Comparison of the stress response after laparoscopic and open cholecystectomy

Background: We designed a prospective controlled animal study to compare the stress response induced after laparoscopic and open cholecystectomy. Methods: Twelve female pigs (20–25 kg body weight) were anesthetized with ketamine, pentobarbital, and fentanyl. The animals were randomized into the following four groups: control (C), pneumoperitoneum with CO₂ at 14–15 mmHg (P), laparoscopic cholecystectomy (LC), and open cholecystectomy (OC). The average duration of the procedure in each group was 35 min. Results: Central venous pressure, mean arterial pressure, pulmonary capillary wedge pressure, and cardiac output were monitored. Measurements were recorded when animals were anesthetized (baseline), immediately before and after surgery, and thereafter every 30 min for a maximum of 3 h. White blood cell count (WBC) was determined from blood samples taken before and after 3 h of surgery. Ultrasound-guided liver biopsies were done preoperatively and after 3 h of surgery. Total RNA was isolated from the liver biopsy specimens. Steady-state mRNA levels of β-fibrinogen (β-fib), α 1-chymotrypsin inhibitor (α1-CTI), metallothionein (MT), heat shock protein 70 (Hsp70), and polyubiquitin (Ub) were detected by Northern blot/hybridization. There were no statistical differences in the hemodynamic parameters among the groups. The number of circulating neutrophils and monocytes decreased only after LC. Expression of Hsp70 was not induced after any surgical procedure, and the mRNA levels of Ub did not change after surgery. The expression of α1-CTI and β-fib (acute phase genes) were similarly increased after LC and OC. Steady-state mRNA levels of MT were slightly increased after P and LC but not after OC. Conclusion: These data indicate that there are no significant differences between LC and OC in terms of induction of the stress response. Received: 19 March 1999/Accepted: 2 July 1999/Online publication: 20 September 2000     

Incisional hernias after laparoscopic vs open cholecystectomy

Background: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. Methods: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n= 142) or open cholecystectomy (OC group, n= 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. Results: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. Conclusions: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure. Received: 16 July 1998/Accepted: 27 November 1998     

Laparoscopic cholecystectomy in the elderly

Background: Advanced age with its concomitant comorbid conditions may be associated with increased postoperative laparoscsopic cholecystectomy (LC) complications and more frequent conversion to open cholecystectomy (OC). The purpose of this study was to evaluate the outcome of LC in patients age 65 and older. Methods: Ninety consecutive patients were studied age 65 and older, of whom 39 (43%) were males and 51 (57%) were females, mean age 74 years (range 65–98), with 20 patients (22%) ≥ 80. Indications for surgery included biliary colic 55 (61%), acute cholecystitis 22 (24%), pancreatitis 10 (11%), and cholangitis 3 (4%). Seventeen patients (19%) had preoperative ERCP, 12 of which were normal; five had sphincterotomy with stone extraction. Comorbid conditions included hypertension (44%), CAD (17%), cardiac arrhythmias (18), CHF (9%), and COPD (7%). Results: Operative time—mean 1 h 51 min ± SD 43 min. Conversion to OC—three patients (3%). Length of stay—mean 5 days (range 1–26). Mortality—two patients (2%) >80 years old, one patient with septicemia and multiorgan failure whose comorbid diseases included CAD, C.F., COPPED, and elevated BP, one patient with MI postsurgery, morbid diseases included DM and CAD. Complications—five patients (5%): bile leak from cystic duct stump (one), postsurgery MI (two), incarcerated incisional hernia (one), septicemia (one). Conclusion: Morbidity rates for LC in the elderly population are not different from that reported for patients less than 65 years of age. (5% vs 6%, Fried et al., Surg Clin North Am 1994;74 [2]: 375–387). Our 2% mortality rate is statistically different from previously reported in a series of patients of all ages (0.6%, Fried et al.). The 3% rate of conversion to OC in this older population is not significantly different from the patients in Fried et al. series (4%). Received: 17 September 1996/Accepted: 14 October 1996     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

