The Effect of Combined Spinal Epidural Anesthesia on Shoulder Pain in Laparoscopic Extraperitoneal Hernia Surgery.

BACKGROUND: Shoulder pain is a condition that seriously discomforts patients and develops caused by a peritoneal tear in laparoscopic extraperitoneal hernia repair (TEP) surgeries. Although surgeons generally prefer general anesthesia for the TEP technique, many studies have been carried out on the use of regional anesthesia in recent years. In our study, we aimed to investigate the efficacy and safety of the combined spinal/epidural anesthesia (CSEA) method to prevent shoulder pain in the TEP technique. METHODS: The patients who operated with the TEP procedure were divided into 2 groups; SA (group 1) and CSEA (group 2). The 2 patient groups were compared in terms of sex, age, body mass index, duration of surgery, total operation time, patient satisfaction, pain scores, length of hospital stay, adverse effects, intraoperative, and postoperative complications. RESULTS: The number of patients in group 1 was 42 and group 2 was 40. The mean operation time was recorded as 55.9 and 80.2 minutes in groups 1 and 2, respectively, which was statistically significantly shorter in group 1 ( P <0.001). Postoperative pain was significantly less in group 2 for the 4th hour ( P <0.0001) and the 12th hour ( P =0.047). There was no difference between the 2 groups in terms of peritoneal tear ( P =0.860). Intraoperative and postoperative shoulder pain was significantly less in group 2 ( P =0.038, P =0015, respectively). CONCLUSION: CSEA is an effective and safe anesthesia method for preventing shoulder pain that develops after TEP surgeries.

Risk factors affecting benign anastomotic stricture in anterior and low anterior resections for colorectal cancer: a single-center retrospective cohort study.

PURPOSE: Although not as life-threatening as anastomotic leakage, anastomotic stricture reduces the quality of life. The risk factors for such an important life complication have not been revealed. This article examines the risk factors affecting anastomotic strictures due to colorectal cancers. METHODS: Patients who underwent anterior and low anterior resection for colorectal cancer under elective conditions between 2015 and 2021 were included in the study. The patients were divided into two groups, those who developed anastomotic stricture and those who did not. The parameters determined between the two groups were compared, and multivariate analysis of statistically significant parameters was performed. RESULTS: A total of 375 patients were included in the study. The anastomotic stricture was detected in 36 (9.6%) patients. In the multivariate analysis, non-mobilization of the splenic flexure and a proximal clean surgical margin of < 10 cm and a distal surgical margin of < 2 cm were identified as risk factors affecting anastomotic stricture. The risk factor with the highest odds ratio in the development of anastomotic stricture is the non-mobilization of the splenic flexure (p = 0.001, OR 11.375). CONCLUSION: It is recommended that the mobilization of the splenic flexure to reduce the development of strictures. In addition, a clean surgical margin of 10 cm proximally and 2 cm distally and high ligation of the inferior mesenteric artery may reduce the development of stricture.

Risk Factors for Conversion in Laparoscopic Totally Extraperitoneal Inguinal Hernioplasty.

BACKGROUND: Conversion is a surgical concern because the surgical technique can change during surgery. Surprisingly, there is no study in the literature on the causes and risk factors leading to conversion in laparoscopic total extraperitoneal inguinal repair (TEP). There is also no consensus on the prevention and causes of this condition in TEP. The aim of this study was to evaluate the risk factors underlying the development of conversion during TEP. MATERIALS AND METHODS: We recruited 962 consecutive patients who underwent TEP between May 2016 and May 2021. All data were collected retrospectively. The outcomes of patients who converted to open surgery were compared with those without conversion. Multivariate analysis identified independent risk factors for conversion. RESULTS: The overall incidence of conversion was 4.05% (n=39). The median age was 42 years (18 to 83) and body mass index was 25.2 kg/m2 (15.67 to 32.9). Significant clinical factors associated with conversion included old age, American Society of Anesthesiologists (ASA) score, large peritoneal tear (PT), Charlson comorbidity index, previous surgery, large hernial defects, presence of scrotal hernia, and the defect size of inguinal hernia. Multivariate analysis identified independent risk factors for conversion: large hernial defect, large PT, previous lower abdominal surgery, previous hernia surgery, and scrotal hernia. CONCLUSION: Conversion is a minor complication seen during TEP and its incidence varies depending on many factors. Previous lower abdominal surgery and a large PT carries a 6-fold increased risk for conversion from laparoscopic to open surgery during TEP.

