Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial.

OBJECTIVE: We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers. BACKGROUND: The standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12-14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines. METHODS: A prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8-10 mmHg) vs. standard-pressure (12-14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed. RESULTS: one hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs. 6, p-value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons. CONCLUSION: low-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).

Is pneumothorax secondary to pneumoperitoneum a real risk in dogs undergoing total laparoscopic gastropexy?

Background: There were described in veterinary literature, the possibility of pneumothorax as a complication of laparoscopic surgery in dogs undergoing laparoscopic ovariectomy associated with total laparoscopic gastropexy. Aim: To assess if spontaneous pneumothorax secondary to pneumoperitoneum is a real risk in dogs undergoing total laparoscopic gastropexy. Methods: Dogs undergoing totally laparoscopic gastropexy received chest X-rays (CXR) in lateral (left and right) and ventro-dorsal projection before and after the surgery. Two veterinary radiologists reported the x-rays and indicated the presence or not of pneumothorax. Results: Postoperative pneumothorax was not detected on postoperative CXR in the total of 76 dogs of the study. Conclusion: The odds risk of pneumothorax after total laparoscopic gastropexy surgical procedure is low.

Effect of ultrasound-guided lung recruitment manoeuvre on perioperative atelectasis during laparoscopy in young infants: A randomised controlled trial.

BACKGROUND: Pneumoperitoneum is a risk factor for perioperative atelectasis in infants. This research aimed to investigate whether lung recruitment manoeuvres guided by ultrasound are more effective for young infants (<3 months) during laparoscopy under general anaesthesia. METHODS: Young infants (<3 months) undergoing general anaesthesia during laparoscopic surgery (>2 h) were randomised to either conventional lung recruitment (control group) or ultrasound-guided lung recruitment (ultrasound group) once per hour. Mechanical ventilation was started with a tidal volume of 8 mL·kg-1, positive end-expiratory pressure of 6 cm H2O and 40% inspired oxygen fraction. Lung ultrasound (LUS) was performed four times (T1 was performed 5 min after intubation and before pneumoperitoneum set, T2 was performed after pneumoperitoneum, T3 was performed 1 min after surgery, and T4 was performed before being discharged from post-anaesthesia care unit [PACU]) in each infant. The primary outcome was the incidence of significant atelectasis at T3 and T4 (defined by LUS consolidation score ≥ 2 in any region). RESULTS: 62 babies were enrolled in the experiment and 60 infants were included in the analysis. Before the recruitment, atelectasis was similar between infants randomised to the control or ultrasound group at T1 (83.3% vs 80.0%; P = 0.500) and T2 (83,3% vs 76.7%; P = 0.519). The incidence of atelectasis at T3 and T4 were lower in the ultrasound group (26.7% and 33.3%), compared with infants randomised to conventional lung recruitment (66.7% and 70%) (P = 0.002; P = 0.004; respectively). CONCLUSIONS: Ultrasound-guided alveolar recruitment reduced the perioperative incidence of atelectasis in infants <3 months during laparoscopy under general anaesthesia.

Effect of expiratory flow limitation on ventilation/perfusion mismatch and perioperative lung function during pneumoperitoneum and Trendelenburg position.

BACKGROUND: Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch. METHODS: This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until seven days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs). RESULTS: Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; P<0.001). CONCLUSIONS: Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study.

BACKGROUND: Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. METHODS: Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg-1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. RESULTS: Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p = 0.55). CONCLUSION: This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: a systematic review and meta-analysis.

Robotic-assisted laparoscopic radical prostatectomy (RARP) has been traditionally performed at a pneumoperitoneum insufflation pressure of 12-15 mmHg. This meta-analysis and systematic review aims to assess the current evidence comparing lower to standard pressure pneumoperitoneum in RARP. Systematic searches of MEDLINE, COCHRANE, SCOPUS and EMBASE were performed to identify articles published up until November 2021 comparing lower pressure with standard pressure pneumoperitoneum in RARP. Standard pressure was defined as > 12 mmHg and lower pressure ≤ 12 mmHg. Estimated blood loss, length of operation, length of hospital stay, post-operative ileus, 30-day readmissions, Clavien-Dindo complications and rate of positive surgical margins were extracted as endpoints of interest. Our searches identified 165 abstracts of which 4 articles with 1319 patients were eligible. Cumulative analysis demonstrated reduced length of stay when a lower pressure was used: WMD - 0.23 (- 0.45 to - 0.02) days (p = 0.03) as well as a reduced rate of post-operative ileus: OR 0.41 (0.22 to 0.77) (p = 0.006). There was no significant increase in length of operation WMD - 1.79 (- 15.96 to 12.38) (p = 0.8), estimated blood loss WMD - 2.89 (- 29.41 to 23.62) (p = 0.83), 30-day readmissions or positive surgical margins OR 1.04 (0.78 to 1.38) (p = 0.81) and RD - 0.01 (- 0.04 to 0.01) (p = 0.3) when using a lower pressure. We have demonstrated reduced length of stay and rates of post-operative ileus, when performing RARP at a lower pressure without a significant increase in length of operation, estimated blood loss, positive surgical margins or complications. The recommendation to use lower pressure pneumoperitoneum is moderate to weak and more randomised control trials are required to validate these results.