Pathophysiological and clinical aspects of the CO2 pneumoperitoneum (CO2-PP)

Experimental studies demonstrated a severe cardiac load of the CO₂ pneumoperitoneum caused by an accelerated after- and a decreased preload. Patients displaying cardiovascular risks are therefore often rejected from laparoscopic surgery. Hence, the pathophysiological changes and the intraoperative risk of the CO₂ pneumoperitoneum in high-risk cardiopulmonary patients (NYHA II–III, n= 15) undergoing laparoscopic cholecystectomy are described. The changes in cardiac after- and preload seem to be due to the elevated intraabdominal pressure rather than transperitoneally resorbed CO₂ and are reversible by desufflation. In one patient conversion to open operation had to be performed because of a severe drop in cardiac output and right ventricle ejection fraction. Mixed oxygen saturation was predicting intraoperative worsening in this case. The described pathophysiological changes may seem to be well tolerated even in high-risk cardiac patients. Monitoring of hemodynamics should include an arterial catheter line and blood gas analyses. Pharmacologic interventions or pressureless laparoscopic procedures might not be necessary as long as laparoscopic cholecystectomy is performed. Received: 13 December 1996/Accepted: 8 January 1997     

Use of the ultrasonic dissecting scalpel in laparoscopic cholecystectomy

Background: We evaluated the use of the ultrasonically activated (harmonic) scalpel (HS) in the performance of laparoscopic cholecystectomy (LC). Methods: A total of 282 consecutive patients, 64 of whom had acute cholecystitis at the time of surgery, underwent LC using HS dissection. Indications for surgery included chronic pain (180 cases), episodes of acute cholecystitis (89 cases), pancreatitis (five cases), and jaundice (seven cases). Twenty-seven patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Results: The mean operating time was 29 ± 9 mins. Eleven procedures were converted to open surgery, (four due to bleeding, six due to unclear anatomy, and one due to an inflammatory mass caused by gangrene/perforation). Complications occurred in 14 patients. They included minor port site infection (four cases), pulmonary atelectasis (three cases), urinary retention (two cases), intraoperative cathetherization not routinely performed, bile leak (two cases, both from cystic duct; one of the cystic duct leaks occurred because of dislodgement of the occluding clip, the other may have been due to duct injury from the clip), pulmonary embolus (one case), and myocardial infarction (one case). Neither of the latter complications were fatal. One patient required a postoperative transfusion due to a fall in hematocrit of 3.2 gr/dl. Conclusions: LC performed with the HS is feasible and effective. Operating time and blood loss were minimal, and the conversion rate was low (3.9%). There were no bile duct injuries. Use of the HS makes dissection easier, thereby helping to reduce operative time and lower the need for conversion to open surgery. Received: 30 April 1999/Accepted: 22 November 1999/Online publication: 4 August 2000     

Hemodynamic consequences of high- and low-pressure capnoperitoneum during laparoscopic cholecystectomy

Background: Peritoneal insufflation to 15 mmHg diminishes venous return and reduces cardiac output. Such changes may be dangerous in patients with a poor cardiac reserve. The aim of this study was to investigate the hemodynamic effects of high (15 mmHg) and low (7 mmHg) intraabdominal pressure during laparoscopic cholestectomy (LC) Methods: Twenty patients were randomized to either high- or low-pressure capnoperitoneum. Anesthesia was standardized, and the end-tidal CO₂ was maintained at 4.5 kPa. Arterial blood pressure was measured invasively. Heart rate, stroke volume, and cardiac output were measured by transesophageal doppler. Results: There were 10 patients in each group. In the high-pressure group, heart rate (HR) and mean arterial blood pressure (MABP) increased during insufflation. Stroke volume (SV) and cardiac output were depressed by a maximum of 26% and 28% (SV 0.1 > p > 0.05, cardiac output p > 0.1). In the low-pressure group, insufflation produced a rise in MABP and a peak rise in both stroke volume and cardiac output of 10% and 28%, respectively (p < 0.05). Conclusions: Low-pressure pneumoperitoneum is feasible for LC and minimizes the adverse hemodynamic effects of peritoneal insufflation. Received: 23 May 1997/Accepted: 11 March 1998     

