References for Anaesthesia for Laparoscopy :

Dr. D.W. Green KCH 30/4/2001

Abballe, C., D. Camaioni, et al. (1993). “Anestesia per colecistectomia laparoscopica: utilizzo del protossido d'azoto nella miscela anestetica.  Giornale di Chirurgia 14(9): 493-5.
A study carried out on 44 patients undergoing laparoscopic cholecystectomy was started in order to evaluate if nitrous oxide is or not contraindicated. The patients were divided in two groups of 22 subjects receiving or not nitrous oxide in the anaesthetic mixture. All the patients received the same preanaesthetic medication (diazepam and atrophine), thiopental and fentanyl as induction drugs, vecuronium as muscle relaxant and isoflurane for maintenance of anaesthesia. Bowel distension, technical difficulty, incidence of postoperative nausea and vomiting were examined. Our conclusions were that nitrous oxide has no clinically deleterious effects during laparoscopic cholecystectomy.

Abdel-Meguid, T. A. and I. H. Hirsch (1997). “Noninsufflative extraperitoneal laparoscopic varicocele ligation.  Techniques in Urology 3(1): 12-5.
Currently, most laparoscopic procedures are performed through the intraperitoneal route utilizing standard insufflative technique to create a working space. We report our experience with the new technique of gasless extraperitoneal varicocelectomy performed in eight subfertile men, in which we effectively dissect the retroperitoneum by using a trocar balloon device (peritoneal distention balloon) and maintain the working cavity with a motorized abdominal wall retractor (Laparofan/Laparolift retraction system). In addition to the primary trocar, two valveless secondary trocars are placed, through which either laparoscopic or standard surgical instruments may be used. The spermatic veins are doubly clipped while the artery is preserved in all cases. The mean operative time was 150 +/- 51 min with no intraoperative complications, and all patients were discharged within 24 h. The average days to return to work was 6.5 +/- 3.0 and the average postoperative analgesic requirement (pain pills) was 23.5 +/- 9.9. There were no significant postoperative complications. Exposure and working space provided by the gasless technique are not as satisfactory as the standard insufflative technique, and operative time is far more extensive. To surmount these limitations in gasless laparoscopy, significant developments are required in retraction technology.

Adornato, D. C., P. L. Gildenberg, et al. (1978). “Pathophysiology of intravenous air embolism in dogs.  Anesthesiology 49(2): 120-7.

Akira, S., A. Yamanaka, et al. (1999). “Gasless laparoscopic ovarian cystectomy during pregnancy: comparison with laparotomy.  American Journal of Obstetrics & Gynecology 180(3 Pt 1): 554-7.
OBJECTIVE: The efficacy and safety of gasless laparoscopic ovarian cystectomy during pregnancy were compared with those of conventional laparotomy.Study Design: Subjects for the 2 study groups were selected from consecutive patients who satisfied all entrance criteria. Seventeen women who underwent gasless laparoscopic cystectomy were compared with 18 women who underwent cystectomy by laparotomy. The intraoperative and postoperative courses, pregnancy outcomes, and complications were compared. RESULTS: The patients' ages, body mass indexes, mean cyst diameters, fetal gestational ages, and types of cysts did not differ significantly between the two groups. Blood loss, analgesic use, and need for tocolytic agents were significantly less in the laparoscopy group than in the laparotomy group. No abortions or preterm deliveries occurred in the laparoscopy group, whereas 1 abortion was recorded in the laparotomy group. CONCLUSION: Gasless laparoscopic ovarian cystectomy offers significant advantages with respect to laparotomy for the pregnant patient.

Alexander, G. D., M. Goldrath, et al. (1973). “Outpatient laparoscopic sterilization under lcoal anesthesia.  American Journal of Obstetrics & Gynecology 116(8): 1065-8.

Allardyce, R. A., P. Morreau, et al. (1997). “Operative factors affecting tumor cell distribution following laparoscopic colectomy in a porcine model.  Diseases of the Colon & Rectum 40(8): 939-45.
BACKGROUND: An increased risk of laparoscopic port wound tumor implantation in the presence of overt or covert abdominal malignancy has been identified. PURPOSE: A porcine laparoscopic colectomy model has been used to quantify the influence surgical practices may have on tumor cell implantation. METHODS: 51Cr-labeled, fixed HeLa cells were injected intraperitoneally before surgery. Tumor cell contamination of instruments, ports, security threads, and excised wound margins was assessed by gamma counting. RESULTS: Greatest contamination occurred in ports used by the operating surgeon under pneumoperitoneum (64 percent of all port wound tumor cells) and mechanical elevation (76 percent). Gasless surgery in patients in the head-down position increased the rostral accumulation of tumor cells in the abdomen and right upper quadrant port wound by 330 and 176 percent, respectively. Under pneumoperitoneum, port movement was the major contributor to port leakage and wound contamination (21 percent of total recovered wound tumor cells per port). Tumor cells were not carried in aerosol form. Instrument passage and the withdrawal of security threads through the abdominal wall increased port wound contamination 430 and 263 percent, respectively, over pneumoperitoneum control ports. Preoperative lavage reduced by 61 percent, but did not eliminate, wound contamination. CONCLUSION: This porcine model may be used to evaluate surgical factors for the impact on port wound contamination.

Anderson, D. E., E. M. Gaughan, et al. (1996). “Laparoscopic surgical approach and anatomy of the abdomen in llamas.  Journal of the American Veterinary Medical Association 208(1): 111-6.
OBJECTIVE--To describe 3 laparoscopic approaches for, and the normal laparoscopic anatomy of, the abdomen in adult llamas and to evaluate the effects of laparoscopy in those llamas. DESIGN--Prospective clinical trial. ANIMALS--Six adult castrated male llamas. PROCEDURE--After induction of general anesthesia, 3 surgical approaches to the abdomen were performed: left paralumbar, ventral midline, and right paralumbar. The abdomen was systematically examined, and anatomic features described. After recovery from anesthesia, all llamas were examined daily for 10 days and CBC was repeated 24, 72, and 120 hours after laparoscopy. RESULTS--Laparoscopy was successfully performed in all llamas by use of the ventral midline and right paralumbar approaches. The laparoscope was inadvertently placed into the left retroperitoneal space in 1 of the 6 llamas when the left paralumbar approach was used. Also, hemorrhage into the abdomen limited the view from the left side in another llama. Various approaches allowed viewing of the first and third forestomach compartments, liver, spleen, kidneys, small intestine, ileum, proximal loop of the ascending colon, spiral colon, and urinary bladder. Postoperative findings included subcutaneous emphysema and edema. Mean WBC count peaked 24 hours after surgery (mean, 23,500 cells/microliter). Generally, neutrophil count increased and lymphocyte count decreased during the 120 hours after surgery. CLINICAL IMPLICATIONS--Laparoscopy may be used for differentiation of medical and surgical lesions in the abdomen of llamas. The site for laparoscopy should be chosen on the basis of the most likely site of the suspected lesion.

anonymous (1989). “Clinical freedom, clinical behaviour, and anaesthesia for laparoscopy [letter; comment].  Anaesthesia 44(12): 999-1000.

anonymous (1990). “Laparoscopic tubal sterilization under local anesthesia [letter; comment].  Obstetrics & Gynecology 75(6): 1060-2.

anonymous (1991). “A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club [published erratum appears in N Engl J Med 1991 Nov 21;325(21):1517-8] [see comments].  New England Journal of Medicine 324(16): 1073-8.
BACKGROUND AND METHODS. The Southern Surgeons Club conducted a prospective study of 1518 patients who underwent laparoscopic cholecystectomy for treatment of gallbladder disease in order to evaluate the safety of this procedure. RESULTS. Seven hundred fifty-eight operations (49.9 percent) were performed at academic hospitals, and 760 (50.1 percent) at private hospitals. In 72 patients (4.7 percent) the operation was converted to conventional open cholecystectomy; the most common reason for the change was the inability to identify the anatomy of the gallbladder as a result of inflammation in the region of this organ. A total of 82 complications occurred in 78 (5.1 percent) of the patients; this is comparable with the rates of 6 to 21 percent that have been reported for conventional cholecystectomy. Overall, the most common complication was superficial infection of the site of insertion of the umbilical trocar. A total of seven injuries to the common bile duct or the hepatic duct occurred during the operation, for a rate of 0.5 percent. Four of the seven injuries were simple lacerations, which were repaired after conversion to conventional cholecystectomy. The incidence of bile-duct injury in the first 13 patients operated on by each surgical group was 2.2 percent, as compared with 0.1 percent for subsequent patients. No complications were attributed directly to either cautery or laser-surgical technique, and similar numbers of complications occurred in academic and private hospitals. The mean hospital stay for the entire group was 1.2 days (range, 6 hours to 30 days). CONCLUSIONS. The results of laparoscopic cholecystectomy compare favorably with those of conventional cholecystectomy with respect to mortality, complications, and length of hospital stay. A slightly higher incidence of biliary injury with the laparoscopic procedure is probably offset by the low incidence of other complications.

Azurin, D. J., L. S. Go, et al. (1995). “Gasless laparoscopic esophagomyotomy.  Surgical Endoscopy 9(10): 1136-8.
A case of gasless laparoscopic esophagogastric myotomy for achalasia is presented. The technical aspects of the technique as well as the benefits of this approach are reviewed.

Baba, S., K. Nakagawa, et al. (1996). “[Experience of 143 cases of laparoscopic surgery in urology--clinical outcome in comparison to open surgery].  Nippon Hinyokika Gakkai Zasshi - Japanese Journal of Urology 87(5): 842-50.
(BACKGROUND). The clinical outcome of laparoscopic surgery performed in 143 patients, including laparoscopic adrenalecotmy, nephrectomy, pelvic lymph node dissection (PLND) and varicocele ligation is reported. (METHODS). In patients who underwent laparoscopic adrenalectomy (32 cases), laparoscopic nephrectomy (7) or PLND (44), the following parameters were evaluated and compared to those obtained in patients undergoing the same surgeries but by conventional open procedure; operation time, hospital stay, pain killer doses and the time necessitated for ambulation. (RESULTS). The operation was successful in 95.8% (137/143). Open laparotomy was necessitated in 4 patients to control bleeding (two in adrenalectomy and two for PLND) and in one nephrectomy case due to massive adhesion with the descending colon. The major complication occurred in 4.2% of the cases, but without mortality. The laparoscopic adrenalectomy, nephrectomy and PLND had an average operating time of 260, 304 and 139 minutes, respectively, while the open surgery for each procedure required 251, 212 and 128 minutes, respectively (p = 0. 24 approximately 0.82). Likewise, the total dose of pain killer was 0.8, 1.8 and 0.9 for the former, whereas it was 3.2, 6.0 and 3.9 for the latter, respectively (p < 0.01). The average hospital stay for laparoscopic surgery was 4.9, 6.4 and 4.7 days in the same order, whereas open adrenalectomy or nephrectomy required about 14 days (p < 0.001). Convalescence was completed within significantly shorter term in patients with laparoscopic surgery. Potential complications of laparoscopic surgery included not only those unique to pneumoperitoneum (8.1%), but also those which may be encountered during any endoscopic operation such as compartment syndrome in the lower extremities. The physiologic changes accompanying increased intra-abdominal pressure affected renal function, characterized by a significant decrease in urinary output (p < 0.02), which, however, resumed to normal range within several hours after the operation without causing permanent renal dysfunction. (CONCLUSION). These results suggest that the laparoscopic surgery in certain area in urology has less morbidity and equal accuracy compared with conventional open surgery.

Bailey, D. M. and A. D. Nicholas (1988). “Comparison of atracurium and vecuronium during anaesthesia for laparoscopy.  British Journal of Anaesthesia 61(5): 557-9.
Atracurium 0.3 mg kg-1 and vecuronium 0.06 mg kg-1 were compared directly in a double-blind randomized trial during anaesthesia for laparoscopy in 57 healthy young women. The effects of the drugs were monitored using a portable electromyograph. Both drugs provided adequate intubating conditions at 3 min, and prompt antagonism of paralysis after administration of neostigmine, but recovery was significantly faster with vecuronium (mean time to 20% recovery of control electromyographic response: vecuronium 15.1 min; atracurium 20.6 min (P less than 0.001)). Atracurium caused a higher frequency of clinically observed allergoid reactions (21%) compared with vecuronium (3%).

Bailie, R., G. Craig, et al. (1989). “Total intravenous anaesthesia for laparoscopy.  Anaesthesia 44(1): 60-3.
Two techniques of total intravenous anaesthesia for laparoscopy were compared in 80 patients. Group 1 received alfentanil, propofol and vecuronium, and Group 2 alfentanil, midazolam, ketamine and vecuronium. Haemodynamic stability after induction and the pressor response to tracheal intubation were significantly different. There was no significant difference in recovery times between the two groups and little difference in other postoperative sequelae.

Banting, S., S. Shimi, et al. (1993). “Abdominal wall lift. Low-pressure pneumoperitoneum laparoscopic surgery.  Surgical Endoscopy 7(1): 57-9.
A method of abdominal wall lift has been developed and evaluated clinically in this unit during the past 18 months. It permits the conduct of laparoscopic procedures at an intraabdominal pressure of 6-8 mm Hg. The technique was introduced for laparoscopic surgery in patients with preexisting cardiac disease and chronic bronchitis. The procedure, by lifting both the abdominal wall and the falciform ligament together, also elevates the central portion of the liver (segments 3-5), thereby improving the surgical exposure. For this reason it is now also used in fit patients with ptotic livers or hypertrophied quadrate lobes undergoing laparoscopic cholecystectomy and common bile duct exploration, and to facilitate left subhepatic exposure in patients during laparoscopic antireflux surgery and vagotomy.

Barkun, J. S., E. J. Keyser, et al. (1999). “Short-term outcomes in open vs. laparoscopic herniorrhaphy: confounding impact of worker's compensation on convalescence.  Journal of Gastrointestinal Surgery 3(6): 575-82.
Over a 28-month period, 123 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open herniorrhaphy (OH) to laparoscopic inguinal herniorrhaphy (LH). The primary end point was duration of convalescence. Sixty-five patients underwent OH and 58 underwent LH. Both groups were well matched for all baseline parameters, although LH patients anticipated a shorter convalescence than OH patients (14.3 +/- 9.4 days vs. 18.5 +/- 10.8 days; P = 0.021). The median duration of hospital stay was one day in both groups. No difference was observed in the duration of convalescence (LH 9.8 +/- 7.4 days; OH 11.6 +/- 7. 7 days) across groups. However, when the data were analyzed after removing patients receiving disability ("worker's") compensation (21 patients), patients undergoing LH recovered on average 3 days faster (LH 7.8 +/- 5.6 days; OH 10.9 +/- 7.5 days; P = 0.02). Patients not receiving worker's compensation appear to have a shorter convalescence after LH compared to OH. Disability compensation is a major confounding variable in determining convalescence and needs to be controlled for in any future trial design.