Application of comprehensive score of risk factors to determine the best time for surgical intervention in neonatal necrotizing enterocolitis.

AIM: Necrotizing enterocolitis (NEC) is a severe digestive systemic disease. Surgery is critical treatment for NEC patients. However, it is still hard to predict the optimal timing of surgery. Our study aimed to explore the indicative effect of comprehensive risk factors method in surgical intervention in NEC patients. METHODS: Retrospective analysis was made on newborns with NEC, who were divided into group I (patients with NEC conservative therapeutic approach or no necrosis or perforation found in NEC operation) and group II (patients with necrosis or perforation found in NEC operation or failure of NEC conservative approach). Clinical manifestations and complications were recorded and the risk factors scores were calculated. The receiver operating characteristic curve and Youden index were calculated. RESULTS: One hundred and six NEC patients in Huizhou Central People's hospital were analysed. Significant difference was observed in the comprehensive scores of the two groups to judge the indications of NEC surgery. Among the risk factors of NEC surgery, the incidence specificity of abdominal induration, abdominal tenderness, hypotension and pneumoperitoneum was 100% in group II. The area under the curve of the comprehensive score of risk factors was 0.981 (95% confidence interval 0.958-1.000). The best cutoff value obtained by the maximum Youden index is 3.5 (sensitivity 97.2%; specificity 52.8%). When the specificity is 100%, the best interception value is 7.5 (sensitivity 91.4%; specificity 100%). Complications such as surgical intervention, mortality, stenosis after conservative treatment, perforation or necrosis during surgery were significantly different in different comprehensive scores. CONCLUSIONS: Abdominal induration, abdominal tenderness, hypotension and pneumoperitoneum are independent predictors of NEC surgery. Comprehensive risk factors score may be a potentially useful clinical decision-making tool for NEC surgery.

An analysis of feasibility of robotic colectomy: post hoc analysis of a phase III randomised controlled trial.

With global expansion of robotic surgery, there is increasing interest in its application in colonic surgery. This study aimed to report the feasibility of robotic assisted colonic resection as a post hoc analysis of a randomised controlled trial (RCT) by comparing outcomes following laparoscopic and robotic colectomy. The PAROS trial was a phase III RCT that compared outcomes in low pressure (LP, 7 mmHg) and standard pressure (SP, 12 mmHg) pneumoperitoneum in elective colectomy. A post hoc analysis was performed to compare clinical and operative outcomes in laparoscopic and robotic colonic resection in a high volume colorectal surgery practice. A health economic comparison was also performed. Data were analysed using IBM SPSS StatisticsTM, version 20. 127 patients were compared [34% (n = 43) robotic, 66% (n = 84) laparoscopic]. LP pneumoperitoneum was practiced in 47% (n = 20) robotic and 50% (n = 42) laparoscopic cases. Cancer procedures were more commonly performed in the robotic group (p = 0.009). Clinical outcomes were comparable including post-operative surgical complications (p = 0.493). Operative times were longer (p = 0.005) but length of hospital stay (LOS) was one day shorter in the robotic group (p = 0.05). Conversion to SP pneumoperitoneum was required in 9.5% (n = 8) of the LP laparoscopic group compared to 2.3% (n = 1) of the LP robotic group. Surgeons reported good operative visibility in all robotic cases and 94% (n = 80) laparoscopic cases. Considering, capital investment and maintenance, instrumentation and LOS, robotic cases were €651 more expensive per case. Robotic-assisted surgery is feasible in colonic resection and may facilitate shorter LOS and the possibility to complete MIS using low pressure pneumoperitoneum.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review.

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

Abstract Background Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. Methods Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. Results Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p= 0.55). Conclusion This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Bariatric surgery: to bleed or not to bleed? This is the question.