The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy

Background: The increased intra-abdominal pressure during pneumoperitoneum, together with the head-up tilt used in upper abdominal laparoscopies, would be expected to decrease venous return to the heart. The goal of our study was to determine whether laparoscopy impairs cardiac performance when preventive measures to improve venous return are taken, and to analyze the effects of positioning, anesthesia, and increased intra-abdominal pressure. Methods: Using invasive monitoring, hemodynamic changes were investigated in 15 ASA class I or II patients under isoflurane–fentanyl anesthesia during laparoscopic cholecystectomy. Before laparoscopy, the patients received an intravenous (IV) infusion of colloid solution if cardiac filling pressures were low, and their legs were wrapped from toes to groin with elastic bandages. Measurements were taken while the patients were awake in the supine (baseline) and head-up tilt (15–20°) positions, and after the induction of anesthesia in the same positions. Measurements were repeated at regular intervals during laparoscopy (intra-abdominal pressure at 13–16 mmHg), after deflation of the gas, and in the recovery room. Results: With the passive head-up tilt in awake and anesthetized patients, the cardiac index (CI), stroke index (SI), central venous pressure (CVP), and pulmonary capillary wedge pressure (PCWP) decreased, and systemic vascular resistance increased. With the patient under anesthesia, SI decreased, but CI did not change significantly as a result of the compensatory increase in heart rate. Carbon dioxide (CO₂) insufflation at the start of laparoscopy produced increases in CVP and PCWP as well as mean systemic and mean pulmonary arterial pressures without changes in CI or SI. Toward the end of the laparoscopy, CI decreased by 15%. The hemodynamic values returned to nearly prelaparoscopic levels after deflation of the gas, and CI was elevated during the recovery period, whereas systemic vascular resistance was decreased in comparison with the baseline. Conclusions: By correcting relative dehydration and preventing the pooling of blood, CI decreased less than 20% during pneumoperitoneum as compared with the baseline awake level. The head-up positioning accounts for many of the adverse effects in hemodynamics during laparoscopic cholecystectomy. Received: 6 November 1998/Accepted: 8 July 1999     

Changing management of gallstone disease during pregnancy

Background: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. Methods: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. Results: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6–10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. Conclusions: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients. Received: 3 April 1997/Accepted: 5 July 1997     

Micropuncture laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. Methods: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. Results: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45–180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. Conclusions: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure. Received: 28 January 1998/Accepted: 7 May 1998     

Short-stay laparoscopic adrenalectomy

Background: We performed a consecutive series of unilateral laparoscopic adrenalectomies (LA) with the expectation of short (less than 24 h) hospital stay. Results were compared with those from laparoscopic cholecystectomy (LC) and unilateral open adrenalectomy (OA). Methods: A combination of chart review and patient questionnaires was used to compare LA (n= 19) to LC (n= 20) regarding length of stay (LOS), narcotic requirements, and time to full recovery. Chart reviews also were used to compare LA to OA (n= 48) regarding operating room time (OR time), LOS, and surgical morbidity. Results: All of the LC patients as compared with 47% of the LA patients were discharged within 24 h. The reason for additional hospitalization in the LA group was pain control. After discharge, the narcotic requirement lasted 6.6 days in the LA group as compared with 3.4 days in the LC group (p < 0.01), but the times until full recovery were not significantly different (12.2 vs 11.3 days respectively). Operating room times did not differ significantly between the LA and OA groups (3.3 and 3.8 h, respectively), but there were fewer postoperative complications and much shorter LOS in the LA group (1.5 vs 6.3 days; p < 0.001), a difference that remained significant even when cases from the same time period were compared. Conclusions: Increased pain in LA as compared with LC patients may result in a slightly longer LOS and higher narcotic requirement during the early postoperative period, but time to full recovery between the two groups is the same. As compared with its open counterpart, LA offers a significant reduction in LOS and morbidity with no increase in OR time. Received: 12 February 1999/Accepted: 24 October 1999/Online publication: 28 April 2000     

