Is cell-mediated immunity affected by laparoscopic cholecystectomy?

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.     

急性坏疽性胆囊炎69例的腹腔镜治疗

目的 探讨腹腔镜治疗急性坏疽性胆囊炎中转开腹的危险因素及影响预后的指标。方法 总结69例急性坏疽性胆囊炎腹腔镜手术的临床资料，包含术前临床指标和预后相关因素。计量资料采用x^-±s表示，行t检验；计数资料行χ^2检验。结果 腹腔镜手术成功完成45例，中转开腹24例；中转开腹的危险因素为年龄（χ^2=2．234，P=0．034）和合并心血管疾病（χ^2=4．983，P=0．027）；早期行腹腔镜手术和术中及时中转开腹的病例预后较好。结论 急性坏疽性胆囊炎应早行腹腔镜探查，若操作困难，应早期及时中转开腹手术；对于高龄和合并有心血管疾病的患者，应行开腹胆囊切除术。     

Postoperative pulmonary function after laparoscopic and open cholecystectomy

In this prospective, randomized study, we compared 42 patients undergoing laparoscopic cholecystectomy and 40 undergoing open cholecystectomy to determine if laparoscopic cholecystectomy results in less respiratory impairment and fewer respiratory complications. Pulmonary function tests, arterial blood-gas analysis and chest radiographs were obtained in both groups before operation and on the second day after operation. Postoperative pain scores and analgesic requirements were also recorded. After operation, a significant reduction in total lung capacity, functional residual capacity (FRC), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and mid-expiratory flow (FEF25-75%) occurred after both laparoscopic and open cholecystectomy. The reductions in FRC, FEV1, FVC and FEF25-75% were smaller after laparoscopic (7%, 22%, 19% and 23%, respectively) than after open (21%, 38%, 32% and 34%, respectively) cholecystectomy. Laparoscopic cholecystectomy was also associated with a significantly lower incidence (28.6% vs 62.5%) and less severe atelectasis, better oxygenation and reduced postoperative pain and analgesia use compared with open cholecystectomy. We conclude that postoperative pulmonary function was impaired less after laparoscopic than after open cholecystectomy.      

腹腔镜与传统开腹手术治疗胆总管结石的临床应用比较

目的比较腹腔镜胆囊切除＋胆总管切开探查取石术和传统开腹胆囊切除＋胆总管切开探查取石术的临床效果和医疗费用。方法55例胆总管结石患者分两组,A组25例行腹腔镜胆囊切除＋胆总管切开取石术;B组30例行传统开腹胆囊切除＋胆总管切开取石术。统计手术时间,术后开始下床活动时间,术后胃肠功能恢复时间,术后住院时间,术后并发症和总住院费用。结果两组患者都顺利完成手术,术后两组各有1例患者胆道造影残留结石,两组手术时间无显著差异,A组患者术后下床活动时间、胃肠功能恢复时间较B组患者早,术后A组住院时间较B组短,住院费用A组较B组增多。结论腹腔镜胆总管切开取石术完全能达到传统开腹胆道切开取石术的效果,并具有创伤小,痛苦少,恢复快的优点,是治疗胆总管结石的理想手术方式之一。     

Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis

BACKGROUND: The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. METHODS: Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care. RESULTS: The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011). CONCLUSION: Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.     

Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial

OBJECTIVE: To compare the results of open versus laparoscopic repair for perforated peptic ulcers. SUMMARY BACKGROUND DATA: Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated peptic ulcers in many institutions. Laparoscopic repair has been used to treat perforated peptic ulcers since 1990, but few randomized studies have been carried out to compare open versus laparoscopic procedures. METHODS: From January 1994 to June 1997, 130 patients with a clinical diagnosis of perforated peptic ulcer were randomly assigned to undergo either open or laparoscopic omental patch repair. Patients were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Patients with clinically sealed-off perforations without signs of peritonitis or sepsis were treated without surgery. Laparoscopic repair would be converted to an open procedure for technical difficulties, nonjuxtapyloric gastric ulcers, or perforations larger than 10 mm. A Gastrografin meal was performed 48 to 72 hours after surgery to document sealing of the perforation. The primary end-point was perioperative parenteral analgesic requirement. Secondary endpoints were operative time, postoperative pain score, length of postoperative hospital stay, complications and deaths, and the date of return to normal daily activities. RESULTS: Nine patients with a surgical diagnosis other than perforated peptic ulcer were excluded; 121 patients entered the final analysis. There were 98 male and 23 female patients recruited, ages 16 to 89 years. The two groups were comparable in age, sex, site and size of perforations, and American Society of Anesthesiology classification. There were nine conversions in the laparoscopic group. After surgery, patients in the laparoscopic group required significantly less parenteral analgesics than those who underwent open repair, and the visual analog pain scores in days 1 and 3 after surgery were significantly lower in the laparoscopic group as well. Laparoscopic repair required significantly less time to complete than open repair. The median postoperative stay was 6 days in the laparoscopic group versus 7 days in the open group. There were fewer chest infections in the laparoscopic group. There were two intraabdominal collections in the laparoscopic group. One patient in the laparoscopic group and three patients in the open group died after surgery. CONCLUSIONS: Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure. It was associated with a shorter operating time, less postoperative pain, reduced chest complications, a shorter postoperative hospital stay, and earlier return to normal daily activities than the conventional open repair.     

Comparison of postoperative acute-phase reactants in patients who underwent laparoscopic v open cholecystectomy: a randomized study

PURPOSE: We investigated the effect of laparoscopic v open cholecystectomy on acute-phase reactants. PATIENTS AND METHODS: Fifty patients were randomized to laparoscopic (Group 1) and 50 to open (Group 2) cholecystectomy. Preoperative and postoperative values for acute-phase reactants (ceruloplasmin, fibrinogen, Westergren sedimentation rate, alpha-1-antitrypsin, haptoglobin, and C-reactive protein) in blood samples were compared. RESULTS: Acute-phase reactants and length of hospitalization were significantly lower in patients who underwent a laparoscopic cholecystectomy than in those who underwent an open cholecystectomy. CONCLUSION: Laparoscopic cholecystectomy appears associated with a less intense stress response and less tissue damage than open cholecystectomy.     

结石性胆囊炎腹腔镜与开腹胆囊切除术的对照研究

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与开腹胆囊切除术(open cholecystectomy,OC)治疗结石性胆囊炎的疗效及并发症.方法:将343例结石性胆囊炎患者分为两组,220例行LC,123例行OC,观察两组手术时间、术中出血量、术后疼痛时间、肛门排气、术...     

Laparoscopic cholecystectomy under spinal anesthesia

BACKGROUND: Regional anesthesia has not been used as the sole anesthetic procedure other than in the scenario of a patient at high risk to undergo laparoscopic cholecystectomy with CO2 pneumoperitoneum under general anesthesia. METHODS: Fifteen ASA grade I or II patients underwent laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under spinal anesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded in a pilot study to assess the feasibility and safety of the procedure. RESULTS: All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score 4 h postoperatively was 1.5 (range, 0-5), at 8 h it was 1 (range, 0-6), and at 24 h it was 1 (range, 0-4). All patients were discharged after 24 h. Follow-up 2 weeks postoperatively showed all but one patient to be satisfied and strongly recommending the anesthetic procedure. CONCLUSION: Laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and at least an equally good recovery as with general anesthesia.     

Laparoscopic cholecystectomy during pregnancy.

Pregnancy is by some considered a contraindication for laparoscopic cholecystectomy. However, no evidence exists to support this opinion. We describe herein a laparoscopic cholecystectomy in a pregnant woman in the 22nd week of gestation with an uneventful postoperative recovery and normal completion of pregnancy. Laparoscopic cholecystectomy can be performed during pregnancy with a slight modification of the operative technique and is less traumatic than open surgery.     

