Direct Trocar Insertion: an Efficient Access Technique for Laparoscopic Cholecystectomy

Aim: To evaluate the feasibility and safety of direct trocar insertion for gaining access to peritoneal cavity in laparoscopic cholecystectomy. Methods: An Observational study was conducted at Surgical unit II Ghulam Mohammad Mahar Medical College Hospital Sukkur from January 2016 to December 2020. Two thousand one hundred twenty (n=2120) patients were included in the study. All the patients who underwent laparoscopic cholecystectomy were included in the study. Informed and written consent was obtained from every patient to participate as study subject. Data was analyzed on SPSS version 16. Mean +/- standard deviation was calculated for age, first port access time and time to establish pneumoperitoneum. Results: Under general anesthesia with patient in supine posture, abdominal access gained by first making small incision of 10mm in skin and subcutaneous fat at sub umbilical region with No. 11 scalpel and then by direct trocar insertion followed by creation of pneumoperitoneum. Cholecystectomy performed. Study variables included first port access time, no. of attempts for DTI, extraperitoneal CO2 insufflation, port site bleeding, visceral injury, port site infection and port site hernia and were recorded on predesigned proforma. Variables like extraperitoneal CO2 insufflation, port site bleeding and visceral injury were expressed as percentage. Conclusion: We conclude that direct trocar insertion is the safe, quick and effective method for creation of pneumoperitoneum and should be employed routinely in all laparoscopic procedures. Keywords: Laparoscpy, Cholecystectomy, Trocars

Effect of Neuromuscular Blockade on Intraoperative Respiratory Mechanics and Surgical Space Conditions during Robot-Assisted Radical Prostatectomy: A Prospective Randomized Controlled Trial

The aim of this study was to investigate whether deep neuromuscular blockade (NMB) may affect intraoperative respiratory mechanics, surgical condition, and recovery profiles in patients undergoing robot-assisted radical prostatectomy (RARP). Patients were randomly assigned to the moderate or deep NMB groups. Pneumoperitoneum was maintained with carbon dioxide (CO2) insufflation at 15 mmHg during surgery. The primary outcome was peak inspiratory pressure (PIP) after CO2 insufflation. Mean airway pressure (Pmean) and dynamic lung compliance (Cdyn) were also recorded. The surgeon rated the surgical condition and surgical difficulty on a five-point scale (1 = extremely poor; 2 = poor; 3 = acceptable; 4 = good; 5 = optimal). Recovery profiles, such as pulmonary complications, pain scores, and recovery time, were recorded. We included 58 patients in this study. No significant differences were observed regarding intraoperative respiratory mechanics including PIP, Pmean and Cdyn, between the two groups. The number of patients with optimal surgical conditions was significantly higher in the deep than in the moderate NMB group (29 vs. 20, p = 0.014). We found no differences in recovery profiles. In conclusion, deep NMB had no significant effect on the intraoperative respiratory mechanics but resulted in optimal endoscopic surgical conditions during RARP compared with moderate NMB.

The endoscopic no-touch saphenous vein harvesting technique

The no-touch saphenous vein harvesting technique is being increasingly used; however, this technique causes more leg wound complications than conventional techniques. Endoscopic saphenous vein harvesting is considered a safe and effective approach for reducing leg complications, despite the fact that experience with this technique remains limited, because leg CO2 insufflation and dissection with a tip cannula to isolate the vein enables the graft to naturally skeletonize. In this video tutorial, we demonstrate our endoscopic no-touch saphenous vein harvesting technique using a reusable saphenous vein retractor system without CO2 insufflation and an electrothermal bipolar vessel sealing device.

Is It the pH That Matters? Challenging the Pathophysiology of Acidemia in a Case of Severe Hypercapnia Secondary to Intraoperative CO2 Insufflation

Background. Acidemia has been long thought to lead to hemodynamic compromise. While some literature to date challenges this idea, there is no consensus on this topic. Case Summary. To our knowledge, this is the most severe case of hypercapnia and acidosis due to carbon dioxide (CO2) insufflation during laparoscopy reported in the literature. Remarkably, this patient remained hemodynamically normal despite having a blood pH below 6.81. This prompts a wider discussion about the effects of blood pH on human physiology. Most patients who present acidotic are critically ill and have confounding underlying metabolic or respiratory pathophysiology driving their illness. In this case, the patient experienced no respiratory insult leading to an increase in blood CO2 but rather had CO2 iatrogenically introduced into the circulatory system, effectively detaching the deleterious effects of CO2 from the respiratory pathologies that so often cause its accumulation. Conclusion. This raises the question, in patients with severe acidosis and hemodynamic compromise, is acidosis a symptom of the underlying process, or is the acidosis itself causing harm?

Pregabalin As A Premedicant To Attenuate Pressor Response In Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

The present study was done to evaluate the ability of oral pregabalin to attenuate the pressor response to airway instrumentation in patients undergoing laparoscopic cholecystectomy under general anesthesia. Sixty-four adult patients aged between 25-55 year of either gender belonging to ASA-1 or ASA2 physical status weighing 50-70 kg were enrolled in this study. Thirty-two patients each were randomized to group A, or group B. Patients in group A received tablet Pregabalin (150mg) and those in group B received placebo orally one hour before induction of anaesthesia. Heart rate, blood pressure, and sedation were assessed preoperatively before giving the tablets and after 30 minutes, and just before induction of anaesthesia. Intraoperative, pulse rate, mean arterial pressure, ECG in the lead II, SPO2 and ETCO2 were monitored. All the above parameters were noted during laryngoscopy and intubation, 3 minutes after CO2 insufflation, and then at every 10-minute interval till the end of surgery. These parameters were also recorded after extubating the patient. The Ramsay sedation scale was used to assess the sedation at the baseline, one hour after drug intake , one hour after extubation and 4 hour after surgery. Any adverse effects in the postoperative period were recorded. The result of our study shows that pre-emptive administration of oral pregabalin 150 mg significantly reduced the pressor response at the time of laryngoscopy and intubation, after CO2 insufflation and just after extubation. We conclude that oral pregabalin premedication is effective in successful attenuation of hemodynamic pressor response to laryngoscopy, intubation and pneumoperitoneum in patients undergoing laparoscopic cholecystectomy