Postoperative drowsiness and emetic sequelae correlate to total amount of carbon dioxide used during laparoscopic cholecystectomy

Background: After laparoscopy with carbon dioxide (CO₂) insufflation early postoperative recovery is often complicated with drowsiness and postoperative nausea and vomiting (PONV). Methods: 25 ASA I − II patients undergoing elective laparoscopic cholecystectomy under standardized anaesthesia were studied in a randomized, prospective study. The conventional CO₂ pneumoperitoneum was compared with the mechanical abdominal wall lift (AWL) method with minimal CO₂ insufflation with special reference to postoperative recovery. Results: Postoperative drowsiness was of a significantly longer duration with the conventional method (p < 0.001) compared with the AWL technique. There was a positive correlation with the total amount of CO₂ used and the duration of drowsiness (r = 0.75, p < 0.01). PONV was seen significantly more often in patients with CO₂ insufflation of more than 121 (p < 0.05). Conclusions: Avoiding excessive CO₂ is beneficial for smoother and more uneventful recovery after laparoscopic cholecystectomy. Received: 11 January 1996/Accepted: 29 May 1996     

Hormone-cytokine response

Background: Changes in blood hormone and cytokine were investigated in patients who underwent laparoscopic cholecystectomy via insufflation (CO₂ group) vs those who had abdominal wall-lifting (Air group). Methods: Seventeen female patients with cholecystolithiasis were randomly divided into two groups. Peripheral blood samples were obtained during perioperative period, and plasma hormone levels (ACTH, cortisol) and serum cytokine levels (TNFα, IL-1β, IL-6, IL-10) were measured. Results: The number of circulating lymphocytes significantly decreased at 1 h after surgery in both groups, but the decrease in the CO₂ group was significantly smaller than that in the Air group. There was no significant difference in hormone elevation between groups. Serum concentrations of IL-6 and IL-10 in the Air group were significantly higher than in the CO₂ group. Conclusions: CO₂ insufflation may reduce cytokine production in laparoscopic cholecystectomy. Received: 10 November 1996/Accepted: 19 February 1997     

Effects of carbon dioxide vs helium pneumoperitoneum on hepatic blood flow

Background: Elevated intraabdominal pressure due to gas insufflation for laparoscopic surgery may result in regional blood flow changes. Impairments of hepatic, splanchnic, and renal blood flow during peritoneal insufflation have been reported. Therefore we set out to investigate the effects of peritoneal insufflation with helium (He) and carbon dioxide (CO₂) on hepatic blood flow in a porcine model. Methods: Twelve pigs were anesthetized and mechanically ventilated with a fixed tidal volume after the stabilization period. Peritoneal cavity was insufflated with CO₂ (n= 6) or He (n= 6) to a maximum intraabdominal pressure of 15 mmHg. Hemodynamic parameters, gas exchange, and oxygen content were studied at baseline, 90 mm and 150 min after pneumoperitoneum, and 30 min after desufflation. Determination of hepatic blood flow with indocyanine green was made at all measured points by a one-compartment method using hepatic vein catheterization. Results: A similar decrease in cardiac output was observed during insufflation with both gases. Hepatic vein oxygen content decreased with respect to the baseline during He pneumoperitoneum (p < 0.05), but it did not change during CO₂ insufflation. Hepatic blood flow was significantly reduced in both the He and CO₂ pneumoperitoneums at 90 min following insufflation (63% and 24% decrease with respect to the baseline; p < 0.001 and p < 0.05, respectively) being this decrease marker in the He group (p= 0.02). Conclusions: These findings suggest that helium intraperitoneal insufflation results in a greater impairment on hepatic blood flow than CO₂ insufflation. Received: 27 March 1996/Accepted: 19 January 1997     