Barone, J. E. and R. M. Lincer (1991). “Correction: A prospective analysis of 1518 laparoscopic cholecystectomies [letter; comment].  New England Journal of Medicine 325(21): 1517-8.

Barone, M. A., D. E. Wildt, et al. (1994). “Gonadotrophin dose and timing of anaesthesia for laparoscopic artificial insemination in the puma (Felis concolor).  Journal of Reproduction & Fertility 101(1): 103-8.
Ovarian response to equine chorionic gonadotrophin (eCG) and human chorionic gonadotrophin (hCG), the effect of timing of anaesthesia relative to hCG injection and the use of laparoscopic intrauterine artificial insemination were examined in the puma (Felis concolor). In Expt 1, females were treated with 100 (n = 6) or 200 (n = 8) IU eCG (i.m.) followed 80 h later by 100 IU hCG (i.m.) and were then anaesthetized 40-43 h after hCG injection for ovarian assessment. Although there was no difference (P > 0.05) in the number of unovulated ovarian follicles, females treated with 200 IU eCG had more (P < 0.05) corpora lutea per female and more corpora lutea as a percentage of the total number of ovarian structures. In Expt 2, all females were treated with 200 IU eCG and 80 h later with 100 IU hCG, and then anaesthetized either 31-39 h (Group A; n = 8) or 41-50 h (Group B; n = 6) after hCG injection for ovarian assessment. All Group B pumas ovulated compared with only three (37.5%) Group A females (P < 0.05). Compared with Group A, Group B pumas had more corpora lutea per female, more corpora lutea as a percentage of the total number of ovarian structures, and fewer unovulated follicles (P < 0.05). One of nine post-ovulatory females laparoscopically inseminated in utero with 16 x 10(6) motile spermatozoa became pregnant and delivered a healthy cub.(ABSTRACT TRUNCATED AT 250 WORDS)

Batorfi, J., V. Kovacs, et al. (1995). “A new method to repair inguino-femoral hernias: laparoscopic hernioplasty.  Acta Chirurgica Hungarica 35(1-2): 159-67.
The development of minimally invasive surgery has accepted the challenge by having tried to repair inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year. "Transabdominal preperitoneal" technique was applied in 61 cases and "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was neither wound infection, nor general complication. Spontaneously dissolving seroma/haematoma of the spermatic cord was noticed (detected by ultrasound) in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%) were considered to be caused by technical unexperience; the affected patients were treated successfully with the "intraperitoneal onlay mesh" technique. It is emphasized that laparoscopic hernioplasty has definite advantages, namely minimal postoperative pain, early mobilization, short hospital stay and early restoration of full physical activity (in 1 to 2 weeks). On the other hand, general anaesthesia and intraperitoneal invasion are required and the operation consumes much time and cost.

Bauer, J. J., J. T. Bishoff, et al. (1999). “Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome.  Journal of Urology 162(3 Pt 1): 692-5.
PURPOSE: We determine the subjective and objective durability of laparoscopic versus open pyeloplasty. MATERIALS AND METHODS: From August 1993 to April 1997, 42 patients underwent laparoscopic pyeloplasty (laparoscopy group) with a minimum clinical followup of 12 months (mean 22). Subjective outcomes and objective findings were compared to those of 35 patients who underwent open pyeloplasty (open surgery group) from August 1986 to April 1997 with a minimum clinical followup of 12 months (mean 58). We assessed clinical outcome based on responses to a subjective analog pain and activity scale. In addition, radiographic outcome was assessed based on the results of the most recent radiographic study. RESULTS: Of the 42 laparoscopy group patients 90% (38) were pain-free (26, 62%) or had significant improvement in flank pain (12, 29%) after surgery. Two patients had only minor improvement and 2 had no improvement in pain. Surgery failed in only 1 patient with complete obstruction. A patent ureteropelvic junction was demonstrated in 98% (41 of 42 patients) of the laparoscopy group on the most recent radiographic study (mean radiographic followup 15 months). Of the 35 open surgery group patients 91% were pain-free (21, 60%) or significantly improved (11, 31%) after surgery. One patient had only minor improvement and 2 were worse. CONCLUSIONS: Pain relief, improved activity level and relief of obstruction outcomes are equivalent for laparoscopic and open pyeloplasty.

Beck, D. H. and P. J. McQuillan (1994). “Fatal carbon dioxide embolism and severe haemorrhage during laparoscopic salpingectomy.  British Journal of Anaesthesia 72(2): 243-5.
We report a case of fatal carbon dioxide embolism and severe haemorrhage during laparoscopic salpingectomy. A sudden decrease in end-tidal carbon dioxide concentration occurred after 1 h of operating time which, together with the clinical signs, suggested carbon dioxide embolism. Haemorrhage after pelvic venous injury was first noted after deflation of the pneumoperitoneum and resulted in potentiation of the adverse haemodynamic effects of massive gas embolism. Minimally invasive surgery involves more extensive tissue trauma and an increased duration of pneumoperitoneum compared with diagnostic laparoscopy and may increase the risk of serious complications.

Berens, E. S. and J. R. Herde (1995). “Laparoscopic vascular surgery: four case reports [see comments].  Journal of Vascular Surgery 22(1): 73-9.
PURPOSE: We report four cases of laparoscopic vascular procedures (two iliofemoral bypasses, one aortobifemoral bypass, and one aortoiliac endarterectomy) performed with a technique that does not require insufflation of the peritoneal cavity with gas. METHODS: Initially in the porcine model and later in patients, we developed a laparoscopic technique with a mechanical arm used to mechanically elevate the abdominal wall, creating a working cavity. Conventional vascular instruments were used in combination with laparoscopic devices. Five to seven ports were needed for the procedures (four to six ports of 0.5 to 1.5 cm and one incision of 4.0 cm). Exposure was maintained by use of roticulating fan retractors and laparotomy sponges. End-to-side technique was used for all graft anastamoses (cross-clamp time of 40 to 70 minutes). Distal anastamoses were performed through an open femoral incision. Operative time was 5 hours (iliac procedure) and 7 hours (aortic procedure). RESULTS: All patients were ambulating and tolerating a regular diet within 24 hours (iliac procedures) or 48 hours (aortic procedures) after operation. They were discharged home on the second (iliac procedures) or third (aortic procedures) postoperative day. Within 1 week they had resumed normal daily activities. No complications occurred, and no blood bank products were transfused. When compared with the standard surgical approach, gasless laparoscopic technique gave a faster postoperative recovery with less pain and decreased the risk of wound herniation, dehiscence, and infection. From a laparoscopic standpoint, the use of disposable instruments was minimized and the theoretical risk of CO2 embolism eliminated. CONCLUSION: These four cases demonstrate that laparoscopic vascular bypass procedures are feasible and that the accepted advantages of laparoscopy can be extended to patients undergoing vascular surgery.

Bessell, J. R., G. J. Maddern, et al. (1994). “Combined thoracoscopic and laparoscopic oesophagectomy and oesophagogastric reconstruction.  Endoscopic Surgery & Allied Technologies 2(1): 32-6.
Subtotal oesophagectomy and stapled oesophagogastric anastomosis is a favoured option for cure or palliation of oesophageal carcinoma. This approach currently involves a thoracotomy and laparotomy exposing the patient to the attendant pulmonary and intrathoracic complications. Alternative approaches to oesophagectomy without thoracotomy have failed to diminish the complication rate and may compromise the chance of cure. An endoscopic approach to the oesophagus is considered to be an evolving solution because it removes the need for thoracotomy and laparotomy but adheres to established oncologic principles. In order to assess the feasibility of complete endosurgical oesophagectomy and immediate reconstruction a non-survival study using 10 pigs was undertaken. Under general anaesthesia a 3-step operation was performed consisting of thoracoscopic oesophageal dissection, laparoscopic gastric mobilisation and thoracoscopic oesophagogastric anastomosis using a circular endoluminal stapler (Stealth-Ethicon). Conversion to open surgery was required only once during a gastric dissection, and all anastomoses were safely constructed thoracoscopically. In three animals small anastomotic tears were repaired with endoscopically-placed sutures. Three animals died intraoperatively, two from an anaesthetic complication prior to the introduction of intra-operative monitoring, and the other following haemorrhage from an hepatic vein traumatised by a liver retractor. This study has shown that endosurgical oesophagectomy is technically feasible and stapled oesophagogastric anastomosis can be performed in a comparable manner to the conventional procedure.

Biswas, T. K. and J. A. Smith (1993). “Laparoscopic total fundoplication: anaesthesia and complications [letter].  Anaesthesia & Intensive Care 21(1): 127-8.

Blobner, M., H. J. Schneck, et al. (1994). “Vergleichende Untersuchungen der Aufwachphase. Laparoskopische Cholezystektomie nach Isofluran-, Methohexital- und Propofolanasthesie.  Anaesthesist 43(9): 573-81.
Total intravenous anaesthesia (TIVA) is increasingly used in short-stay surgery such as laparoscopic cholecystectomy. TIVA may provide fast recovery of psychomotor function, thus being of benefit to both the patient's behaviour and postoperative management. The purpose of this prospective study was to compare postoperative recovery from TIVA using propofol or methohexitone as the hypnotic component and balanced anaesthesia with isoflurane. PATIENTS AND METHODS. After giving informed consent and approval by the ethical committee of our hospital, 51 patients (ASA I, II) were investigated in a prospective study. Patients were randomised to receive either isoflurane, methohexitone, or propofol. Perioperative management with regard to premedication, intraoperative analgesia, relaxation, ventilation, and postoperative analgesia was carried out identically for all groups. Postoperative vigilance, pain, and nausea scores were assessed 15, 30, 60, 120, and 360 min after extubation with a visual analogue scale (VAS). At the same points, psychomotor recovery was investigated with the following assays: sedation as shown in Table 1; orientation with ten questions as to person, time, and location; memory as expressed by the patient's ability to repeat five words; a calculation test with five subtractions of the number 7 beginning from 100; and word generation by the number of words with an initial "m" given within 1 min and with animal names. Data were analysed with Kruskal Wallis' test for multiple comparisons between the groups and with Friedman's test for repeated measurements. All values are given as medians (interquartile range) or ranges. RESULTS. There was no difference between the groups' physical condition (Table 2). All intraoperative parameters compared well between groups; the management of anaesthesia was smoother with isoflurane than with the other anaesthetics. Psychomotor recovery was somewhat faster in the propofol group than the methohexitone group, as indicated by sedation score, orientation, memory and calculation tests (Table 4), word generation tests (Fig. 4), and subjective vigilance score (Fig. 3). The difference in recovery time between the propofol and isoflurane groups was minimal and without any significance or relevance. The incidence of postoperative nausea was significantly lower after balanced anaesthesia with isoflurane (24%, P < 0.05) as compared to TIVA with either propofol (53%) or methohexitone (41%). However, there were only minor differences between the groups; the ability to cooperate and be mobilised was not limited. DISCUSSION. Each of the three techniques used in this study is suitable for anaesthesia in patients undergoing laparoscopic cholecystectomy. Since fast recovery of vigilance and psychomotor function is very important in outpatient surgery, opioid-supplemented propofol anaesthesia is well established. Inhalation anaesthesia with isoflurane in air/oxygen without adding nitrous oxide compares well to propofol TIVA for laparoscopic surgery.

Bojahr, B., W. Straube, et al. (1997). “Erste Erfahrungen und Ergebnisse mit der gaslosen laparoskopischen pelvinen Lymphonodektomie in Kombination mit der vaginalen radikalen Hysterektomie nach Schauta beim Zervixkarzinom Stadium IB.  Zentralblatt fur Gynakologie 119(10): 492-9.
In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.

Bordahl, P. E., J. C. Raeder, et al. (1993). “Laparoscopic sterilization under local or general anesthesia? A randomized study.  Obstetrics & Gynecology 81(1): 137-41.
OBJECTIVE: To assess the safety, acceptability, and economy of local anesthesia and intravenous (IV) sedation versus short-term general anesthesia for laparoscopic sterilization. METHODS: We randomly allocated 125 of 150 consecutively sterilized women to either local or general anesthesia. No women were excluded, but 25 chose not to participate. The women were interviewed before surgery, and they returned a standardized questionnaire after discharge from the hospital. All laparoscopic tubal sterilizations were performed by senior gynecologists. Midazolam was used as premedication. In the local-anesthesia group, lidocaine with adrenaline was infiltrated infraumbilically and bupivacaine was applied to each tube. Midazolam and alfentanil were used as IV sedation. In the general-anesthesia group, intubation anesthesia was accomplished with alfentanil and propofol; atracurium was used for muscle relaxation. RESULTS: In the local-anesthesia group, operation time was shorter, perioperative discomfort was modest, and the costs of equipment were lower than in the general-anesthesia group. There was less postoperative abdominal pain and less need of analgesics, and the patients were more awake in the evening. The rise in heart rate and blood pressure were higher in the local-anesthesia group, and external oxygen was necessary to avoid apnea. Anesthetic surveillance was therefore mandatory. CONCLUSIONS: Local analgesia was highly acceptable to the majority of patients as well as to the gynecologists. The operation time was less, postoperative recovery was quicker, and the women were less bothered by abdominal pain and sore throat. There was a substantial reduction in anesthesia costs. Anesthetic surveillance during surgery was necessary.

Bossuto, E., L. Bonatti, et al. (2000). “Colecistectomia laparoscopica gasless. La nostra esperienza su 130 casi confrontati con 450 casi trattati con la tecnica con CO2.  Minerva Chirurgica 55(4): 201-3.
Alongside the technique based on the creation of an abdominal cavity for surgery following the introduction of gas (usually CO2) into the peritoneal cavity, a new method has been developed. This involves the use of an atraumatic mechanical lifting device connected to the same abdominal wall (gasless laparoscopy). The authors report a technique that uses an inflatable cushion inserted into the abdomen through a periumbilical incision. The cushion is connected to an external motorized hydraulic jack fixed to the operating table, fitted with an electric motor and friction gear. Between May 1991 and June 1998, 580 patients underwent laparoscopic cholecystectomy. Since December 1995 a total of 130 patients have undergone surgery using gasless laparoscopy. Shoulder pain and pain in the upper abdominal quadrant were no longer reported; pain was present in 70% of the patients operated using the CO2 technique. There was also a marked reduction in the anesthesiological risks, above all in elderly patients with cardiopulmonary insufficiency. Surgical manoeuvres are made easier owing to the possibility of using traditional surgical instruments. Washing and continuous aspiration allow a good control of intraoperative hemostasis, and reduce the phenomenon of lens misting without the risk of losing pneumoperitoneum. Less visibility of the surgical field was reported, particularly in obese patients, above all because of the reduced diaphragmatic distension and the lack of displacement of the intestinal loops. In the authors' opinion the gasless technique is suitable above all in patients affected by cardiopulmonary disorders in whom hypercapnia might represent a significant operating risk.