腹腔镜胆囊切除术与小切口胆囊切除术的比较

目的：探讨胆囊切除术适应证患者的理想术式。方法：回顾219例腹腔镜胆囊切除术(LC)与107例小切口胆囊切除术(MC)的临床资料,从手术适应证、手术创伤、并发症、术后恢复经过等方面对比分析两者的优缺点。结果：两者比较,LC创伤小,术后并发症较多。MC手术适应证宽。两者术后恢复差异无显著性。结论：两种术式各有优缺点,其中一种术式并不适应所有胆囊切除适应证的患者。选择何种术式,应根据患者的具体情况决定。     

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted. Methods: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors. Results: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia. Conclusions: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events. This material was presented in part as abstracts at the Euroanaesthesia Congress in Glasgow, Scotland, 2003     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy

Background: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. Methods: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). Results: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. Conclusions: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Laparoscopic cholecystectomy: historic perspective and personal experience.

Operative laparoscopy has been an important diagnostic and therapeutic method in gynecological surgery for more than 15 years. Laparoscopic gastrointestinal surgery has only recently become accepted among general surgeons. Laparoscopic appendectomy was the first such procedure performed, in 1983, followed by cholecystectomy in 1987. Laparoscopic biliary tract surgery has been shown to offer the patient a number of advantages in patient care, such as reducing the length of hospitalization and recovery, minimizing postoperative pain and discomfort, and nearly eliminating the disfigurement associated with a major abdominal operation. Although initially offered only to those patients with uncomplicated biliary tract disease, this procedure is now safely performed in individuals with acute cholecystitis and choledocholithiasis. We describe the development of laparoscopic gastrointestinal surgery in Europe as well as our method of performing endoscopic cholecystectomy. The current results of 690 laparoscopic cholecystectomies performed at our institution are included.     

腹腔镜与开腹胆总管切开取石术应激反应差异分析

目的比较两种手术术式应用于结石患者治疗时应激反应差异。方法选取胆总管结石患者80名,随机分为腹腔镜组和开腹组,每组40例,均接受胆囊切除术和胆总管切开取石术;应用SPSS 20.0软件包进行数据处理,术中出血量、手术时间、术后胃肠道功能恢复时间、术后住院时间、Cor、C-P、FT3水平等计量资料以(x珋±s)表示,采用t检验;不良反应发生率等计数资料采用χ2检验,P0.05为差异具有统计学意义。结果腹腔镜组患者术中出血量、肠道功能恢复时间和住院时间显著低于开腹组(t=12.019,t=6.757,t=10.343,P0.01)。腹腔镜组患者术后3 d内血清皮质醇(Cor)、C-肽(C-P)和游离三碘甲状腺原氨酸(FT3)水平显著优于开腹组(t=6.296,t=11.030,t=7.408,P0.01)。腹腔镜组患者术后并发症发生率显著低于开腹组(χ2=15.313,P0.01)。结论腹腔镜胆总管切开取石术术中损伤小、术后恢复快患者应激反应小并发症发生率低,具有临床应用价值。     

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     

腹腔镜与开腹结直肠癌手术短期效果的对比研究

目的:对比分析腹腔镜与开腹结直肠癌手术的短期效果。方法:回顾分析2001～2010年1 743例结直肠癌患者的临床资料,其中864例行腹腔镜手术8,79例行开腹手术。结果:相对开腹组,腹腔镜组切口小([5.5±1.8)cm vs.(23±3.5)cm,P<0.01;]失血量少([110±41)ml vs.(350±56)ml,P<0.01);]术后阿片类镇痛剂使用例数少(179 vs.261,P<0.01);首次下床活动时间早([1.9±0.9)天vs.(2.5±1.2)天,P<0.01;]肠道功能恢复快([2.5±0.6)天vs.(3.8±0.7)天,P<0.01;]术后住院时间短[(6.5±1.3)天vs.(8.4±1.5)天,P<0.01;]术后并发症发生率低(15.7%vs.27.6%,P<0.01)。淋巴结清扫数量、标本切缘阳性率两组差异无统计学意义(P>0.05)。结论:腹腔镜结直肠癌手术安全可行,可取得与开腹手术相同的根治效果,且具有切口小、出血少、疼痛轻、术后住院时间短、并发症发生率低等优势,值得推广。     