Laparoscopic cholecystectomy and time-course changes in renal function

Background: Recently, the retraction method has been used to reduce intraabdominal pressure (IAP) during laparoscopic surgery. The purpose of this study was to determine the serial changes in renal function during laparoscopic cholecystectomy (LC) using the retraction method. Methods: Urine output, effective renal plasma flow (ERPF), and glomerular filtration rate (GFR) were measured serially in seven patients who underwent LC with 12 mmHg pneumoperitoneum (High-IAP group) and five who underwent LC using the retraction method with 4 mmHg pneumoperitoneum (Low-IAP group). Results: Urine output, ERPF, and GFR were decreased during pneumoperitoneum in the High-IAP group, whereas no significant changes in any of these parameters were observed in the Low-IAP group. Conclusions: Our findings demonstrate that reduction of IAP to 4 mmHg using the retraction method prevents the transient renal dysfunction caused by prolonged 12 mmHg pneumoperitoneum during LC, suggesting that the retraction method reduces the risk of perioperative renal dysfunction during laparoscopic surgery. Received: 26 March 1996/Accepted: 27 July 1996     

Immediate and delayed effects of laparoscopic Nissen fundoplication on pulmonary function

Background: An effort was made to assess the respiratory outcomes of laparoscopic Nissen fundoplication (LNF). Methods: Prospective follow-up of 69 patients undergoing LNF for gastroesophageal reflux disease. Outcomes included pulmonary function testing, 24-h pH recording, esophageal manometry, and symptom assessment. Results: There was an improvement (p < 0.0001) in heartburn and cough scores. There was a significant fall in spirometry (p < 0001), diffusing capacity (p < 0.0001), and respiratory muscle strength (p < 0.0001) 36 h after surgery, which had returned to baseline by 1 month. At 6 months, the patients (n= 16) with impaired preoperative diffusing capacity showed improvement (17.8 ± 3.7 to 19.8 ± 4.6 ml/min/mmHg, p= 0.0245). Conclusion: Patients undergoing LNF have impaired gas exchange before surgery which tends to improve 6 months after surgery. There is an early reversible impairment in respiratory function due to diaphragm dysfunction. Patients with a preoperative 1-s forced expired volume > 1.5, or 50% predicted, are unlikely to develop signficant early respiratory complication. Received: 22 April 1996/Accepted: 9 July 1996     

Laparoscopic cholecystectomy for acute cholecystitis: Can the need for conversion and the probability of complications be predicted?

Background: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. Methods: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. Results: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc³, and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of ∼40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38°C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. Conclusion: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power. Received: 14 July 1999/Accepted: 21 December 1999/Online publication: 10 July 2000     

Immediately recognizable benefits and drawbacks after laparoscopic colon resection for benign disease

Background: A prospective assessment of the impact of laparoscopic colon resection (LCR) was carried out in order to quantify immediately recognizable benefits and limitations of this approach. Methods: Elective LCR was attempted in 95 selected patients (mean age 64 years, range 39–81 years) presenting with benign disease of the colon. A completely intracorporeal approach was adopted. Results were compared with a control group of 90 patients who had previously undergone open colectomy (OC) by the same surgeons at the same institution. Results: There were no perioperative deaths. Intraoperative complications included difficult extraction of accidentally detached anvil (n= 1), air leak at colonoscopy (n= 2), and conversion to OC (n= 1). Operating time was significantly longer after LCR compared with OC (180 ± 10.3 vs 116 ± 97, p < 0.001). Passage of flatus (3.5 ± 1.2 days vs 4.4 ± 1.4, p < 0.5) and morbidity (4 vs 3, p= 0.48) were not significantly different in the two groups. Hospital stay was significantly shorter after LCR (5.2 ± 1.3 days vs 12.2 ± 1.9 days, p < 0.001). Theater and ward costs were, respectively, significantly increased ($ 2,829.6 ± 340 vs $ 1,422 ± 318, p < 0.001) and decreased ($ 2,600 ± 366 vs $ 6,022 ± 916, p < 0.001) in LCR patients compared with the OC group. There was no significant difference in total hospital costs ($ 10,929 ± 369 vs $ 9,944 ± 1,014). Conclusions: LCR does not appear to offer any immediately recognizable advantages. Received: 15 October 1996/Accepted: 13 December 1996     