Bozkurt, P., G. Kaya, et al. (2000). “Systemic stress response during operations for acute abdominal pain performed via laparoscopy or laparotomy in children [see comments].  Anaesthesia 55(1): 5-9.
We compared the endocrine and metabolic changes during acute emergency abdominal surgery performed using either laparoscopy or laparotomy in children. Twenty-nine children aged 1.5-14 years were assigned to undergo laparoscopy (n = 15) or laparotomy (n = 14) with a standard anaesthesia technique. Arterial blood gases and blood prolactin, cortisol, interleukin-6, glucose, insulin, lactic acid and epinephrine levels were determined 5 min after the induction of anaesthesia, 30 min into surgery and at the end of surgery. Intra-operative heart rate and mean arterial pressure were stable in both groups. In the laparoscopy group, slight respiratory acidosis occurred during surgery (p < 0.01) but there were no changes in the laparotomy group. Insulin, cortisol, prolactin, epinephrine, lactate and blood glucose levels increased in both groups (p < 0.05) although there was no difference between the groups. The surgical stress and trauma imposed by laparoscopy seems similar to that caused by laparotomy in children undergoing emergency abdominal surgery.

Brams, D. M., M. Cardoza, et al. (1993). “Laparoscopic repair of traumatic gastric perforation using a gasless technique.  Journal of Laparoendoscopic Surgery 3(6): 587-91.
Laparoscopy has been used in the evaluation of injuries secondary to blunt and penetrating trauma. In this case report, we describe the use of a new gasless laparoscopic technique using conventional instruments to successfully evaluate and repair a traumatic gastric perforation.

Burmucic, R. (1987). “Die Sterilisation der Frau unter besonderer Berucksichtigung der laparoskopischen Tubensterilisation.  Wiener Klinische Wochenschrift 99(21): 751-63.
Within recent years female sterilization has gained a place of great importance as an effective contraceptive method. Nowadays sterilization is hardly subject to any formal restrictions, but is solely the responsibility of the woman concerned, the couple or the physician. The indications for sterilization may be divided into two main groups, namely for medical indications and family planning. Sterilization is carried out on the uterus or tubes. Today the method of choice is laparoscopic tubal sterilization. The most frequently used procedure and the safest way of tubal occlusion is bipolar electrocoagulation of the entire isthmic tubal portions without additional section of the tubes. The complication rate in laparoscopic tubal sterilization depends on the type of anaesthesia, on the skill of the operator and on patient risk factors such as obesity etc. Minor intraoperative complications are of little importance since they are easily remedied during laparoscopy. Severe complications are rare, but have to be corrected immediately by laparotomy. Pregnancies on account of failure in sterilization procedure may be due to the occlusion technique, the lack of experience of the operator, the timing of sterilization and the observation period. Altogether 2372 laparoscopic tubal sterilizations were performed at the University Department of Obstetrics and Gynaecology in Graz between January 1st, 1975 and December 31st, 1985. During these eleven years a specific technique has been developed, whereby standard methods were simplified and improved. No intrauterine cannula for mobilizing the uterus is applied to avoid infection or perforation. The preferred "single-puncture technique" offers many advantages over the older "double-puncture technique", since fewer instruments are needed and the operation is less time-consuming, eliminating the danger of a second puncture. Moreover, the procedure is easier to perform and the cosmetic result better. In high-risk patients, especially the extremely obese, the laparoscopic technique has been improved by a special method of introducing the trocar.

Burns, J. M., D. M. Hart, et al. (1988). “Effects of nadolol on arrhythmias during laparoscopy performed under general anaesthesia [see comments].  British Journal of Anaesthesia 61(3): 345-6.
Cardiac arrhythmias are a well recognized complication of anaesthesia for laparoscopy. The effect of nadolol, given by mouth 12 h before operation, was compared with placebo on arrhythmias in 86 females undergoing laparoscopy. All types of arrhythmia were documented; there was a 97% incidence in the placebo group, but in the nadolol group there was a smaller incidence of supraventricular tachycardia, ventricular ectopics and atrioventricular dissociation (P less than 0.01). There was no significant difference in the incidence of sinus bradycardia. Nadolol may be recommended as a safe agent to be given by mouth before laparoscopy to reduce the frequency of cardiac arrhythmias during anaesthesia.

Caceres, D. and K. Kim (1978). “Spinal anesthesia for laparoscopic tubal sterilization.  American Journal of Obstetrics & Gynecology 131(2): 219-20.

Caldwell, J. E., J. M. Braidwood, et al. (1985). “Vecuronium bromide in anaesthesia for laparoscopic sterilization.  British Journal of Anaesthesia 57(8): 765-9.
Vecuronium bromide 70 micrograms kg-1 was used to facilitate tracheal intubation and provide neuromuscular blockade in 52 patients undergoing laparoscopic sterilization. Anaesthesia was maintained with 67% nitrous oxide in oxygen. Patients were monitored clinically and by tactile assessment of the evoked response of the adductor pollicis to a supramaximal train-of-four stimulation. Intubating conditions were assessed at 90 s in the first 33 patients, and were poor. They improved significantly in the subsequent 19 patients when intubation was delayed until 150 s (P less than 0.05). Operating conditions were good in all except two patients. Residual neuromuscular blockade was antagonized rapidly at completion of surgery by neostigmine 2.5 mg i.v., which was administered provided there was at least one twitch response. The mean duration of the procedure was 14.3 min (SD 2.5 min). The mean time from injection of neostigmine to satisfactory spontaneous breathing and neuromuscular recovery was 1.6 min (SD 0.7 min).

Casey, W. F. (1984). “Laparoscopy under local anaesthesia [letter].  Journal of the Royal Society of Medicine 77(11): 985-6.

Catani, M., R. De Milito, et al. (2000). “Colecistectomia con tecnica laparoscopica gasless. Intervento di scelta in un paziente con elevato rischio operatorio.  Minerva Chirurgica 55(1-2): 45-8.
Disadvantages related to CO2 pneumoperitoneum in high risk patients (anesthesiologic classification in III and IV ASA), have led to the development of the abdominal wall retractor, a device designed to facilitate laparoscopic surgery without conventional pneumoperitoneum. A case of a patient with acute cholecystitis, well-compensated liver cirrhosis, and high respiratory and cardiologic risk (ASA III class), submitted to laparoscopic cholecystectomy with gasless technique is reported.

Chang, F. H., Y. K. Soong, et al. (1996). “Laparoscopic myomectomy of large symptomatic leiomyoma using airlift gasless laparoscopy: a preliminary report.  Human Reproduction 11(7): 1427-32.
Despite the expanding role of laparoscopic surgery in many gynaecological fields, some discrepancies still exist regarding the efficacy of laparoscopic myomectomy in treating patients with large symptomatic leiomyoma. In this report, a better operative procedure and the results of treatment are evaluated. Patients (n = 14) presenting with infertility, menorrhagia, pressure symptoms or pelvic mass associated with a large leiomyoma were managed with laparoscopic myomectomy using airlift gasless laparoscopy. Uterine size ranged from 14 to 24 weeks gestational age and the weight of the myoma ranged from 246 to 669 g (mean 454); operative time ranged from 78 to 165 min (mean 104) and blood loss from 90 to 580 ml (mean 201). No major complication occurred during the operation or follow-up. All except one patient were discharged within 72 h of the operation and resumed normal activity within 1 week. When myomectomy is indicated, the airlift gasless laparoscopic approach appears to offer a better alternative to abdominal or pneumoperitoneum laparoscopic surgery in selected cases. Airlift gasless laparoscopy has several advantages: (i) small abdominal incisions and minimal endoscopic equipment are required; (ii) the excised leiomyomata mass can be easily cut into strips and removed through the small abdominal incision; (iii) the uterine defect can be more efficiently repaired using easily performed suture techniques; (iv) high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum; and (v) the potential risk of metabolic and haemodynamic derangements during pneumoperitoneum laparoscopy are obviated. Gasless laparoscopy also has some disadvantages. The exposure obtained with gasless laparoscopy is not as good, under some circumstances, as that achieved by pneumoperitoneum. For patients who are thin, and even those with moderate obesity, the exposure obtained with airlift mechanical suspension is adequate; however, morbidly obese patients with previous abdominal surgery with suspected pelvic adhesions can incur some problems during the operation because of a poor operative field.

Chen, R. N., R. G. Moore, et al. (1998). “Laparoscopic pyeloplasty. Indications, technique, and long-term outcome.  Urologic Clinics of North America 25(2): 323-30.
Laparoscopic pyeloplasty is one of several minimally invasive treatment options for UPJ obstruction. In fact, several endoscopically and fluoroscopically controlled methods of incising the obstructed UPJ are now available that are significantly less invasive and less morbid in comparison with open pyeloplasty. However, the long-term success rates of these incisional techniques are less than the rates reported for open pyeloplasty. Several causes of obstruction may be present in the primarily obstructed UPJ, including kinking or compression related to crossing vessels or intrinsic narrowing at the UPJ. One potential reason for the inferior success rates of incisional methods in comparison with open pyeloplasty is that the former techniques address the intrinsically narrowed UPJ but may not address extrinsic problems such as kinking of the ureter associated with fibrotic bands or compression from crossing vessels. Laparoscopic pyeloplasty addresses all potential causes of obstruction. Any fibrotic bands kinking the ureter are divided, and the ureter is spatulated through the level of the UPJ prior to completion of the anastomosis. If a crossing vessel is encountered, a dismembered pyeloplasty is performed, the ureter and renal pelvis are transposed to the opposite side of the vessels, and the anastomosis is completed. An additional disadvantage of incisional techniques is the significant risk of hemorrhage following incision of the UPJ, with as many as 3% to 11% of patients requiring blood transfusion. Hemorrhage may occur owing to an errant anterior incision, the presence of a crossing vessel, incision into the renal parenchyma adjacent to the UPJ, or as the result of bleeding from the percutaneous access site. In contrast, mean estimated blood loss in the authors' series of 57 laparoscopic pyeloplasties was 139 mL, and none of the patients required blood transfusion. Although it is more morbid in comparison with retrograde or fluoroscopically controlled endopyelotomy, laparoscopic pyeloplasty seems at least comparable to antegrade percutaneous endopyelotomy in terms of the length of hospitalization and patient convalescence. Laparoscopic pyeloplasty, however, offers a higher success rate than with incisional techniques, not only from a radiographic standpoint but from a subjective standpoint as determined by the results of the analogue pain and activity questionnaire. The major disadvantage of laparoscopic pyeloplasty is the need for proficiency in laparoscopic techniques and for a longer operative time. As a result, the literature on laparoscopic pyeloplasty consists primarily of small series. Janetschek and co-workers reported on a series of 17 patients who underwent laparoscopic pyeloplasty, including 14 via a transperitoneal approach and 3 via a retroperitoneal approach. Procedures performed included ureterolysis alone, dismembered pyeloplasty, and nondismembered (Fenger) pyeloplasty. "Fenger-plasty" is similar to Y-V pyeloplasty and is performed by incising the UPJ longitudinally and closing the incision transversely in a Heineke-Mikulicz fashion. Janetschek and colleagues reported a 100% success in the eight patients who underwent dismembered pyeloplasty but believed that this technique was too cumbersome and should be reserved for patients with long stenoses, dorsally crossing vessels, or large renal pelvis. Because two of the four patients undergoing ureterolysis alone failed treatment, Janetschek and colleagues have abandoned this technique. They now prefer the Fenger-plasty technique, even in the setting of ventrally crossing vessels, because the technique can be performed quickly with one to three sutures, and the anastomosis can be sealed with fibrin glue and a flap of Gerota's fascia. Their experience with this technique, however, remains relatively limited. Technologic advances such as the Endostitch device have facilitated reconstructive laparoscopic procedures such as pyeloplasty. (ABSTRACT TRUNCATED)

Chiang, M. H., J. O. Wong, et al. (1995). “[The effect of needleless electroacupuncture in general anesthesia during laparoscopic surgery].  Acta Anaesthesiologica Sinica 33(2): 107-12.
BACKGROUND: Three kinds of pain-relieving substances, namely, endorphins, enkephalins and dynorphins, can be released by stimulating the relevant acupoints with the dense-disperse mode of nerve stimulator. The neurochemical mechanisms of pain relief by acupoint stimulation have been widely studied and proved. In the present study, we investigated the modulatory effect of needleless electroacupuncture on the inhaled general anesthesia during laparoscopic surgery. METHODS: Forty gynecologic patients of ASA class I-II status, scheduled for elective laparoscopic surgery, were randomly allocated to study and control groups. Induction and intubation were performed in the same fashion and anesthesia was maintained with inhaled general anesthetics: 50% N2O in oxygen and isoflurane, which was adjusted to keep the hemodynamic changes within +/- 10% of their preoperated level. HANS (LY 257), a special nerve stimulator with 2 Hz and 100 Hz dense-disperse wave, was used to stimulate the bilateral Yang Ling Chuan (G34), Zusanli (S36) acupoints in patients of the study group during the surgery. RESULTS: We found that needleless electroacupuncture significantly lowered the volume concentration of isoflurane from 1.0 +/- 0.33% to 0.74 +/- 0.19% (p < 0.05) at 30 min after the start of operation. Furthermore, it also significantly shortened the recovery time from 11.4 +/- 3.3 min to 8.8 +/- 3.2 min (p < 0.05). CONCLUSIONS: Under general anesthesia, the application of needleless electroacupuncture can reduce the volume concentration of isoflurane and shorten the post-anesthetic recovery time during laparoscopic surgery.

Chiu, H. H. and K. H. Ng (1977). “Complication of laparoscopy under general anaesthesia.  Anaesthesia & Intensive Care 5(2): 169-71.
Two cases are presented in which injury to the stomach occurred in association with laparoscopy under general anaesthesia. The common aetiological factor was gastric inflation resulting from I.P.P.V. via mask. Precautionary measures in the anaesthetic induction technique are described.