Diagnostic Value of Serum Cytokines in Predicting a Complicated Acute Appendicitis.

The diagnostic role of serum cytokines depends on the etiology and pathogenesis of acute appendicitis but the clinical significance of these cytokines in the differential diagnosis of complicated acute appendicitis remains unclear. To investigate the prediction of progression and diagnostic values of interleukin-6, interleukin-1 beta, and tumor necrosis factor-alpha in complicated acute appendicitis. This study was conducted in 100 patients with a definitive diagnosis of acute appendicitis and 20 individuals assigned for the control group. Venous blood was collected to assess biochemical tests, as well as interleukin-6, interleukin-1ß, and tumor necrosis factor-α levels. Serum levels of all parameters were dramatically higher in the complicated group compared with uncomplicated. Duration of hospitalization, rates of postoperative infection, intraabdominal abscess, and re-hospitalization were higher in complicated group. Cut-off points of WBC, CRP, NLR, interleukin-6, interleukin-1ß and tumor necrosis factor-α were 13.5x103/µL, 1.92 mg/dL, 6.09, 23.4 pg/mL, 5.6 pg/mL and 24 pg/mL (p=0.0014, p<0.001, p=0.009, respectively and p<0.001 for the rest). AUC of interleukin-6 was larger than AUCs of all other parameters, suggesting the highest predicting power of interleukin-6 among other parameters. Serum interleukin-6, interleukin-1ß, and tumor necrosis factor-α levels are valuable diagnostic parameters to predict a complicated acute appendicitis.

Comparison of General, Epidural, and Spinal Anesthesia in Laparoscopic TEP (Total Extraperitoneal Repair) for Inguinal Hernia.

PURPOSE: Laparoscopic total extraperitoneal repair (TEP) is one of the most preferred minimally invasive methods for inguinal hernia repair. In our study, we aimed to compare the advantages and disadvantages of general anesthesia (GA), spinal anesthesia (SA), and epidural anesthesia (EA) for TEP operations. MATERIALS AND METHODS: This is a retrospective study involving 221 patients who underwent TEP surgery for inguinal hernia between January 2018 and July 2020. Patients were divided into 3 groups as GA (n=77), SA (n=70), and EA (n=74). Demographic data of the patients, duration of anesthesia and surgery, perioperative and postoperative complications, postoperative pain, anatomical delineation, hospital stay and quality of life were evaluated. RESULTS: Anesthesia time was the longest in the EA group (23.1±2.32 min) and significantly prolonged the operation time (P<0.001). When the visual analog scale scores were compared, it was observed that the patients in the GA group felt significantly more pain (P<0.001). While the rates of hypotension and headache were higher in regional anesthesia (P<0.001 and P<0.002), there was no significant difference in urinary retention, postoperative nausea/vomiting, and shoulder pain (P=0.274, 0.262, and 0.314, respectively). SA and EA groups were found to be superior compared with the GA group in terms of patient satisfaction (P<0.001). CONCLUSION: Regional anesthesia (SA and EA) can be safely performed in TEP surgeries, gives results similar to the anatomical delineation satisfactory and complication rates of GA, and results in less postoperative pain.

Treatment of Anastomotic Leaks With EndoVac After Low Anterior Resection in Colorectal Cancers.

INTRODUCTION: Endoscopic drainage should preferably be tried unless the abscess caused by the anastomotic leak is generalized and disseminated into the abdominal cavity. The aim of this study was to evaluate the results of patients treated with EndoVac. PATIENT AND METHODS: The medical records of patients who underwent low anterior resection and were treated using the EndoVac therapy system due to the detection of an anastomotic leak were retrospectively evaluated. RESULTS: Thirty-three of the patients with detection of anastomotic leaks were treated using EndoVac therapy system. The mean number of application of the EndoVac therapy system was 5.8 (1 to 12) for each patient. Mean duration of hospitalization of the patients was 24.5 (9 to 92) days. Five patients underwent a second operation during the follow-up period after application of the EndoVac therapy system. In our study, the number of patients recovering without the need for additional treatment is 30 (30/33). Our success rate was 90.1%. CONCLUSIONS: The EndoVac therapy system is an alternative and helpful system in the treatment of colorectal anastomotic leaks without reoperation needed. It can also prevent permanent stoma.

Is early anvil placement an alternative technique to reduce anastomotic leak after rectosigmoid cancer resection?