BACKGROUND: Bariatric surgery procedures are the most successful and durable treatment for morbid obesity. Hemorrhage represents a life-threatening complication, occurring in 1.3-1.7% of bariatric surgeries. MATERIALS AND METHODS: We examined patients undergoing Bariatric Surgery from July 2017 to June 2020 (Group A) and those operated from July 2020 to June 2022 (Group B) in our Department. Starting from July 2020 we have implemented intraoperative measures to prevent postoperative bleeding, increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneal pressure of CO2 to 8 mmHg in the last 15 min of the operation. RESULTS: The study gathered 200 patients divided into the two described groups. The mean age of Group A is 44 ± 8.49 and 43.73 ± 9.28. The mean preoperative BMI is 45.6 kg/m2 ± 6.71 for Group A and 48.9 ± 7.15 kg/m2 for Group B. Group A recorded a mean MAP of 83.06 ± 18.58 mmHg and group B a value of 111.88 ± 12.46 mmHg (p value < 0.05 and z-score is 4.15226 and the value of U is 13,900). We observed 9 cases of bleeding in group A, most of them being treated with medical therapy and transfusions; only 1 hemodynamically unstable patient underwent re-laparoscopy. We reported only 2 cases of bleeding in group B, one of which required blood transfusions. CONCLUSION: From our study we can conclude that increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneum pressure of CO2 to 8 mmHg in the last 15 min of the operation led to a decrease in bleeding cases in group B and, most importantly, all the bleedings were easily controllable with medical therapy and/or transfusions. These measures allowed us to reduce postoperative bleeding.

Clinical Application of Peritoneal Dialysis Catheterization without Capsular Puncture Technique.

Objective: To summarize the advantages of peritoneal dialysis (PD) catheters without capsular puncture (only one pneumoperitoneum needle) puncture technique conducted by our center. Methods: The study examines the clinical data of PD patients (including the general situation of patients, intraoperative and postoperative characteristics, and complications) undergoing pneumoperitoneum needle catheterization from January 2019 to May 2021 in the Department of Nephrology at the First Affiliated Hospital of Hebei North University (the largest peritoneal dialysis center in Zhangjiakou). Results: A total of 153 surgical cases were collected. There were 91 males and 62 females. The mean (± standard deviation) age was 56.1 ± 18.6 years, and the mean (± standard deviation) follow-up time was 16.7 ± 8.2 months. The average operation time was 30.33 minutes with a standard deviation of 14.80 minutes. The length of abdominal incision is 2.38 ± 0.42 cm, and the blood loss was about 26.3 ± 9.2 ml, including 2 cases of laparoscopic reposition of drift tube, 0 case of pipe blockage, 3 cases of fluid leakage, 1 case of peritoneal dialysis catheter tunnel infection, 4 cases of outlet infection, 12 occurrences of peritonitis, 121.3 patient months in peritonitis, and 0 times in omentum wrapping without bladder injury, incisional hernia, or intestinal injury. Conclusion: Relative to open operation, the peritoneal dialysis (PD) catheters with pneumoperitoneum needle puncture technique has the following advantages: simpler operation, shorter operation time, less bleeding, less injury, less complications, and higher safety. Moreover, there are no additional costs compared with open operation. Thus, the technique is recommended for clinical applications.

The impact of low-pressure pneumoperitoneum on robotic-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion: a case-control study.

PURPOSE: To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD). METHODS: A retrospective case-control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system. RESULTS: Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar. CONCLUSION: With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum.

Pneumothorax, Pneumomediastinum, and Pneumoperitoneum After Combined Abdominoplasty and Liposuction: Rare Adverse Events.

ABSTRACT: Liposuction is a relatively safe surgical procedure, with most complications being minor in nature. However, there are a few life-threatening complications that should not be underestimated. We present a case of a patient who developed bilateral pneumothoraces, pneumomediastinum, and pneumoperitoneum after combined liposuction and abdominoplasty. Although this presentation is rare, clinicians should keep a high index of suspicion in patients presenting with shortness of breath, chest pain, and/or abdominal pain after liposuction.

Comparison of Changes in the Optic Nerve Sheath Diameter Following Thoracic Epidural Normal Saline Injection in Laparoscopic Surgery.