Chiu, A. W., W. J. Huang, et al. (1996). “Laparoscopic ligation of bilateral spermatic varices under epidural anesthesia.  Urologia Internationalis 57(2): 80-4.
Feasibility and safety of laparoscopic ligation of bilateral internal spermatic varices under epidural anesthesia were assessed in 11 patients. Another 11 patients undergoing the same procedure under ventilation-assisted anesthesia served as controls. Patients in both groups belonged to the American Society of Anesthesia functional class I. Arterial blood analyses were obtained (1) in the horizontal supine position; (2) in the 15 degrees Trendelenburg position; (3) at 15 min after carbon dioxide pneumoperitoneum insufflation, and (4) at 15 min after desufflation in the supine position. In the epidural anesthesia group arterial blood parameters and respiratory rate remained stable in the Trendelenburg position. After intraperitoneal insufflation of carbon dioxide for 15 min, the arterial carbon dioxide level increased from 40.1 +/- 2.2 to 42.1 +/- 2.6 mm Hg, the respiratory rate increased from 17.0 +/- 1.4 to 20.6 +/- 1.2/min, the blood pH value decreased from 7.386 +/- 0.027 to 7.355 +/- 0.034, all values showing statistically significant differences. These changes returned to the preinsufflation level 15 min after release of the pneumoperitoneum. The above-mentioned parameters remained unchanged under the pneumoperitoneum by assisted ventilation in the control group. The mean time of surgery was similar in both groups: 82 and 90 min for the groups having general and epidural anesthesia, respectively. All laparoscopic procedures were accomplished successfully under general anesthesia. However, failure to ligate the internal spermatic varices occurred in 3 patients under epidural anesthesia, mainly due to patient intolerance to abdominal distension. The operation was continued under intubated general anesthesia for relaxing the abdominal muscle to provide an adequate working space. In 8 patients being successfully operated under epidural anesthesia, 5 experienced mild but tolerable abdominal distension; 2 complained of shoulder pain intraoperatively. Although laparoscopic ligation of internal spermatic varices could be accomplished in some patients under epidural anesthesia, it carried a high failure rate, more intraoperative morbidity, and significant arterial blood gas alterations. Routine ventilation-assisted anesthesia is suggested for therapeutic laparoscopy even for an easy procedure such as the ligation of the internal spermatic varices.

Chow, W. P., A. Loganath, et al. (1993). “Response of ovary in young women experiencing laparoscopy under general anaesthesia.  Medical Journal of Malaysia 48(1): 56-63.
This study investigated whether changes in circulating levels of immunoreactive oestradiol-17 beta (E2), progesterone (P) and testosterone (T) occur in women at follicular (n = 18, age 25 to 39 years) and luteal (n = 17, 25 to 39 years) phases of the normal menstrual cycles, experiencing laparoscopy after intravenous sedation with general anaesthesia. The pre- and intra-operative follicular phase plasma steroid hormone concentrations were 153.5 +/- 84.3 vs 297.4 +/- 220.8 pg/ml for E2, 2.0 +/- 3.2 vs 3.3 +/- 3.8 ng/ml for P and 746.6 +/- 415.9 vs 1325.8 +/- 535.1 pg/ml for T, respectively. The corresponding luteal phase steroid levels were 259.7 +/- 120.2 vs 382.7 +/- 188.7 pg/ml, 7.0 +/- 4.8 vs 9.9 +/- 6.1 ng/ml and 819.4 +/- 355.7 vs 1703.5 +/- 1058.1 pg/ml. Using the Wilcoxon rank sum test, intra-operative hormone levels with the exception of P in the luteal phase were found to be significantly elevated (p < 0.05). The results suggest that laparoscopy under general anaesthesia evokes increased secretion of ovarian hormones, possibly via the activation of hypothalamo-pituitary-ovarian axis.

Chui, P. T., T. Gin, et al. (1993). “Anaesthesia for laparoscopic general surgery.  Anaesthesia & Intensive Care 21(2): 163-71.
Laparoscopic surgery minimises postoperative morbidity. Patient benefits include reduction in postoperative pain, better cosmetic result and quicker return to normal activities. Hospital stay is shortened resulting in a reduction in overall medical cost. The intraoperative requirements of laparoscopic surgery however can lead to serious physiological changes and complications. While there is a low but definite perioperative mortality rate associated with minor gynaecologic laparoscopic procedures, laparoscopic general surgical procedures are performed on older patients and patients with acute surgical conditions and are likely to be associated with a higher incidence of perioperative complications. The major problems during laparoscopic surgery are related to the cardiopulmonary effects of pneumoperitoneum, systemic carbon dioxide absorption, extraperitoneal gas insufflation, venous gas embolism and unintentional injuries to intra-abdominal structures. An appraisal of the potential problems is essential for optimal anaesthetic care of patients undergoing laparoscopic surgery. Appropriate anaesthetic techniques and monitoring facilitate surgery and allow early detection and reduction of complications. The need for rapid recovery and short hospital stay impose additional demands on the anaesthetist for skillful practice.

Cohen, M. M., W. Young, et al. (1996). “Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario? [see comments].  CMAJ 154(4): 491-500.
OBJECTIVE: To examine the effect of the introduction of laparoscopic cholecystectomy (LC) on patterns of practice (number of cholecystectomy procedures, case-mix and length of hospital stay) and patient outcomes in Ontario. DESIGN: Cross-sectional population-based time trends using hospital discharge data. SETTING: All acute care hospitals in Ontario where cholecystectomy was provided. PATIENTS: All 119,821 Ontario residents who underwent cholecystectomy between 1989-90 and 1993-94. After exclusions (initial bile duct exploration, cancer, incidental cholecystectomy, or missing codes for age, sex or residence) 108,442 patients remained. OUTCOME MEASURES: Number of cholecystectomy procedures, proportion of patients with acute or chronic gallstone disease, length of hospital stay, and rates of death, readmission, and bile duct injury and other in-hospital complications after cholecystectomy by year. RESULTS: The number of cholecystectomy procedures increased by 30.4% between 1989-90 and 1993-94. The number of patients with chronic gallstone disease increased by 33.6%, and the number who underwent elective surgery increased by 48.3%. The proportion of procedures performed as LC increased from 1.0% in 1990-91 to 85.6% in 1993-94. Patients who received LC tended to be younger female patients with chronic gallstone disease with no coexisting conditions undergoing elective operations. The mean length of stay, adjusted for case-mix differences, was significantly lower in 1993-94 than in 1989-90 (2.6 days v. 7.5 days) (p < 0.05); the values for LC and open cholecystectomy in 1993-94 were 1.8 days and 7.3 days respectively. The decrease in the crude death rate over the study period (0.3% to 0.2%) was not significant (relative odds 1.10, 95% confidence interval [CI] 0.72 to 1.69). In 1993-94 the adjusted risk of readmission to hospital within 30 days was 1.38 (95% CI 1.19 to 1.58) as compared with 1989-90. Over the 5 years the rate of bile duct injuries tripled (0.3% in 1989-90 v. 0.9% in 1993-94). The adjusted risk of having at least one complication after cholecystectomy in 1993-94 was 1.90 (95% CI 1.75 to 2.07) as compared with 1989-90. CONCLUSIONS: LC has had a substantial effect on the number of cholecystectomy procedures performed, the type of patient having the gallbladder removed and the length of hospital stay. Death rates are unchanged, but the odds of readmission and in-hospital complications are both increased. Future research should be directed toward determining the reasons for the overall increase in rates, developing methods to reduce bile duct injuries and identifying other relevant outcomes, such as patient satisfaction with the procedure.

Collins, S. J., A. L. Robinson, et al. (1996). “A comparison between total intravenous anaesthesia using a propofol/alfentanil mixture and an inhalational technique for laparoscopic gynaecological sterilization.  European Journal of Anaesthesiology 13(1): 33-7.
Thirty patients undergoing laparoscopic gynaecological sterilization, as day-cases, were randomly allocated to receive either total intravenous anaesthesia (TIVA) with a propofol and alfentanil mixture or a standard inhalational technique. Immediate recovery, as measured by times to awakening, co-operation and orientation, and psychomotor recovery, as measured by 'P' deletion studies, were not significantly different between the two groups. TIVA produced a significant reduction in post-operative nausea at both 1 and 2 h post-operatively, as measured by a visual analogue scale (P < 0.01). No patient in the TIVA group vomited whereas two vomited in the inhalational group. There were no differences between the two groups with respect to suitability for discharge home and no incidences of awareness. We conclude that TIVA with a propofol and alfentanil mixture provides satisfactory anaesthesia for gynaecological sterilization, with good recovery characteristics and a low incidence of post-operative nausea and vomiting.

Coptcoat, M. J. (1992). “Laparoscopy in urology: perspectives and practice.  British Journal of Urology 69(6): 561-7.

Coptcoat, M. J. (1995). “Overview of extraperitoneal laparoscopy.  Endoscopic Surgery & Allied Technologies 3(1): 1-2.
Recent developments in extraperitoneal endoscopic techniques are causing a second wave of excitement amongst laparoscopic surgeons. In certain situations, there are definite advantages over an intraperitoneal alternative but the new interest of many surgeons for whom this has always been a more natural open route is also very welcome and timely. Many of the frustrating problems of access into the extraperitoneal space have been overcome by the introduction of an expanding dissecting balloon which both creates an adequate working space and tamponades potentially small haemorrhagic vessels torn in the dissection. Routine laparoscopic techniques can then take over using carbon dioxide for insufflation. The major advantage for the patient seems to be reduced post-operative pain but the major problem facing the surgeon is one of orientation in a space where there are no recognisable anatomical landmarks. This problem is being overcome with adjuvant radiological techniques.

Coptcoat, M. J. (1995). “The future of laparoscopy in urology.  Annales d Urologie 29(2): 117-21.
Laparoscopy has not changed urological techniques as radically as could be supposed, as only 17% of urological techniques are performed by laparoscopy instead of the predicted 70%. However, this limited proportion corresponds to 30% of urological operating time. The author proposes a combination of open surgery and laparoscopy in certain cases. Laparoscopy is responsible for lower blood loss, less postoperative pain, a shorter hospital stay and a very small scar which account for its popularity among patients. A rational combination of laparoscopy, endoscopy and open surgery to treat urological diseases should be developed in the future.

Cottin, V., B. Delafosse, et al. (1996). “Gas embolism during laparoscopy: a report of seven cases in patients with previous abdominal surgical history.  Surgical Endoscopy 10(2): 166-9.
The use of laparoscopic surgery has grown considerably, and the occurrence of some accidents, albeit rare, is now reported. Among them, gas embolism can induce a bad postoperative outcome. We report seven cases of carbon dioxide embolism (CO2) during laparoscopic surgery. In the seven cases gas embolism occurred during insufflation or a few minutes later. All the patients had a previous abdominal or pelvic surgical history. Five patients presented cardiac bradycardia or arrhythmia. Cardiovascular collapse or cyanosis was the first manifestation in three cases. Sudden bilateral mydriasis was the earliest neurologic sign, present in five cases. Finally, the gas embolism complication was lethal in two cases. In summary, this study strongly stresses the need for precise rules of prevention of gas embolism, and close monitoring of cardiac rhythm during insufflation of carbon dioxide. The patients who had previous surgery should be considered as a risk population.

Couture, P., D. Boudreault, et al. (1997). “Haemodynamic effects of mechanical peritoneal retraction during laparoscopic cholecystectomy.  Canadian Journal of Anaesthesia 44(5 Pt 1): 467-72.
PURPOSE: Abdominal wall retraction (AWR) was recently proposed as an alternative for CO2 pneumoperitoneum. In this study we evaluated the cardiorespiratory effects of AWR during laparoscopic cholecystectomy. METHODS: Fifteen patients were studied during laparoscopic cholecystectomy using AWR. Monitoring included heart rate (HR), mean arterial pressure (MAP), pulse oxymetry (SpO2), end-tidal CO2 (PETCO2) minute ventilation, and peak inspiratory pressure (PIP). Using transoesophageal echocardiography, the transgastric short axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). These parameters were measured at predetermined periods: 1) five minutes after anaesthetic induction, 2) five minutes after AWR insertion, 3) 15 min after AWR insertion, and 4) after the end of surgery. RESULTS: No change in any measured parameter was observed over time in the AWR group except for an increase in MAP (P < 0.05) after AWR insertion. There were no changes in EDA, ESA and EF during the study, reflecting stable global cardiac function. In addition, no embolic episodes were observed during surgery. CONCLUSION: Our results demonstrate that the use of gasless abdominal distention for laparoscopic cholecystectomy results in a stable haemodynamic profile in healthy patients without cardiac disease, except for a brief increase in MAP after the AWR insertion. The advantages of AWR over conventional pneumoperitoneum should be confirmed in higher risk patients in a prospective, randomized study.

Coventry, D. M. (1995). “Anaesthesia for laparoscopic surgery.  Journal of the Royal College of Surgeons of Edinburgh 40(3): 151-60.
Laparoscopic surgery offers patients a significant number of advantages, including a reduction in pain and cosmetic injury that facilitates early ambulation and a rapid return to normal activities. Although the surgery is of a minimally invasive nature, there are a number of specific physiological alterations occurring as a result of creating the pneumoperitoneum and the postural changes involved in optimizing patient position. These may be particularly in patients with pre-existing respiratory and cardiovascular disease. In addition, there may be surgical hazards related to trocar insertion or other instrumental injuries leading to haemorrhage, peritonitis or gas embolism. It is important for all clinicians involved with these cases to be familiar with the physiological alterations and potential hazards and for the anaesthetist to employ appropriate techniques and monitoring to allow early detection of problems and to minimize perioperative morbidity.

Cravello, L., C. D'Ercole, et al. (1999). “Laparoscopic surgery in gynecology: randomized prospective study comparing pneumoperitoneum and abdominal wall suspension.  European Journal of Obstetrics, Gynecology, & Reproductive Biology 83(1): 9-14.
OBJECTIVE: To compare laparoscopic surgery using insufflation of carbon dioxide gas with laparoscopic surgery using abdominal wall retractor in gynecology. Setting: University hospital. DESIGN: Prospective randomized study. MATERIAL AND METHODS: Fifty-one patients were assigned to the gasless laparoscopy group, and 52 patients were assigned to the laparoscopy group with pneumoperitoneum. Patients presented with ovarian cyst, endometriosis, acute salpingitis, hydrosalpinx and extra-uterine pregnancy. RESULTS: No severe complications were noted. One conversion to laparotomy was performed in each group. Eight gasless laparoscopic procedures were converted into laparoscopy with pneumoperitoneum; difficulties appeared in patients with adhesions following laparotomy and in cases of unsatisfactory exposure of the pelvis. No differences appeared between the two groups in terms of complications, quality of the operative sequelae, and duration of hospitalization. CONCLUSION: Gasless surgery is a recent technique and progress in modifying the equipment is necessary to reduce conversions.

Critchley, L. A., J. A. Critchley, et al. (1993). “Haemodynamic changes in patients undergoing laparoscopic cholecystectomy: measurement by transthoracic electrical bioimpedance.  British Journal of Anaesthesia 70(6): 681-3.
Using transthoracic electrical bioimpedance with the BoMed NCCOM3-R7, we measured cardiovascular changes in 16 ASA I and II Chinese patients undergoing laparoscopic cholecystectomy. The peritoneal cavity was insufflated with carbon dioxide to a pressure up to 15 mm Hg. Tidal volume, minute volume and end-tidal carbon dioxide partial pressure were kept constant. Insufflation resulted in a mean (SD) 13 (14)% decrease in stroke index (SI) (P < 0.01), but the effect on cardiac index (CI) was more variable (mean 7 (17)% decrease, range 36% decrease to 22% increase (P = 0.07)). Mean arterial pressure increased by 55 (29)% (P < 0.001) and systemic vascular resistance index increased by 63 (33)% (P < 0.001), with the maximum effect occurring 10-15 min after the commencement of insufflation. Multiple regression analysis showed a greater decrease in SI in patients with a small body mass index and large intraperitoneal pressure (P = 0.01), while a greater decrease in CI was found in patients with a small body mass index and younger age (P = 0.001). Three patients had a further reduction in CI during surgery, with one patient having a 48% decrease compared with pre-induction values. Deflation of the peritoneum resulted in an increase in both CI (25 (26)%) and (22 (29)%) (P < 0.01) to values which were not different from pre-induction data. Arterial blood-gas analysis showed decreases in pH and base excess after 1 h of insufflation (P < 0.01).

