation) age, 59.4 (16.5) years; 31 (57.4%) years females]. All patients underwent LC, with 29 cases undergoing a two-phase therapeutic regimen for common bile duct (CBD) lithiasis, consisting of endoscopic retrograde cholangiopancreatography followed by sequential LC. The early cholecystectomy group (EC) comprised 17 patients (31.5%), while the delayed cholecystectomy group (DC) included 37 patients (68.5%). EC was significantly correlated with lower length of stay (p-value 0.0001) and significantly lower rate of ERCP usage during perioperative period. Conclusions: EC in the first 4 days after admission provides significant benefits such as prevention of recurrent pancreatitis, reduction in complications, and decreased length of stay for patients with mild and moderately severe AP.

Enhanced Recovery After Surgery in Laparoscopic Cholecystectomy - A Systematic Review.

BACKGROUND AND AIM: Enhanced Recovery After Surgery (ERAS) is a modern concept that aims to improve the perioperative patient care by implementing an evidence-based, patient-centered team approach. This paper aims to analyze the outcome, variations and limits of the ERAS-protocols used for laparoscopic cholecystectomy. Methods: We performed a systematic review on PubMed, Google Scholar, Web of Science to document the outcomes of applying various ERAS protocols in laparoscopic cholecystectomy (LC). After applying the inclusion and exclusion criteria, 8 papers, totaling 1453 patients that underwent LC, were included in the qualitative analysis. ERAS-protocols applied in those studies include various pre-, intra- and postoperative measures intended to boost the surgical recovery of the patients and shorten their hospital stay, without exposing them to hazardous encounters. Results: Patients undergoing laparoscopic cholecystectomy within an ERAS-specific protocol are proven to have lower levels of postoperative pain, nausea and vomiting, with no statistically significant risk of postoperative complications. The postoperative results show that ERAS-laparoscopic cholecystectomy is a feasible and safe procedure, that may shorten the postoperative recovery after LC. Conclusions: Further studies are needed to establish a consensus regarding the perioperative protocol, before implementing ERAS for LC in clinical routine.

Comparison of remimazolam tosilate and propofol during induction and maintenance of general anesthesia in patients undergoing laparoscopic cholecystectomy: a prospective, single center, randomized controlled trial.

BACKGROUND: Remimazolam tosilate (RT) is a new, ultrashort-acting benzodiazepine. Here, we investigated the efficacy and safety of RT for general anesthesia in patients undergoing Laparoscopic Cholecystectomy (LC). METHODS: In this study, 122 patients undergoing laparoscopic cholecystectomy were randomly allocated to receive either remimazolam tosilate (Group RT) or propofol group (Group P). RT was administered as a slow bolus of 0.3 mg kg- 1 for induction, followed by 1.0-2.0 mg kg- 1 h- 1 for maintenance of general anesthesia. Propofol was started at 2 mg kg- 1 and followed by 4-10 mg kg- 1 h- 1 until the end of surgery. The primary outcome was the time to bispectral index (BIS) ≤ 60. The secondary outcome included the time to loss of consciousness (LoC), and the time to extubation. Adverse events were also assessed. RESULTS: A total of 112 patients were recruited for study participation. Among them, the time to BIS ≤ 60 in Group RT was longer than that in Group P (Group RT: 89.3 ± 10.7 s; Group P: 85.9 ± 9.7 s, P > 0.05). While the time to LoC comparing remimazolam and propofol showed no statistical significance (Group RT: 74.4 ± 10.3 s; Group P: 74.7 ± 9.3 s, P > 0.05). The time to extubation in Group RT was significantly longer than that in Group P (Group RT: 16.0 ± 2.6 min; Group P: 8.8 ± 4.3 min, P < 0.001). Remimazolam tosilate had more stable hemodynamics and a lower incidence of hypotension during general anesthesia. CONCLUSIONS: Remimazolam tosilate can be safely and effectively used for general anesthesia in patients undergoing Laparoscopic Cholecystectomy. It maintains stable hemodynamics during induction and maintenance of general anesthesia compared with propofol. Further studies are needed to validate the findings. TRIAL REGISTRATION: Chictr.org.cn ChiCTR2300071256 (date of registration: 09/05/2023).

Comparison of inflammatory markers in low-pressure pneumoperitoneum with deep neuromuscular block versus standard pressure pneumoperitoneum among patients undergoing laparoscopic cholecystectomy for gallstone disease: a randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. METHODOLOGY: This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A-Low-pressure group in which pneumoperitoneum pressure was kept low (8-10 mmHg) with deep Neuromuscular blockade (NMB) and Group B-Normal pressure group (12-14 mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24 h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. RESULTS: Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative-pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6 h and 24 h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. CONCLUSION: Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings.

The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration.

BACKGROUND: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. METHOD: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. RESULTS: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3-5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. CONCLUSION: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.

Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis.

Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.