BACKGROUND: Thoracic epidural analgesia is useful for postoperative pain control after upper abdominal surgery. However, epidural analgesia in patients undergoing laparoscopic surgery may potentiate an increase in intracranial pressure (ICP). ICP can be effectively evaluated by measuring the optic nerve sheath diameter (ONSD). OBJECTIVES: The purpose of this study is to investigate changes in the ONSD following thoracic epidural normal saline injection during laparoscopic surgery. STUDY DESIGN: Prospective randomized trial. SETTING: An interventional pain management clinic in South Korea. METHOD: This study included 60 patients receiving thoracic epidural catheterization for postoperative pain control following laparoscopic or open gastrectomy. Patients were divided into 3 groups. The open group consisted of patients undergoing open gastrectomy without epidural normal saline injection. The lapa-saline and lapa groups consisted of patients undergoing laparoscopic gastrectomy with and without 10 mL epidural normal saline injection, respectively. The ONSD was measured using ultrasound at 4 time points. RESULTS: The lapa-saline group showed the most pronounced increase in the ONSD compared to the open and lapa groups at the time points of T1 and T2. Only the lapa-saline group demonstrated 4 patients with ONSD values of more than 5.8 mm. The increase in the ONSD continued even after the deflation of pneumoperitoneum in the lapa-saline group, whereas the ONSD in the lapa group returned to near baseline value after the deflation of pneumoperitoneum. LIMITATIONS: Epidural normal saline was injected instead of a local anesthetic to prevent the occurrence of hypotension. However, the injection of epidural normal saline is considered to be the same physiological condition causing elevation of ICP compared with epidural injection with local anesthetics. CONCLUSIONS: The lapa-saline group showed the most pronounced increase in the ONSD. The ONSD values higher than 5.8 mm were observed only in the lapa-saline group. The increase in the ONSD continued even after the deflation of pneumoperitoneum only in the lapa-saline group.

Recurrent spontaneous pneumoperitoneum secondary to intestinal dilatation caused by allied disorders of Hirschsprung's disease: a case report.

BACKGROUND: Allied disorders of Hirschsprung's disease (ADHD) mainly present with bowel obstruction, intestinal dilatation, and chronic constipation, while recurrent spontaneous pneumoperitoneum was rarely reported. We aimed to report a case of recurrent spontaneous pneumoperitoneum caused by ADHD. CASE PRESENTATION: A 59-year-old female patient presented with progressive and severe constipation in the past 30 years. She suffered from abdominal discomfort, which was described as 'gurgling' during the last three years. Radiography showed free-air and intestinal dilatation, without any other diseases, and she was identified with recurrent spontaneous pneumoperitoneum. Gastrointestinal transit test indicated gastrointestinal motility disorder, and anorectal manometry confirmed the presence of rectal anus-suppressing reflex. Subtotal colectomy was performed to relieve apparent constipation, and the postoperative pathological examination of the colon demonstrated proliferation of nerve fibers and hyperplasia of myenteric plexuses, as well as a relatively scarcity of ganglion cells in the myenteric plexus. Based on the presentations and the postoperative pathology, she was diagnosed with ADHD. The recurrent spontaneous pneumoperitoneum was regarded as the gas escape from dilated intestines, which was in high pressure. All the symptoms and her mental state were improved after the treatment with gastrointestinal decompression and enteral nutrition. However, during follow-up visits, she had intestinal infection, and suffered from severe diarrhea and water-electrolyte imbalance, and the patient eventually died at 17 months after the diagnosis. CONCLUSION: ADHD could be a rare cause of recurrent spontaneous pneumoperitoneum, and are mainly undiagnosed or misdiagnosed. A full-thickness biopsy of the gastrointestinal tract (especially the small intestine and sigmoid colon) and differential diagnosis are recommended for the definitive diagnosis. While the ADHD have shown a poor prognosis, timely and long-term treatment with intestinal decompression and nutritional therapy could help relieve symptoms and provide a better quality of life for such patients.

Active aspiration versus simple compression to remove residual gas from the abdominal cavity after laparoscopic cholecystectomy: a randomized clinical trial.

PURPOSE: After laparoscopic surgical procedures, residual gas in the abdominal cavity can cause post-operative pain, which is commonly located in the shoulder region. Previous studies suggested that post-laparoscopy pain can be prevented by active suctioning of intraabdominal gas at the end of surgery. METHODS: This randomized controlled trial (registered at DRKS 00,023,286) compared active suctioning versus manual compression in their ability to reduce pain after laparoscopic cholecystectomy. Patients scheduled for laparoscopic cholecystectomy were eligible for trial participation. The primary outcome measure was post-operative pain intensity after 12 h. All the patients were examined by MRI scanning to quantify the intraabdominal gas volume after the intervention. RESULTS: As planned, 60 patients were recruited. The two groups (n = 30 each) were very similar at the end of surgery. Active suctioning reduced the amount of residual pneumoperitoneum more than simple compression (median volume 1.5 versus 3.0 ml, p = 0.002). The primary outcome measure, abdominal pain after 12 h, was slightly lower in the intervention group (- 0.5 points, 95% confidence interval + 0.5 to - 1.7), but without reaching statistical significance (p = 0.37). After 12 h, shoulder pain was present in 10 patients in each group (p = 1.0). Independent of group assignment, however, residual gas volume was significantly associated with higher pain intensity. CONCLUSIONS: Active suctioning appears to have only a minor preventive effect on post-laparoscopy pain, probably because evacuation of the pneumoperitoneum remains incomplete in some patients. Other more effective maneuvers for gas removal should be preferred.