Cunningham, A. J. (1994). “Laparoscopic surgery--anesthetic implications.  Surgical Endoscopy 8(11): 1272-84.
Laparoscopic cholecystectomy is a relatively new surgical procedure which is enjoying ever-increasing popularity and presenting new anesthetic challenges. The advantages of shorter hospital stay and more rapid return to normal activities are combined with less pain associated with the small limited incisions and less postoperative ileus compared with the traditional open cholecystectomy. The efficacy of laparoscopic appendectomy and hemicolectomy has been recently evaluated. However, there have been no prospective randomized studies to date comparing laparoscopic with traditional laparotomy techniques. The physiological effects of prolonged pneumoperitoneum and the longer duration of surgery with the laparoscopic techniques are of concern. The application of laparoscopic inguinal hernia repair may be limited because, unlike traditional surgical hepair, general anesthesia is required and concerns have been expressed about the duration of surgery and the possibility of hernia recurrence. Notwithstanding case reports and series describing successful diaphragmatic and hiatus hernia repair using a laparoscopic surgical technique, the frequently encountered complications of cervical surgical emphysema, pneumothorax, and pneumomediastinum, attributed to passage of insufflating gas through weak points or defects in the diaphragm, must be of major concern. Anesthesiologists must maintain a high index of suspicion for these potential complication and must undertake appropriate monitoring. If there is clinical evidence of a tension pneumothorax, immediate chest tube decompression is indicated. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiological changes associated with patient positioning and pneumoperitoneum creation. The choice of anesthetic technique for upper abdominal laparoscopic procedures is most frequently limited to general anesthesia. Controlled ventilation avoids hypercarbia, and an anesthetic technique incorporating antiemetics and nonsteroidal anti-inflammatory agents has reduced postoperative nausea and vomiting following laparoscopic cholecystectomy. The use of nitrous oxide during laparoscopic procedures remains controversial. Laparoscopic cholecystectomy is a major advance in the management of patients with symptomatic gall-bladder disease. However, in the present era of cost containment, older and sicker patients may present for this procedure on the day of surgery without adequate preoperative evaluation. Anesthesiologists should thus be prepared to recommend deflation of the pneumoperitoneum and possibly conversion to an open procedure if hemodynamic, oxygenation, or ventilation difficulties arise during the procedure.

Cunningham, A. J. (1999). “Anesthetic implications of laparoscopic surgery.  Yale Journal of Biology & Medicine 71(6): 551-78.
Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease.

D'Ercole, C., L. Cravello, et al. (1996). “Gasless laparoscopic gynecologic surgery.  European Journal of Obstetrics, Gynecology, & Reproductive Biology 66(2): 137-9.
OBJECTIVE: Evaluate gasless laparoscopic gynecologic surgery as an alternative to conventional technique with carbon dioxide insufflation. STUDY DESIGN: Retrospective study of 49 cases. RESULTS: Gasless laparoscopic gynecologic surgery was successful in 90% of cases. The gasless technique permits the surgical team to use the laparoscopic and vaginal approach simultaneously. CONCLUSIONS: Gasless laparoscopic gynecologic surgery seems to be a reliable alternative to conventional laparoscopy for selected indications.

D'Urbano, C., F. Fuertes Guiro, et al. (1996). “Colecistectomia laparoscopica "gasless" mediante elevatore della parete addominale.  Giornale di Chirurgia 17(3): 121-4.
The Authors present a new gasless laparoscopic cholecystectomy method using an abdominal wall elevator with subcutaneous traction ("laparotenser"). Fifty patients between May 1994 and March 1995 were operated by videolaparoscopy using this new gasless method. Twenty of them were operated with Nagai's method while the laparotenser was used in the remaining thirty. The results obtained are similar to those using pneumoperitoneum. It has been observed a global reduction of costs, less postoperative pain, no influence in cardiovascular and metabolic indexes. No complications were reported during the postoperative period but two cases of conversion to laparotomy not related to the method used were needed. Laparoscopic cholecystectomy without pneumoperitoneum using the subcutaneous elevator of the abdominal wall ("laparotenser") has demonstrated that it's possible to operate in a working space similar to that created by the pneumoperitoneum. After an initial period of distrust towards the laparoscopic methods without pneumoperitoneum it has been accepted that gasless methods multiply the indications to minimally invasive surgery in patients with cardiorespiratory problems considered no ideal candidates to laparoscopic cholecystectomy with pneumoperitoneum.

de Grood, P. M., J. B. Harbers, et al. (1987). “Anaesthesia for laparoscopy. A comparison of five techniques including propofol, etomidate, thiopentone and isoflurane.  Anaesthesia 42(8): 815-23.
This is a report about five anaesthetic techniques for laparoscopy. Propofol and etomidate were used for total intravenous anaesthesia. Propofol, etomidate and thiopentone were used as induction agents prior to inhalational anaesthesia with isoflurane and nitrous oxide. Fentanyl was used for analgesia. Induction with propofol and thiopentone was rapid. Etomidate induction was characterised by myoclonus. Maintenance was smooth with inhalational anaesthesia. Of the groups that received total intravenous anaesthesia, propofol provided stable anaesthesia but required extra bolus doses. Recovery was the most rapid following total intravenous anaesthesia with propofol. Postoperative side effects were much lower after propofol. No difference was observed between the groups with regard to changes in arterial blood pressure and heart rate.

de Souza, R. M. and A. R. Lazzaron (1999). “Controlled trial of preperitoneal local anaesthesia for reducing pain following laparoscopic hernia repair [letter; comment].  British Journal of Surgery 86(1): 137.

Debrock, M. and I. Brosens (1979). “Laparoscopic tubal ring sterilization under local anesthesia.  European Journal of Obstetrics, Gynecology, & Reproductive Biology 9(1): 41-4.

Delogu, G., C. Tomasello, et al. (1995). “Colecistectomia laparoscopica: stima di alcune complicanze perioperatorie in rapporto a due differenti metodiche di anestesia.  Minerva Chirurgica 50(10): 863-9.
Two anaesthetic managements for elective laparoscopic cholecystectomy were compared in 64 patients in order to investigate some perioperative complications: 1) bowel distension during surgery. 2) recovery from anaesthesia. 3) post-surgery incidence of emesis and pain. In addition, the quality of postoperative peristalsis as well as the time of dimissal were recorded. Group I (n = 30) was treated with NLA in N2O-O2 and Group II (n = 34) received propofol plus fentanyl in air-O2. Bowel distension, evaluated by surgeon at 15 min intervals throughout the operation was similar in both the groups as well as postoperative peristalsis recuperation. During the first 12 hours after laparoscopy no differences were found at any times of observation in the incidence or severity of emesis and pain between the two different anaesthesia patients. In subjects which were given propofol the psychomotor recovery was more rapid than after NLA, particularly during the first 6 hours after surgery. The patients were discharged between 36-48 hours following the operation independently from anaesthetic management. It is concluded that both the anaesthetic techniques provide similar intra/postoperative conditions, except the early recovery that is more rapid for the propofol patients. The overall frequency of emesis and pain was rather high in both the groups, suggesting a routine medication with analgesics and antiemetics.

Delogu, G., G. Famularo, et al. (1999). “General anesthesia mode does not influence endocrine or immunologic profile after open or laparoscopic cholecystectomy.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 9(5): 326-32.
To verify the impact on stress response and the influence of anesthesia on endocrine/immunologic changes, we have investigated the plasma level of norepinephrine, cortisol, TNFalpha, and IL-6 in 46 patients scheduled for laparotomy and laparoscopic cholecystectomy at 2, 6, 12, and 24 h after the operation. Among subjects who underwent open approach, 9 received fentanyl anesthesia and 13 received isoflurane anesthesia. In the laparoscopy group, 14 patients were given fentanyl anesthesia and 10 were given isoflurane anesthesia. The results obtained confirmed that laparoscopic cholecystectomy is associated with a lesser immunoendocrine response, and the two anesthesia models do not interfere with plasma changes of the assessed hormones and cytokines.

Dempsey, D. T., M. M. Kalan, et al. (1999). “Comparison of outcomes following open and laparoscopic esophagomyotomy for achalasia.  Surgical Endoscopy 13(8): 747-50.
BACKGROUND: Minimally invasive esophagomyotomy is replacing open surgery for achalasia, but data comparing these procedures performed by the same surgical team are sparse. The purpose of this study was to compare the morbidity and clinical outcome following laparoscopic and open esophagomyotomy. METHODS: Twelve consecutive patients referred for elective surgery between August 1995 and August 1997 underwent laparoscopic myotomy and partial fundoplication. They were compared to a group of 10 patients chosen from a larger pool of 20 patients who had open surgery during the same period performed by our own group. The mean length of follow-up in the laparoscopic group was 16 months; in the open group, it was 60 months. Both groups had similar demographics and clinical features. Each patient had at least one previous pneumatic dilatation. Inpatient records were reviewed. Patients were interviewed using a symptom assessment and patient satisfaction questionnaire. RESULTS: As compared to the open operation, laparoscopic esophagomyotomy with partial fundoplication resulted in significantly (p < 0.05) less blood loss (50 +/- 26 cc versus 220 +/- 127 cc), parenteral narcotic use (2.1 +/- 1.0 days versus 5.3 +/- 1.4 days), time in hospital (2.7 +/- 1.0 days versus 8.8 +/- 2.6 days), and time off work (19 +/- 16 days versus 85 +/- 60 days). There were similar results for the laparoscopic and open groups in the improvement in dysphagia (92% versus 90%) and patient satisfaction with surgery (84% versus 80%). CONCLUSIONS: Laparoscopic esophagomyotomy for achalasia results in symptomatic improvement and high patient satisfaction comparable to the open procedure but with significantly less morbidity.

Derouin, M., P. Couture, et al. (1996). “Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy.  Anesthesia & Analgesia 82(1): 119-24.
Using transesophageal echocardiography (TEE), 16 patients (ASA physical status I-III), undergoing laparoscopic cholecystectomy, were assessed for the occurrence of episodes of gas embolism and cardiovascular changes related to those emboli. The long-axis four-chamber view was monitored continuously, except for predetermined intervals where the transgastric short-axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). In one patient, we monitored the longitudinal view of the superior and the inferior vena cava. The monitoring of the patients also included: heart rate (HR), mean arterial pressure (MAP), arterial saturation by pulse oximetry (Spo2), end-tidal CO2 (ETCO2), minute ventilation (VE), and peak inspiratory pressure (PIP). Embolic events were defined as the appearance of gas bubbles in the right cardiac chambers. We observed gas embolism in 11/16 patients (five during peritoneal insufflation and six during gallbladder dissection). Using the longitudinal view of the superior and inferior vena cava (IVC), we found that these emboli were transmitted through the IVC. No episode of cardiorespiratory instability (decrease in MAP > or = 10 mm Hg, Spo2 < 90%) was observed. There was no significant difference in cardiorespiratory variables between patients who presented gas embolism (n = 11) and patients who did not (n = 5) during the studied period. In this small group of patients, we conclude that gas embolism occurs commonly during laparoscopic cholecystectomy but that these gas emboli cause minimal cardiorespiratory instability.

Dexter, S. P., J. P. Griffith, et al. (1996). “Activation of coagulation and fibrinolysis in open and laparoscopic cholecystectomy.  Surgical Endoscopy 10(11): 1069-74.
BACKGROUND: Activation of coagulation and fibrinolysis occurs as a stress response to surgery and may predispose the patient to thromboembolic complications. Other components of the surgical stress response (cytokine release, neurohumoral response, etc.) have been shown to differ between laparoscopic and open cholecystectomy, and the aim of this study was to investigate the effects of laparoscopic and open surgery on the coagulation and fibrinolytic pathways. METHODS: Fourteen patients undergoing laparoscopic cholecystectomy and 12 patients undergoing open cholecystectomy had blood taken in the perioperative period for fibrinopeptide A (FPA) prothrombin fragment F1.2, antithrombin 3, tissue plasminogen activator (tPA) and its fast-acting inhibitor plasminogen activator inhibitor-1 (PAI-1 antigen and activity), and the euglobulin clot lysis time (ECLT). RESULTS: The only significant differences between the two groups occurred 6 h after surgery when the ECLT was longer (p < 0.005; Mann Whitney), and PAI-1 antigen and activity were higher (p < 0.01 and p < 0.001, respectively; Mann Whitney) after open cholecystectomy than laparoscopic cholecystectomy. CONCLUSIONS: Other changes in fibrinolysis and coagulation were similar for open and laparoscopic cholecystectomy. With respect to hemostasis, laparoscopic cholecystectomy does not increase the risk of thromboembolic complications compared to the conventional procedure.

Di Sebastiano, N., L. Bonetti, et al. (1993). “Meccanica respiratoria e scambio dei gas nella anestesia per colecistectomia per via laparoscopica.  Minerva Anestesiologica 59(10): 487-92.
OBJECTIVE. To evaluate the influence of endoabdominal CO2 insufflation during anaesthesia for laparoscopic cholecystectomy on airway pressure, gas exchange and their relationships. DESIGN. Perspective; clinical investigation. SETTING. Operating room at a central general hospital. PATIENTS. 14 patients (3 males and 11 females) ASA 1-2, non smokers, without lung disease, scheduled for elective laparoscopic cholecystectomy. INTERVENTIONS. During balanced anaesthesia (N2O/O2, Fentanyl, Isoflurane), with fixed minute ventilation, endoperitoneal insufflation of CO2 held at constant pressure (21 cm H2O). MEASUREMENTS. Serial measurements of: Airway pressure, near-static compliance, ETCO2, CO2 minute production, blood gas analysis and derived data: P(a-A)O2, P(a-ET)CO2, Vd/Vt. MAIN RESULTS. During insufflation peak and pause pressures increased by 6 cm H2O and mean pressure; by 3 cm H2O; Compliance was reduced by 48%; PaO2 decreased evenly with time (p > 0.05) irrespective of the airway pressure. PaCO2, PECO2, VCO2 and Vd/Vt after a sharp increase stabilized at 30% (mean value) over the baseline. P(a-ET)CO2 and Vd/Vt fluctuate in the physiological range except for two short but significant changes (p > 0.05) at insufflation and desufflation time. CONCLUSIONS. Laparoscopic technique for cholecystectomy, at least in healthy patients, produces relevant changes in airway pressures but only minor modifications of gas exchange, similar to those seen during general anaesthesia. This technique can be safely used for routine operation with standard monitoring equipment.