Postoperative Hepatic Catabolic Stress Response in Patients with Cirrhosis and Chronic Hepatitis

Open (OC) or laparoscopic (LC) cholecystectomy is considered a relative contraindication in patients with liver cirrhosis. The effect of LC and OC on the hepatic catabolic stress response was studied in patients with postnecrotic liver cirrhosis and chronic hepatitis to define the most suitable procedure from a metabolic point of view. Altogether 14 patients with cirrhosis and 14 with chronic hepatitis were randomized to LC or OC (n= 7 in each group). The increase in the functional hepatic nitrogen clearance (FHNC) was quantified. Changes in glucose, insulin, glucagon, cortisol, epinephrine, norepinephrine, and prostaglandin E₂ (PGE₂) were observed. There was no difference in FHNC between LC and OC in any of the patients. Among cirrhotic patients OC caused a 132% increase in FHNC (p < 0.05) and among the hepatitis patients a 69% increase (p < 0.05). In contrast, there was no significant increase following LC in any of the patients. OC increased fasting glucose and insulin in the hepatitis patients (p < 0.01 and p < 0.001, respectively) and in the cirrhosis group (p < 0.01 and p < 0.05, respectively). Alanine stimulation increased glucose in hepatitis patients after OC (p < 0.05) and after LC (p < 0.01). Stimulated glucagon increased after OC in the hepatitis group (p < 0.05). During stimulation cortisol was higher following LC in hepatitis patients (p < 0.01) and cirrhotic patients (p < 0.05). Fasting PGE₂ was down-regulated after LC in hepatitis patients (p < 0.05) and cirrhotic patients (p < 0.01) and after OC in the hepatitis group (p < 0.001). FHNC is similar after LC and OC. Thus from a metabolic point of view, LC has no advantage over OC.     

Transesophageal echocardiographic assessment of hemodynamic function during laparoscopic cholecystectomy in healthy patients

Background: This study aimed by means of transesophageal echocardiography, to evaluate hemodynamic changes induced by pneumoperitoneum in patients with normal cardiac performance. Methods: In this study, 11 ASA I–II patients (mean age, 39 years) with normal cardiac performance undergoing laparoscopic cholecystectomy were evaluated. A 5-MHz transesophageal biplane phased-array transducer connected to an echocardiographer was inserted after induction of anesthesia. Data were collected at three different times: before insufflation (T1), 10 min after insufflation (T2), and 5 min after desufflation (T3). At these same times, heart rate, systolic blood pressure, diastolic blood pressure, end-tidal carbon dioxide (CO₂), and peak airway pressure were recorded. Statistical analysis was performed using one-way and two-way analysis of variance (ANOVA). A p value less than 0.05 was considered significant. Results: End-systolic and end-diastolic diameters of the left ventricle, contractility, and performance parameters did not change significantly. Conversely, at insufflation, color Doppler area of the mitral backflow increased significantly (p < 0.05) when already present or showed up abruptly (T1: 0.22 ± 0.28 cm²; T2: 1.28 ± 1.02 cm²; T3: 0.49 ± 0.53 cm²). Conclusions: Such an event is not interpreted as a mitral insufficiency. It is possibly the result of a ``contrast effect' caused by the absorption of CO₂ microbubbles in the blood. Received: 12 April 1998/Accepted: 23 June 1999