INTRODUCTION: Anastomotic leakage (AL) is one of the most disastrous complications after rectosigmoid cancer operations. The aim of this study is to investigate the effect of the insertion time of circular stapler anvil on assessing the blood supply of the proximal colon segment, and thus to evaluate the prevention of early anastomotic leaks. MATERIAL METHODS: A total of 57 patients were included in the study, 25 patients in group A and 32 patients in group B, respectively. From the beginning of the operation to the time of anvil placement in group A, it was 32.08 (± 7.34) minutes, and in group B it was 92.19 (± 16.63) minutes. None of the patients in group A had AL, and 4 patients in group B had AL. DISCUSSION: Our study shows that the anvil must be placed at the beginning of the dissection to evaluate the anomalies that cause anastomotic leaks. We think that this method increases the reliability of the anastomosis line. Thus, the hospitalization period of the patients was shortened and they returned to their active lives faster. In addition, patients used less antibiotics and they needed less medical treatment. KEY WORDS: Anastomotic leaks, Anvil, Rectosigmoid cancer placement, Stapler colorectal.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience.

PURPOSE: Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD. METHODS: The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed. RESULTS: There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively). CONCLUSIONS: CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Effects of COVID-19 pandemic on general surgical emergencies: are some emergencies really urgent? Level 1 trauma center experience.

PURPOSE: The aim of this paper is to investigate the effect of COVID-19 pandemic on general surgical emergencies as well as analyzing the effectiveness of measures taken in reducing the incidence of COVID-19 in patients and healthcare professionals. METHODS: Patients who underwent emergency surgery between the pandemic period of March 14th to May 15th 2020 and within the same period from the previous year were reviewed retrospectively. COVID-19 incidence in patients and health professionals working in the general surgery department during these periods was questioned. RESULTS: Demographic data were similar between the two time periods. The number of patients who underwent surgery in the pandemic group (n = 103) was lower than the control group (n = 252). There was a 59.1% reduction in emergency surgeries. The biggest decreases were the admissions of incarcerated hernia, uncomplicated appendicitis and acute cholecystitis (92%, 81.3%, 47.3%, respectively). During the pandemic, an increase was of patient rates who underwent surgery for complicated appendicitis and AMIO (p = 0.001, p = 0.019, respectively). The rate of mortality was higher in patients who underwent emergency surgery during pandemic (p = 0.049). The results of COVID-19 screening were positive in 6 (6/103, 5.82%) patients undergoing emergency surgery. None of the doctors working in the ward were infected with COVID-19 infection (0/20). The screening tests were positive in only two nurses working on the ward (2/24, 8.33%). CONCLUSION: In this and similar pandemics, we suggest that a new algorithm is necessary to approach emergencies and the results of this study can contribute to that end.

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair Under Epidural Anesthesia Versus General Anesthesia.

INTRODUCTION: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair. The present study aims to compare the advantages and disadvantages of the TEP technique under general anesthesia (GA) and epidural anesthesia (EA). MATERIALS AND METHODS: The patients were divided into 2 groups as those undergoing TEP under EA (Group 1) and those undergoing TEP under GA (Group 2). The 2 patient groups were compared in terms of sex, age, body mass index data, duration of surgery, total operation time, patient satisfaction, VAS scores (1, 4, 12, and 24 h), length of hospital stay, and postoperative complications. RESULTS: The number of patients operated under EA (Group 1) was 30, and the number of patients operated under GA (Group 2) was 32. Only in the postoperative first hour VAS scores was statistically significantly less and the need for analgesia evaluated in both groups was found to be statistically significantly lower in Group 1 (P<0.001). The mean operation time was recorded as 62 and 46.50 minutes in Groups 1 and 2, respectively, which was statistically significantly shorter in Group 2 (P<0.001). There was no difference between the 2 groups regarding complications, hospital stay, recovery, or surgery time. Conversion rate is 0 in both groups. CONCLUSIONS: Lower postoperative VAS scores and lower postoperative VAS scores and lower analgesic used requirements of EA, it is thought that EA can be safely applied in the TEP procedure as an alternative in patients who cannot be administered GA.

High-Volume, Low-Concentration Intraperitoneal Bupivacaine Study in Emergency Laparoscopic Cholecystectomy: A Double-Blinded, Prospective Randomized Clinical Trial.