Diamant, M., J. L. Benumof, et al. (1977). “Laparoscopic sterilization with local anesthesia: complications and blood-gas changes.  Anesthesia & Analgesia 56(3): 335-7.
Arterial blood-gas changes were studied in 21 healthy women undergoing laparoscopic sterilization with local anesthesia and supplemental IV sedation, employing CO2 as the inflating gas. No significant hypercarbia was noted. Two patients became transiently apneic following IV medication and 2 became extremely agitated during the procedure. This constituted a major nonsurgical complication rate of 19 percent. Safety requirements for patients undergoing this procedure is suggested.

Dieckmann, W., M. Anderer, et al. (1977). “Ist bei der laparoskopischen Sterilisation in Lokalanaesthesie die Spontanatmung ausreichend?  Archiv fur Gynakologie 224(1-4): 39-40.

Dion, Y. M., F. Gaillard, et al. (1996). “Experimental laparoscopic aortobifemoral bypass for occlusive aortoiliac disease.  Canadian Journal of Surgery 39(6): 451-5.
OBJECTIVE: To describe a totally laparoscopic technique for aortobifemoral bypass to treat aortoiliac atheromatous occlusive disease. DESIGN: A feasibility study. SETTING: A university teaching hospital. SUBJECTS: Six piglets weighing between 70 and 80 kg were submitted to a totally laparoscopic retroperitoneal aortobifemoral bypass, performed through six trocar sites, with abdominal suspension and a gasless technique. No minilaparotomy was performed. After systemic heparinization, the infrarenal aorta was cross-clamped and the aortic bifurcation stapled. An end-to-end aorto-prosthetic anastomosis was performed. Retroperitoneal tunnels were created to allow each limb of the graft to join its corresponding femoral artery by a conventional anastomosis. INTERVENTION: Totally laparoscopic aortobifemoral bypass. MAIN OUTCOME MEASURES: Duration of the procedure, intraoperative blood loss and operative complications, bleeding in the immediate postoperative period. Evaluation of the aortic anastomosis at autopsy. RESULTS: All aortobifemoral bypasses were completed in less than 4 hours. Intraoperative blood loss did not exceed 250 mL. No intraoperative complication was encountered except occasional bleeding at the aortic anastomosis upon releasing the arterial clamp. This was controlled with a collagen sponge (three cases) or extra stitches (two cases). The animals were observed for 15 minutes before sacrifice. Autopsy revealed a normal aortic anastomosis in all cases and a normal progression of the limbs of the graft under the ureters in the retroperitoneal tunnels. CONCLUSIONS: This animal model demonstrates the feasibility of the aortobifemoral bypass through a laparoscopic approach. The retroperitoneal anatomy of the piglet is similar to that of man. Aortic surgery can be conducted as for the standard technique. We used a similar approach to perform the first human, totally laparoscopic aortobifemoral bypass with an end-to-end anastomosis.

Duh, Q. Y., A. L. Senokozlieff-Englehart, et al. (1999). “Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia.  Archives of Surgery 134(2): 151-6.
BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Duvaldestin, P. (1996). “Y a-t-il des contre-indications anesthesiques a la chirurgie coelioscopique.  Journal de Chirurgie 133(8): 355.

Edelman, D. S. (1991). “Laparoscopic cholecystectomy under continuous epidural anesthesia in patients with cystic fibrosis [letter].  American Journal of Diseases of Children 145(7): 723-4.

Eden, C. G., A. C. Haigh, et al. (1994). “Laparoscopic nephrectomy results in better postoperative pulmonary function.  Journal of Endourology 8(6): 419-22; discussion 422-3.
The pulmonary response to nephrectomy was studied in 16 patients undergoing laparoscopic (n = 8) or open (n = 8) nephrectomy using a standardized anesthetic technique. Although there was no significant difference between the two groups at 24 hours, postoperative pulmonary function measures (P = 0.02-0.03) and oxygenation (P = 0.03) were significantly better in the laparoscopic surgery group at 48 hours. The median opiate analgesic requirement (P = 0.02) and the number of nights spent in the hospital (P = 0.003) also were significantly lower in this group. The results of this study suggest that laparoscopic nephrectomy offers a real biological advantage in terms of postoperative preservation of lung function and that this might therefore be the safest technique for nephrectomy in patients with limited respiratory reserves.

Eden, C. G. and M. J. Coptcoat (1996). “Assessment of alternative tissue approximation techniques for laparoscopy.  British Journal of Urology 78(2): 234-42.
OBJECTIVE: To investigate the feasibility and results of applying alternative techniques of tissue approximation for experimental urothelial re-anastomosis in an open and laparoscopic setting. MATERIALS AND METHODS: The study was carried out in two phases; in phase 1, an open porcine ureteric re-anastomosis was performed using gelatin/resorcin/ formaldehyde (GRF) glue, fibrin glue or potassiumtitanyl-phosphate laser tissue-welding with a fluorescein-doped human albumin solder. The anastomoses were assessed both immediately, by leak pressure, and by the operating time, upper tract urodynamic studies and light and scanning electron microscopy, 6 weeks after surgery. In phase 2 the best technique from phase 1 was compared with sutured controls for porcine retroperitoneoscopic dismembered pyeloplasty, using the same assessment criteria. RESULTS: In phase 1, GRF glue produced adhesion which was insufficiently flexible to withstand rotation of the anastomosis and this technique was therefore abandoned. Fibrin-glued anastomoses withstood leak pressures equal to those from laser-welding (P = 0.91) and gave similar changes in maximum pressure with a Whitaker test at 6 weeks (P = 0.30), but were superior in requiring a shorter operating time (P = 0.02) and in their electron and light microscopic appearances. In phase 2, fibrin glue gave similar changes in maximum pressure with a Whitaker test to those from polyglactin 910 sutures (P = 0.51) but withstood higher leak pressures (P = 0.01), had a shorter operating time (P = 0.01) and had superior electron and light microscopic appearances. CONCLUSION: Fibrin glue produced effective experimental laparoscopic pelvi-ureteric anastomoses within less operating time than did sutured controls. Such anastomoses withstood supra-physiological pressures, with no evidence of functional obstruction and with a more favourable histological result after 6 weeks. Laparoscopic evaluation of this modality in a clinical setting is now justified.

Edoga, J. K., K. V. James, et al. (1998). “Laparoscopic aortic aneurysm resection.  Journal of Endovascular Surgery 5(4): 335-44.
PURPOSE: To describe a laparoscopic technique for resection of infrarenal abdominal aortic aneurysms (AAAs). METHODS: The operation is based on the principle of retroperitoneal reinforced staple exclusion of the aneurysm sac with aortobifemoral or aortoiliac bypass using gas and gasless laparoscopic techniques. Patients were eligible for this procedure if their infrarenal AAAs (with or without iliac artery involvement) were considered appropriate for surgical resection; however, renal or other visceral arterial stenoses, aneurysmal disease requiring surgical treatment, and/or aneurysms of the hypogastric arteries excluded patients from laparoscopic AAA resection. RESULTS: Of 31 candidates for this procedure, 9 were excluded owing to high surgical risk. Twenty-two patients (16 males; age range 62 to 88 years) were deemed appropriate for the laparoscopic procedure. Maximum aneurysm diameter ranged from 4.0 to 8.0 cm. The operation was completed successfully in 20 (91%) patients. Two (9%) deaths in high-risk patients admitted early to the study occurred within 30 days of surgery. The only major complication was an injured ureter, for which a nephrectomy was performed. Comparison to a historical cohort of conventionally treated patients showed that the study group needed less ventilator support, had shorter intensive care and hospital stays, and resumed diet earlier despite relatively prolonged anesthesia and aortic clamping times. CONCLUSIONS: The laparoscopic approach to infrarenal AAAs appears feasible, with several potential advantages in low- and moderate-risk patients. Once the technique is optimized, randomized prospective studies will be needed to verify the apparent benefits demonstrated by these initial patients.

Einarsson, S. G., A. Cerne, et al. (1998). “Respiration during emergence from anaesthesia with desflurane/N2O vs. desflurane/air for gynaecological laparoscopy.  Acta Anaesthesiologica Scandinavica 42(10): 1192-8.
BACKGROUND: The complications related to anaesthesia usually occur in the early postoperative period. Hypercapnia and hypoxaemia may result from any persistent depression of the respiratory drive relative to the metabolic demand. The purpose of this study was to compare the respiratory effects of desflurane anaesthesia with or without nitrous oxide during the period of emergence. METHODS: Twenty patients scheduled for a standardised surgical procedure, laparoscopic hysterectomy, were randomly allocated to anaesthesia with 1.3 MAC of desflurane/N2O (Group 1) or desflurane alone (Group 2), with 10 patients in each group. Times of resumption of spontaneous breathing and extubation were recorded and elimination rates of carbon dioxide, end-tidal concentrations of desflurane and N2O, and blood gases were measured. RESULTS: Spontaneous breathing was resumed in both groups when pH had decreased by about 0.07 and PaCO2 increased by about 1.4 kPa compared with the values at the end of 1.3 MAC anaesthesia with controlled normoventilation. There were no significant differences between the groups with regards to extubation time, 6 vs. 13 min, or total MAC value at extubation, 0.20 vs. 0.19 in Group 1 and 2, respectively. Neither did the groups differ in minute ventilation, end-tidal carbon dioxide, oxygen concentrations, or blood gases. CO2 elimination decreased in both groups from about 220 ml 70 kg-1 min-1 at the end of anaesthesia to a lowest value of about 160 ml 70 kg-1 min-1. CONCLUSION: The respiratory profiles during recovery from gynaecological laparoscopy with either desflurane/N2O or desflurane anaesthesia were similar with fast resumption of spontaneous breathing, short time to extubation, and no signs of CO2 retention.

Eriksson, H., J. Haasio, et al. (1995). “Recovery from sevoflurane and isoflurane anaesthesia after outpatient gynaecological laparoscopy.  Acta Anaesthesiologica Scandinavica 39(3): 377-80.
As the low blood solubility (blood gas partition coefficient 0.69) of sevoflurane suggests a rapid emergence from anaesthesia, recovery from sevoflurane anaesthesia was compared to isoflurane in outpatient gynaecological laparoscopy. Fifty ASA I or II, consenting women participated in a randomised, controlled and single blind study. The patients received, after induction of anaesthesia with propofol, either sevoflurane or isoflurane, both with 67% nitrous oxide in oxygen, for maintenance of anaesthesia. The study drug was administered at 1 MAC (end tidal concentration 0.6% for sevoflurane and 0.5% for isoflurane) but adjusted in 0.5 MAC steps, if clinically indicated. Before the end of surgery the end tidal concentration of the study drug was reduced to 0.5 MAC. Recovery assessments were made from the time anaesthetic gases were discontinued. The subjects were able to open eyes in 2.3 (0.8-7.0) min and 4.1 (2.0-6.8) min, orientate in 2.8 (1.0-6.8) min and 4.7 (2.2-8.3) min and follow orders in 2.6 (0.7-6.8) min and 4.3 (1.2-7.3) min, in the sevoflurane and isoflurane groups, respectively (P < 0.05) [median (range)]. Walking was achieved in 72 (24-464) min and 66 (35-134) min, tolerance of oral fluids in 37 (15-88) min and 35 (45-161) min and voiding in 262 (96-459) min and 217 (52-591) min in the sevoflurane and isoflurane groups, respectively (NS). Overall home readiness was achieved in 281 (96-708) min after sevoflurane group and 242 (96-591) min after isoflurane (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Eshraghi, N., M. Farahmand, et al. (1998). “Comparison of outcomes of open versus laparoscopic Nissen fundoplication performed in a single practice.  American Journal of Surgery 175(5): 371-4.
BACKGROUND: We reviewed Nissen fundoplications performed in a single practice from January 1989 to March 1997, encompassing our transition from open to laparoscopic procedures. Because all operations were done by two surgeons in the same two hospitals, the study is well controlled for comparisons. METHODS: Records of 271 consecutive patients were reviewed. RESULTS: From 1989 to 1992 all patients underwent open fundoplication (n = 78). Thereafter, with increasing frequency, laparoscopic fundoplication was performed. The laparoscopic group was slightly younger (48 +/- 14 years) than the open group (54 +/- 13 years), but gender distribution and body mass index (BMI) did not differ. Mean operating time for laparoscopic cases was 163 +/- 58 minutes compared with 148 +/- 59 minutes for open cases (NS). Intraoperative complication rate was 8% for both groups. Length of hospitalization was shorter for patients undergoing laparoscopic surgery (2.4 days versus 7.2 for open procedures, P <0.05). In follow-up, 82% of the open Nissen group were asymptomatic compared with 84% of the laparoscopic Nissen group. The same proportion of patients required reoperation for dysphagia (3% for each group). Of patients who had the open procedure, 21% had wound complications. None of those treated laparoscopically had long-term morbidity from trocar insertion sites. CONCLUSION: Equal effectiveness in treating reflux combined with shorter hospitalization and absence of wound complications makes the laparoscopic approach the preferred method for performing fundoplication.

Esposito, C., G. L. Monguzzi, et al. (2000). “Laparoscopic treatment of pediatric varicocele: a multicenter study of the italian society of video surgery in infancy.  Journal of Urology 163(6): 1944-6.
PURPOSE: We report preliminary results of a multicenter study of the Italian Society of Video Surgery in Infancy on the laparoscopic treatment of pediatric varicocele. MATERIALS AND METHODS: A total of 161 children 6 to 16 years old (median age 12.5) underwent laparoscopic treatment of varicocele at 6 pediatric surgery divisions. Varicocele was on the left side in 159 cases (98.7%) and bilateral in 2 (1.3%). Two boys had recurrent left varicocele. All children were treated with laparoscopy, including ligation of the spermatic veins only in 28 (17.3%), and ligation of the testicular veins and artery in 133 (82.7%). In 10 boys (6.2%) an additional procedure was done simultaneously, including closure of an apparently patent peritoneal vaginal duct on the right side in 7 and resection of epiploic adhesions between the intestinal loops and abdominal wall from previous appendectomy in the remaining 3. RESULTS: Average operative time was 30 minutes and hospitalization was about 24 hours. At followup there were 13 minor complications (8%), including left hydrocele in 9 children who underwent the Palomo technique, minor scrotal emphysema in 2 and umbilical granuloma in 2. In our series varicocele recurred in 1 boy (3.5%) who underwent ligation of the spermatic veins only and in 3 (2.2%) treated with the Palomo technique. CONCLUSIONS: Our preliminary experience shows that the results of the laparoscopic approach are comparable to those of the open approach. However, the important advantages of laparoscopy over the open approach are its minimal invasiveness and precision of intervention. Moreover, laparoscopy allows treatment of other intra-abdominal pathological conditions using the same anesthesia, as in 10 patients in our series. We believe that ligating the testicular veins and artery is preferable to ligating the testicular veins only, even if the incidence of hydrocele is not negligible after the Palomo procedure.