Minimizing ports to improve laparoscopic cholecystectomy

BACKGROUND: Minimizing the number and scope of ports used to perform laparoscopic cholecystectomy attempts to build on the improvements in postoperative pain control, rapid return to activity and work, patient satisfaction, and cosmetic result achieved by the laparoscopic method. METHODS: We studied 141 patients in two sequential studies: the first a prospective randomized trial with 41 patients, and the second an examination of the more minimal procedure in 100 patients. In the randomized trial, patients underwent laparoscopic cholecystectomy with three ports: three 5-mm ports or two 10-mm ports and one 5-mm port. The 100 patients underwent the three 5-mm port procedure. RESULTS: In the randomized trial, differences were not statistically significant. However, on the average, the group with three 5-mm ports required less medication over less time, had less postoperative pain, and took less time to return to activity than the second group with larger ports. A statistically significant difference was found in incisional pain between the smaller group (21 patients) with two 10-mm ports and one 5-mm port and the larger group (100 patients) with three 5-mm ports, whether the measure was overall incisional pain (p = 0.014) or a comparison based on specific ports (p = 0.001). The percentage of cases requiring port enlargement to remove the gallbladder was not significantly different between the groups. There were no conversions to an open procedure, no fourth trocars added, and no complications. No patient required overnight hospitalization. CONCLUSIONS: Reducing the number and size of ports in laparoscopic cholecystectomy sustains or enhances the improvements initiated by performing laparoscopic rather than open cholecystectomy. In a comparison of microlaparoscopic procedures, patients undergoing the procedure with the shorter incisions experienced significantly less pain.     

The effect of preoperative intravenous use of tenoxicam: a prospective, double-blind, placebo-controlled study.

In this study, we aimed to investigate the postoperative pain relief effect of preoperative tenoxicam usage in patients who undergo elective laparoscopic cholecystectomy or groin hernia repair. Eighty patients undergoing laparoscopic cholecystectomy or groin hernia repair procedures were randomized to receive either physiologic serum at 100 mL (group I, n = 40) or 20 mg iv tenoxicam (group II, n = 40) immediately before induction. Postoperative analgesic requirement, peroperative side effects and complications of drugs, operating time, post-operative mobilization time and pain score, hospitalization time, and patient pleasure were recorded. Postoperative pain was assessed by the visual analogue scale (VAS) on the recovery unit (RU), at 4, 8, and 24 h and every day at the same times in the morning. The RU median VAS score was also not different when Group 1 was compared with Group 2 (p = .97). However, the postoperative 4-h and 8-h median VAS score was significantly less (p = .01 and p = .03, respectively); first postoperative mobilization time was earlier in group 2 (p = .32). The median pain score and intramuscular analgesic requirement of patients were also reduced in Group 2 in postoperative day 1 (p = .015). The median duration of intramuscular analgesic requirement and total amount of intramuscular analgesic used in patients were also significantly less in Group 2 (p = .0001 and p = .0001, respectively). Thus, this study showed that preoperative use of iv tenoxicam is safe, simple, and effective for postoperative pain relief after laparoscopic cholecystectomy or inguinal hernia repair.     

高龄患者腹腔镜结直肠切除术安全性的研究

目的:评价为高龄患者行腹腔镜结直肠切除术的安全性及可行性。方法:回顾分析2003年8月至2008年8月我院择期行结直肠切除术中大于等于70岁高龄患者的临床资料。比较同期56例腹腔镜结直肠切除术和52例开腹手术患者的一般情况、疾病分类、手术指标、术后恢复情况和治疗效果。患者平均年龄开腹组74岁,腹腔镜组73岁。两组患者术前合并症、美国麻醉师协会术前危险度评分、疾病类型均无显著差异。结果:平均手术时间开腹组192min,腹腔镜组187min,P=0.616。开腹组术中平均出血218ml,腹腔镜组约86ml,P=0.000。腹腔镜组1例中转开腹。两组均无死亡病例。肠功能恢复时间开腹组5d,腹腔镜组3d,P=0.000。进流食时间开腹组5d,腹腔镜组4d,P=0.026。平均住院时间开腹组22d,腹腔镜组18d,P=0.000。术后心肺并发症发生率开腹组26.9%,腹腔镜组10.7%,P=0.030。结论:为高龄患者行腹腔镜结直肠切除术安全可行,可减少患者术中出血量,降低术后心肺并发症的发生率,加快术后胃肠功能恢复,缩短住院时间等。