Background. Laparoscopic cholecystectomy (LC) often results in postoperative pain, especially in the abdomen. Intraperitoneal local anesthesia (IPLA) reduces pain after LC. Acute cholecystitis-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent LC with IPLA application. The aim was to determine the postoperative analgesic efficacy of high-volume, low-dose intraperitoneal bupivacaine in urgent LC. Materials and Methods. Fifty-seven patients who were American Society of Anesthesiologists physical status I or II were randomly assigned to receive either normal saline (control group) or intraperitoneal bupivacaine (test group) at the beginning or end of urgent LC. The primary outcome was the postoperative pain score of the Visual Analogue Scale (VAS). The secondary outcomes included Visual Rating Prince Henry Scale (VRS), patient satisfaction, and analgesic consumption. Results. Postoperative VAS scores at the first and fourth hours were significantly lower in the test group than in the control group (P < .001). Postoperative VRS scores at the first, fourth, and eighth hours were significantly lower in the test group than in the control group (P < .001, P = .002, P = .004, respectively). Analgesic use was significantly higher in the control group at the first postoperative hour (P < .001). Shoulder pain was significantly lower, and patient satisfaction was significantly higher in the test group relative to the control group (both P < .001). Conclusion. High-volume, low-concentration intraperitoneal bupivacaine resulted in better postoperative pain control and reduced incidence of shoulder pain and analgesic consumption in urgent LC.

Outcomes of laparoscopic sleeve gastrectomy by means of esophageal manometry and pH-metry, before and after surgery.

INTRODUCTION: Gastroesophageal reflux is a major problem after sleeve gastrectomy. There is still insufficient understanding of how it occurs and whether it is due to the sphincter length, relaxation, or pressure differences. AIM: This study evaluates the effect on the lower esophageal sphincter of the laparoscopic sleeve gastrectomy (LSG) technique applied in surgery in cases of morbid obesity using ambulatory 24-h pH monitoring (APM) and esophageal manometry (EM). MATERIAL AND METHODS: A retrospective examination was carried out on the APM and EM tests performed preoperatively and postoperatively in cases of LSG. The parameters examined were the body mass index (BMI), amplitude pressure of the esophagus (AP), total length of the lower esophageal segment (LESL), resting pressure of the LES (LESP), residual pressure of the LES (LESR), relaxation time of the LES, intragastric pressure, and the DeMeester score. RESULTS: A total of 62 cases with available data were evaluated. A statistically significant difference was determined between the preoperative values and the 3-month postoperative values of BMI, LESP, and relaxation time of the LES. A statistically significant increase was determined in the DeMeester score, and the increase in the total number of reflux episodes longer than 5 min was found to be the most responsible for this increase. No significant difference was determined in the other parameters. CONCLUSIONS: The LSG was found to cause a reduction in LESP, and an increase in acid reflux causing an extended relaxation time of the LES. This was confirmed by the increase seen in the DeMeester score.

Laparoscopic Lavage Versus Aspiration Alone in Perforated Acute Appendicitis: A Prospective Randomized Controlled Study.

The optimal method for preventing abscesses in perforated appendicitis is unclear. We compared the efficacy of lavage versus aspiration for periappendicular collections/abscesses in perforated appendicitis. Our study included 286 patients. After the removal of the appendectomy material, those who underwent aspiration without prior lavage were assigned to Group I, whereas those who underwent aspiration after lavage with 500 mL physiological saline were assigned to Group II. The primary outcome measure was postoperative complications. Secondary outcome measures were intraoperative complications, morbidity, and mortality. Group I comprised 174 patients (60 female and 114 male; mean age 34.47±17.40 y), whereas Group II comprised 112 patients (39 female and 73 male; mean age 36.22±18.60 y). The 2 groups were not significantly different in age, hospitalization duration, sex, abscess formation, morbidity, or mortality. Our results demonstrate that aspiration of the surgery area without prior lavage is sufficient and can be safely applied in perforated appendicitis.

The importance of defecography in the assessment of the etiology of chronic constipation: An analysis of 630 patients.

OBJECTIVE: Chronic constipation is an entity with a high prevalence in the community. In our study, we analyzed the importance of defecography in the assessment of the etiology of chronic constipation. MATERIAL AND METHODS: Patients who were admitted to our hospital outpatient general surgery clinic with complaints of constipation between July 2010 and January 2014, and who had their demographic data and defecography results recorded were included in the study. The demographic data of patients who underwent defecography and their results were recorded along with patient gender and age. RESULTS: The defecography was abnormal in 573 patients (90.9%) while it was normal in 57 patients (9.1%). CONCLUSION: Defecography is the current standard method of examination in etiological investigations for constipation, and it should be performed in each patient with a diagnosis of chronic constipation.