Eubanks, T. R., P. Omelanczuk, et al. (2000). “Outcomes of laparoscopic antireflux procedures.  American Journal of Surgery 179(5): 391-5.
BACKGROUND: Laparoscopy has increased the number of patients undergoing operative correction of gastroesophageal reflux disease (GERD). Symptom improvement has been most commonly reported as the means to assess operative outcome. We compared symptomatic outcome to postoperative pH testing at short-term follow-up to determine the accuracy of clinical assessment at predicting whether acid exposure would be normal or abnormal. METHODS: Of 640 patients who had antireflux surgery between 1993 and 1999, 228 (36%) agreed to repeat manometry and 24-hour pH monitoring 8 to 12 weeks postoperatively and are the subject of this study. Symptom resolution was assumed if the frequency was less than once per week. Normal acid exposure consisted of a distal esophageal pH below 4 less than 4% of the time and a DeMeester composite score less than 14.7. Accuracy of symptom scoring was calculated using acid exposure as the standard.RESULTS: The primary symptom was improved in 93% of the 228 patients. Acid exposure was reduced from a preoperative DeMeester score of 71 to 16 (P <0.05). Eighty percent of patients had normalization of acid exposure postoperatively. Heartburn was the only symptom to have a significant correlation with acid exposure in the postoperative period (P <0.05). Heartburn resolved in 181 patients, 168 of whom had normal acid exposure (true negative). Thirty-eight patients without symptoms had abnormal acid exposure (false negative). Nine patients had persistent heartburn with abnormal acid exposure (true positive) whereas 13 patients had persistent heartburn with normal acid exposure (false positive). Thus, the positive predictive value of heartburn was 43%, the negative predictive value was 82%, and the overall accuracy was 78%. CONCLUSIONS: Operative treatment improves both the symptoms of GERD and the degree of acid exposure as measured by pH monitoring. The most accurate symptom for predicting acid exposure in the postoperative period is heartburn. Although the absence of heartburn postopertively is fairly reliable at predicting normal acid exposure on pH testing, the presence of heartburn warrants postoperative pH monitoring, as more than half of these patients will have normal acid exposure.

Eypasch, E., R. Stuttmann, et al. (1995). “Anaesthesia for laparoscopic closure of perforated peptic ulcer--any harm or benefit?  Endoscopic Surgery & Allied Technologies 3(4): 171-3.
Laparoscopic closure of perforated peptic ulcer is technically feasible (1). Haemodynamic changes during laparoscopic operations are known and may have an adverse influence on outcome in patients who have peritonitis, are hypovolemic or even septic (2-4). A complete physiological understanding of CO2-inflation of an abdomen in diffuse peritonitis is still missing. The purpose of this study is to compare perioperative variables of general anaesthesia in patients undergoing open or conventional laparoscopic closure of perforated peptic ulcer.

Fagevik Olsen, M., K. Josefson, et al. (1999). “Chest physiotherapy does not improve the outcome in laparoscopic fundoplication and vertical-banded gastroplasty.  Surgical Endoscopy 13(3): 260-3.
BACKGROUND: Chest physiotherapy is a common practice after open reflux and obesity surgery. It is now possible to perform fundoplication and vertical banded gastroplasty (VBG) by the laparoscopic technique. The aim of this study was to evaluate in a prospective, randomized, controlled trial whether chest physiotherapy affects the postoperative course. METHOD: A series of 40 patients underwent laparoscopic fundoplication; another 40 underwent laparoscopic VBG. Twenty patients in each series received prophylactic chest physiotherapy; the other 20 served as control patients and were not given any information or training. RESULTS: Postoperatively, all patients had a significant reduction in respiratory function, measured as oxygen saturation, forced vital capacity, and peak expiratory flow, but the differences between the groups within each series were not significant. Postoperatively, one patient in the VBG treatment group had hypoxemia (SaO2 <92%) versus two control patients. One control patient developed postoperative pneumonia. CONCLUSIONS: This study indicates that routine chest physiotherapy is not necessary in patients undergoing laparoscopic upper gastrointestinal surgery, such as fundoplication and VBG.

Falk, G. L. (1996). “Anaesthesia for laparoscopic surgery [letter].  Journal of the Royal College of Surgeons of Edinburgh 41(1): 61-2; discussion 62.

Fernandez Lopez de Hierro, M. C., M. Manalich Vidal, et al. (1981). “Variaciones de la concentracion de CO2, O2, pH, bicarbonato y exceso de base en pacientes sometidas a examen laparoscopico ginecologico bajo anestesia general.  Revista Espanola de Anestesiologia y Reanimacion 28(1): 15-20.

Ferzli, G., P. Sayad, et al. (1999). “The feasibility of laparoscopic extraperitoneal hernia repair under local anesthesia.  Surgical Endoscopy 13(6): 588-90.
BACKGROUND: Laparoscopic preperitoneal herniorrhaphy has the advantage of being a minimally invasive procedure with a recurrence rate comparable to open preperitoneal repair. However, surgeons have been reluctant to adopt this procedure because it requires general anesthesia. METHODS: In this report, we describe the technique used in the laparoscopic repair of inguinal hernias under local anesthesia using the preperitoneal approach. We also report our results with 10 inguinal hernias repaired using the same technique. RESULTS: Ten patients underwent their primary inguinal hernia repairs under local anesthesia. None were converted to general anesthesia. Four patients received a small amount of intravenous sedation. Three patients had bilateral hernias. There were five direct and eight indirect hernias. The average operative time was 47 min. The average lidocaine usage was 28 cc. All patients were discharged within a few hours of the surgery. There were no complications. Follow-up has ranged from 1 to 6 months. There has been no recurrences to date. CONCLUSIONS: The extraperitoneal laparoscopic repair of inguinal hernia is feasible under local anesthesia. This technique adds a new treatment option in the management of bilateral inguinal hernias, particularly in the population where general anesthesia is contraindicated or even for patients who are reluctant to receive general or epidural anesthesia.

Fielding, G. A., M. Rhodes, et al. (1999). “Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases.  Surgical Endoscopy 13(6): 550-4.
BACKGROUND: Morbid obesity occurs in 2-5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients. MATERIALS AND METHODS: A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications. RESULTS: All patients have needed band adjustments of 1-4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss. CONCLUSIONS: Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience.

Fierro, G., M. Sanfilippo, et al. (1997). “Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy (TPLIH) under regional anaesthesia.  International Surgery 82(2): 205-7.
BACKGROUND: In an attempt to investigate whether laparoscopy really is a major advance in the treatment of inguinal hernia, the authors performed laparoscopic transabdominal preperitoneal inguinal herniorrhaphy under regional anaesthesia in 15 consecutive patients, 7 of whom with severe medical conditions contraindicating general anaesthesia. METHODS: In the first 5 patients (Group 1) an epidural anaesthesia was performed, whereas in the following 10 patients (Group 2), fentanyl was added to the epidural anaesthesia, and bupivacaine was administered into the subarachnoid space. RESULTS: Results from Group 1 were poorer than those obtained in Group 2. All patients complained of shoulder pain and discomfort which required the intraoperative administration of analgesics in 7 patients and conversion to open repair in one patient. CONCLUSIONS: Although laparoscopy is a feasible and effective procedure in repairing inguinal hernias, it is not indicated in high-risk patients who can be safely, effectively, and less expensively treated with open tension-free repair techniques under local anaesthesia.

Figueredo-Gaspari, E. and L. Canosa-Ruiz (1997). “Necesidades de alfentanilo durante la anestesia total intravenosa. Comparacion entre la colecistectomia laparoscopica y por laparotomia subcostal.  Revista Espanola de Anestesiologia y Reanimacion 44(3): 103-7.
OBJECTIVE: To quantify intraoperative consumption of alfentanil in cholecystectomy by laparoscopy or by the traditional approach; to evaluate its relation to time until extubation, presence and intensity of postoperative pain and vomiting. PATIENTS AND METHODS: Prospective, non randomized study. Forty female physical status ASA I-II patients between 18 and 60 years of age scheduled to undergo subcostal cholecystectomy by subcostal laparotomy (group CSL, n = 20) or by laparoscopy (group CL, n = 20). Total intravenous anesthesia with propofol, alfentanil and atracurium was provided. A continuous infusion of alfentamil 1 microgram/kg/min was used, with a supplement of 7 micrograms/kg when mean arterial pressure (MAP) rose more than 10% above baseline or with a supplement of 14 micrograms/kg when MAP rose 20% or more above baseline. Variables measured were intraoperative alfentanil requirements, time until extubation, presence and intensity of pain in the immediate postoperative period and incidence of vomiting. RESULTS: Alfentanil consumption was 1.81 and 1.63 micrograms/kg/min and time to extubation was 17.5 and 14.05 min in the CL and CSL groups (p < 0.05), respectively. There was less pain in the early postoperative period in the CL group (36.8% for the CL patients as opposed to 85% in the CSL group, p < 0.01) and pain was less intense (p < 0.01). The incidence of vomiting was 42.1% in group CL and 25% in group CSL (p = NS). CONCLUSIONS: Insufflating the pneumoperitoneum for laparoscopic surgery brings about hemodynamic changes that increase intraoperative consumption of alfentanil during surgery, and this can lead to delayed awakening.

Fishburne, J. I., Jr., K. F. Omran, et al. (1974). “Laparoscopic tubal clip sterilization under local anesthesia.  Fertility & Sterility 25(9): 762-6.

Fishburne, J. I., Jr. (1977). “Office laparoscopic sterilization with local anesthesia.  Journal of Reproductive Medicine 18(5): 233-4.

Flax, S. (1996). “The gasless laparoscopic Burch bladder neck suspension: early experience.  Journal of Urology 156(3): 1105-7.
PURPOSE: We evaluated the gasless extraperitoneal laparoscopic Burch bladder neck suspension. MATERIALS AND METHODS: This retrospective study included 47 patients with type II stress urinary incontinence treated sequentially with this technique between September 1994 and September 1995. Balloon dissection was used to develop the extraperitoneal space. A mechanical retraction system was used with conventional laparotomy instruments to perform laparoscopic Burch bladder neck suspension. RESULTS: Of the 47 patients who underwent this procedure 3 (6%) required conversion to an open operation. Obesity and previous pelvic surgery were not contraindications to this technique. The only major complication involved blood loss necessitating conversion to an open operation. Average operative time was 96.4 minutes and average hospital stay was 3.5 days. Followup at 2 to 15 months (mean 8.2) indicated successful results (that is no pads were required) in 44 patients (90%). CONCLUSIONS: Gasless laparoscopic bladder neck suspension has a lower open surgery rate, and may be performed more rapidly than conventional carbon dioxide laparoscopic Burch bladder neck suspension. Previous multiple operations and obesity are not contraindications to the technique.

Fleming, R. Y., T. B. Dougherty, et al. (1997). “The safety of helium for abdominal insufflation.  Surgical Endoscopy 11(3): 230-4.
BACKGROUND: A search for alternative methods of abdominal insufflation has been prompted by the fact that CO2 insufflation may cause acidosis, decreased cardiac output, increased systemic vascular resistance, and increased cardiac filling pressures. This study evaluates the safety and the cardiopulmonary effects of helium abdominal insufflation (HAI). METHODS: Thirteen ASA class III and IV patients undergoing laparoscopic procedures were studied in a prospective, nonrandomized protocol using HAI. Cardiopulmonary parameters were measured before and after anesthetic induction and every 30 min during HAI. Abdominal insufflation pressure was initially 10 mmHg and was increased to 15 mmHg after 30 min. All measurements were repeated 15 min after deflation of the abdomen. Changes were evaluated by ANOVA. RESULTS: No significant cardiopulmonary complications were observed. No patient developed hypercarbia or acidosis. Peak inspiratory pressure increased with HAI from 20 +/- 1 to 34 +/- 2 cm H2O (p < 0.0001). Cardiac index decreased (3.35 +/- 0.19 vs 2.37 +/- 0.19 l/min/m2; p = 0.0303) and systemic vascular resistance increased (1,123 +/- 66 vs 1,406 +/- 126 dyne . s/cm5; p = 0.0512) while cardiac filling pressures increased with insufflation to 15 mmHg. CONCLUSIONS: Minimal cardiac and pulmonary aberrations were observed. Helium was safe for abdominal insufflation and may be the insufflating agent of choice in patients with significant cardiopulmonary disease.

Fleshman, J. W., R. D. Fry, et al. (1996). “Laparoscopic-assisted and minilaparotomy approaches to colorectal diseases are similar in early outcome.  Diseases of the Colon & Rectum 39(1): 15-22.
OBJECTIVE: The purpose of this study was to compare laparoscopy with minilaparotomy approaches to colorectal diseases. METHOD: Outcomes after minilaparotomy and laparoscopy were prospectively compared for a 12-month period. RESULTS: Minilaparotomy was performed in 35 patients to achieve right colectomy (14), left colectomy (8), total colectomy (2), low anterior resection (6), abdomino-perineal resection (2), colostomy (1), and ileal resection (1). Laparoscopic techniques were used in 52 patients to perform right colectomy (20), left colectomy (11), low anterior resection (5), abdominoperineal resection (7), total colectomy (3), ileal resection (1), colostomy (3), transverse colectomy (1), and colostomy closure (1). Mean operative times were 69 minutes for minilaparotomy (range, 33-180) and 173 minutes for laparoscopy (range, 60-300). Mean incision lengths were 12 (range 8-18) cm and 8 (range, 0-25) cm; mean time to bowel movement was four (range, 1-7) days and 3.9 (range, 0-8) days; mean day of discharge was 6.9 (range 3-15) days, and 6 (range, 1-15) days postoperatively, respectively. Laparoscopy procedures were completed in 39 of 52 patients (75 percent); mean time to bowel movement was 3.5 (range, 0-6) days, and mean day of discharge was 5.3 (range, 1-14) days (P = <0.005). CONCLUSION: The use of a small incision, whether by minilaparotomy or by laparoscopy, results in similar early return of function and discharge.

Fletcher, D. R. (1995). “Laparoscopic cholecystectomy in Australia--outcomes and costs.  Surgical Endoscopy 9(11): 1230-5.

Fornara, P., C. Doehn, et al. (2000). “Why is urological laparoscopy minimally invasive?  European Urology 37(3): 241-50.
OBJECTIVES: Laparoscopic procedures have been developed and established with the view that a similar operative effect can be achieved with less traumatization, especially as far as systemic stress response is concerned. We report a prospective, controlled, nonrandomized animal and patient study to determine the systemic response to laparoscopic and open surgical procedures. METHODS: In the animal study, 26 female pigs underwent either a laparoscopic bilateral varix ligation followed by bilateral nephrectomy (group I), sole introduction of trocars (group II) or sole establishment of an open surgical approach (group III). In the patient study, 145 patients underwent various laparoscopic procedures (nephrectomy, renal cyst marsupialization, varix ligation), open surgical procedures (nephrectomy, inguinal orchiectomy) or extracorporeal shockwave lithotripsy (ESWL). The serum parameters interleukin (IL)-6, IL-10 and C-reactive protein (CRP) were measured before, during and after the operative procedure. RESULTS: In animals and patients, laparoscopy resulted in significantly lower serum levels of CRP during and after the operative procedure. Animals in group I showed a 5-fold elevation, in group II a 3-fold elevation and in group III a 9-fold elevation of CRP. In patients, the increase of CRP was twice as high after open unilateral nephrectomy than after laparoscopic unilateral or bilateral nephrectomy. IL-6 showed less marked elevation during laparoscopy, ESWL and minor operative procedures like laparoscopic varix ligation or inguinal orchiectomy when compared to an open unilateral nephrectomy. The parameter IL-10 showed no significant differences among the patient groups. CONCLUSIONS: The extent of the acute phase reaction to the operative trauma correlates much more convincingly to the approach than to the extent of the procedure. Only larger operations like nephrectomy trigger a systemic acute phase reaction, which can be limited by the laparoscopic access. For minor operative procedures like varix ligation or exploration of cryptorchidism, laparoscopy offers technical advantages rather than minimal invasiveness.

Fukushima, R., Y. J. Kawamura, et al. (1996). “Interleukin-6 and stress hormone responses after uncomplicated gasless laparoscopic-assisted and open sigmoid colectomy.  Diseases of the Colon & Rectum 39(10 Suppl): S29-34.
PURPOSE: Laparoscopic colectomy has increasingly been advocated as an option for treatment of colonic disease. The purpose of this study was to compare effects of laparoscopic-assisted sigmoid colectomy (LAS) and conventional open colectomy (OPEN) on postoperative cytokine and stress hormone responses. METHODS: Fourteen patients with sigmoid colon cancer, apparently free of preoperative complications, were analyzed. Patients in both groups underwent sigmoid colectomy with lymphadenectomy. LAS was performed by the gasless abdominal wall-lifting method. A 5 cm incision was placed at the beginning of the operation. Blood samples were taken preoperatively and postoperatively for measurement of interleukin-6, glucagon and C-reactive protein. Urinary catecholamine excretions were also determined postoperatively. RESULTS: The two groups of patients were similar with respect to age (61 +/- 7 for LAS vs. 64 +/- 9 for OPEN) and sex. Intraoperative blood loss did not differ significantly between groups (112 +/- 97 ml for LAS vs. 366 +/- 380 ml for OPEN). Operative times for LAS tended to be longer than those for OPEN (231 +/- 67 vs. 169 +/- 45 minutes; P = 0.08). Similar time courses of postoperative interleukin-6, C-reactive protein, and stress hormone responses were observed in both groups. No significant differences were observed in the magnitude of changes except that the serum interleukin-6 level on day of surgery (postoperative day 0) was significantly higher in LAS patients than in those receiving OPEN. In addition, interleukin-6 levels showed a significant positive correlation with operative duration (r = 0.582; P < 0.05). CONCLUSIONS: Data suggest that stress responses after sigmoid colectomy, in patients undergoing LAS, are comparable with those of patients receiving OPEN and that the early interleukin-6 response after surgery appears to be associated with operative time.

Ganansia, M. F., T. P. Francois, et al. (1989). “Atrioventricular Mobitz I block during propofol anesthesia for laparoscopic tubal ligation.  Anesthesia & Analgesia 69(4): 524-5.

Garcia-Miguel, F. J., F. J. Alsina, et al. (1997). “Anestesia para colecistectomia laparoscopica en un paciente sometido a trasplante cardiaco.  Revista Espanola de Anestesiologia y Reanimacion 44(9): 376-7.

Georgiou, L., M. Bousoula, et al. (2000). “Combined thoracic epidural and general anaesthesia with laryngeal mask airway for laparoscopic cholecystectomy in a patient with myasthenia gravis [letter].  Anaesthesia 55(8): 821-2.

Giurgiu, D. I., D. R. Margulies, et al. (1999). “Laparoscopic common bile duct exploration: long-term outcome.  Archives of Surgery 134(8): 839-43; discussion 843-4.
HYPOTHESIS: Transcystic laparoscopic common bile duct exploration (LCBDE) with biliary endoscopy results in excellent long-term clinical outcome and patient satisfaction. DESIGN: Prospective cohort study of unselected patients found to have common bile duct stones during laparoscopic cholecystectomy between October 1989 and April 1998. A mailed survey assessed symptoms, outcome, and satisfaction. SETTING: A large community teaching hospital. PATIENTS: Two hundred seventeen patients with common bile duct stones. INTERVENTION: Transcystic LCBDE with choledochoscopy. MAIN OUTCOME MEASURES: Success of LCBDE, morbidity, postoperative symptoms, and satisfaction. RESULTS: One hundred sixteen surveys (54%) were returned. Mean follow-up was 60 months. The LCBDE procedure failed in 6 patients and endoscopic retrograde cholangiopancreatography was performed in 4 patients (3%). One patient had unsuspected retained stones. No patient had late recognition of retained stones or a bile duct stricture. Abdominal pain was present in 90 patients (89%) preoperatively and in 29 patients (26%) postoperatively (P = .001). The LCBDE procedure reduced 3 specific pain profiles: epigastric, from 47% (n = 54) to 7% (n = 8); back, from 31% (n = 36) to 6% (n = 7); and shoulder, from 18% (n = 21) to 2% (n = 2). When pain persisted, it was different in character in 15%. All nonpain symptoms (such as nausea, bloating, indigestion, and gas) were reduced from 78% (n = 91) to 34% (n = 39) (P = .001) except diarrhea. Diarrhea was present in 24 patients (22%) preoperatively and postoperatively, though it was a new postoperative symptom in 11 patients (11%). One hundred two patients (95%) were satisfied or mostly satisfied with LCBDE. CONCLUSIONS: Pain and nonpain symptoms, while reduced significantly after LCBDE, may persist. The LCBDE procedure does not result in common bile duct strictures or a significant rate of retained stones. This relatively new treatment for common bile duct stones is safe and effective.

Glaser, F., G. A. Sannwald, et al. (1995). “General stress response to conventional and laparoscopic cholecystectomy.  Annals of Surgery 221(4): 372-80.
OBJECTIVE: In many retrospective and prospective observational studies, laparoscopic cholecystectomy (LC) compares favorably with conventional cholecystectomy (CC), with respect to length of hospital stay, postoperative pain, and pulmonary function, indicating a diminished operative trauma. Comparison of laboratory findings (stress hormones, blood glucose, interleukins) are a possibility to objectify stress and tissue trauma of laparoscopic and conventional cholecystectomy. SUMMARY BACKGROUND DATA: Major body injury, surgical or accidental, evokes reproducible hormonal and immunologic responses. The magnitude of many of these changes essentially is proportional to the extent of the injury. METHODS: In a prospective study, biochemical stress parameters were measured in the blood of patients undergoing elective cholecystectomy because of symptomatic cholecystolithiasis. Patients with acute cholecystitis, pancreatitis, choledocholithiasis, or malignant disease were excluded. Values from 40 patients after LC and from 18 patients after CC were compared. Both groups had similar patient characteristics, baseline values, and perioperative care, except for deeper anesthesia during CC. RESULTS: On postoperative day 1, epinephrine (p = 0,05), norepinephrine (p = 0.02), and glucose (p = 0.02) responses were higher after CC. Two days postoperatively, norepinephrine remained higher after CC (p < 0.01). Interleukin-1 beta responses were higher during (p < 0.01) and 6 hours after CC (p = 0.03). Interleukin-6 responses were higher 6 hours (p = 0.03), 1 day (p = 0.02), and 2 days (p < 0.01) after CC. CONCLUSIONS: The results show significant lower values of intraoperatively and postoperatively measured epinephrine, norepinephrine, interleukin-1 beta, and interleukin-6 in patients with laparoscopic cholecystectomy, indicating a minor stress response and tissue trauma in this group of patients. The results correspond to the favorable results of most other trials evaluating clinical aspects of laparoscopic cholecystectomy.

Glerup, H., H. Heindorff, et al. (1995). “Elective laparoscopic cholecystectomy nearly abolishes the postoperative hepatic catabolic stress response.  Annals of Surgery 221(3): 214-9.
OBJECTIVE: Surgery results in a catabolic state of postoperative stress, where the efficiency of the liver to convert amino acids to urea is increased. This study measured the metabolic consequences of the less traumatic laparoscopic surgery in elective cholecystectomy compared with traditional open surgery technique. SUMMARY BACKGROUND DATA: The authors previously have shown that open cholecystectomy doubles the urea synthesis measured by the means of the functional hepatic nitrogen clearance. Glucagon and cortisol increased by 50% (p < 0.05) and 75% (p < 0.05), respectively, after open cholecystectomy. METHODS: Patients undergoing uncomplicated elective laparoscopic cholecystectomies were included. Preoperatively and on the first postoperative day, blood and urine samples were drawn every hour under basal conditions and during amino acid infusion. The urea synthesis rate was calculated from the urea excreted in urine and accumulated in total body water. Functional hepatic nitrogen clearance was quantified as the slope of the linear relation between blood amino-N concentration and the urea synthesis rate. The results were compared with an historic matched group of patients who underwent open cholecystectomies and were studied by the same protocol. RESULTS: The laparoscopic cholecystectomy increased the functional hepatic nitrogen clearance by only 25% (from 8.7 +/- 0.9 to 11.1 +/- 1.5 mL/sec [mean +/- SEM; p < 0.05]), compared with a doubling after open cholecystectomy (from 9.4 +/- 0.9 to 17.6 +/- 3.3 mL/sec [p < 0.05]). The difference between the groups was significant (p < 0.05). Neither glucagon nor cortisol increased significantly after laparoscopic cholecystectomy. CONCLUSIONS: The laparoscopic technique results in a much smaller postoperative hepatic catabolic stress response and probably reduced tissue loss of amino-N. This may be important for the more rapid convalescence and reduced postoperative fatigue.

Goggin, P. and E. Doyle (1996). “Anaesthesia for laparoscopic surgery [letter].  Journal of the Royal College of Surgeons of Edinburgh 41(1): 62-3.

Goldberg, J. M. and W. G. Maurer (1997). “A randomized comparison of gasless laparoscopy and CO2 pneumoperitoneum.  Obstetrics & Gynecology 90(3): 416-20.
OBJECTIVE: To determine if the theoretic advantages of gasless laparoscopy are realized in direct comparison to laparoscopy with pneumoperitoneum. METHODS: Fifty-seven patients undergoing laparoscopic surgery chose to participate in this trial and were randomized after the induction of general anesthesia. Twenty-nine of the 57 patients were randomized to the pneumoperitoneum group. Of the 28 patients in the gasless group, six were converted to pneumoperitoneum because of inadequate exposure. The adequacy of exposure and ease of surgery were assessed with a subjective score, and the times to exposure and for incision closure were recorded. Various anesthetic factors were measured. Patients completed an analog pain score in the recovery area and for the first 5 postoperative days. Analgesic and antiemetic use also was recorded, as was the number of days to return to normal activity. RESULTS: Times to achieve exposure and close incisions were longer, and exposure and ease of surgery were worse in the gasless group. Patients in the gasless group had lower diastolic blood pressure, minute ventilation, peak inspiratory pressures, and end tidal pCO2. There were no differences in body temperature, systolic blood pressure or heart rate, postoperative pain scores, analgesic or antiemetic use, or times to hospital discharge or return to activity between the groups. CONCLUSION: Performing laparoscopy using the Laparolift device compromised surgical exposure and thus increased technical difficulty. Patients realized no benefits from its use in terms of postoperative discomfort or return to activity. Eliminating the pneumoperitoneum allowed lower minute ventilation and peak inspiratory pressures, and end tidal pCO2 was lower. Although the concept of gasless laparoscopy holds appeal, the current prototype is not well-suited for infertility procedures.

Gomella, L. G., T. A. Abdel-Meguid, et al. (1997). “Laparoscopic urologic surgery outcome assessment.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 7(2): 77-86.
Laparoscopic surgery is an evolving technique that began to be applied widely in urology in the early 1990s. We have conducted an ongoing multicenter study of laparoscopic urologic surgery to identify any changes in utilization, complications, and short- and long-term outcomes. Laparoscopic urologic surgical procedures were assessed in three successive phases: retrospective initial experience [P1] (before 1991), and prospectively, an intermediate phase [P2] (1991-1992) and a late phase [P3] (1993-1994). The late phase group was followed for 1 year through 1995 to identify any delayed complications. In the P1 group, 114 patients are included; 105 underwent laparoscopic pelvic lymph node dissection (LPLND), 7 underwent laparoscopic variocele ligation (LVL), and 2 underwent other procedures. The complication rates in P1 are 21% (total): 10.5% (major) and 10.5% (minor). The P2 group includes 148 patients; 132 underwent LPLND, 10 underwent LVL, and 6 underwent other procedures. The complication rates decreased to 16.2% (total): 6% (major) and 10.1% (minor). The latest group (P3) includes 326 subjects; 245 had LPLND, 39 had LVL, and 42 had other procedures. More improvement in outcome is shown in this phase with a 7.98% total complication rate: 0.92% major and 7.05% minor. In addition, other parameters such as operative time and hospital stay show improvement through the successive phases. There were no significant long-term complications in the latest study group. This study demonstrates a continual improvement in outcome and changes in utilization patterns as urologists become more experienced with laparoscopic surgery. The complexity of the procedures performed has increased with a decrease in the complication rates overall.

Goodman, N. W. (1992). “Local anaesthesia to prevent post-laparoscopic shoulder pain [letter; comment].  Lancet 339(8797): 868-9.

Gordon, A. G. (1984). “Laparoscopy under local anaesthesia [editorial].  Journal of the Royal Society of Medicine 77(7): 540-1.

Graham, S. G. and A. R. Aitkenhead (1993). “A comparison between propofol and desflurane anaesthesia for minor gynaecological laparoscopic surgery.  Anaesthesia 48(6): 471-5.
Fifty-seven healthy female patients who underwent gynaecological laparoscopic surgery received either desflurane or propofol for induction and maintenance of anaesthesia. Inhalational induction was generally well tolerated, and consciousness was lost in approximately 2 min (mean end-tidal concentrations of desflurane were 8.3% with 60% nitrous oxide, and 7.1% with oxygen). Recovery of consciousness and orientation were more rapid in patients in whom anaesthesia was maintained with desflurane than with propofol, but there were no differences in psychomotor function test scores at 30 min. The data suggest that desflurane provides controllable anaesthesia and rapid recovery of consciousness after laparoscopic surgery.

Greville, A. C. and E. A. Clements (1990). “Anaesthesia for laparoscopic cholecystectomy using the Nd:Yag laser. The implications for a district general hospital [see comments].  Anaesthesia 45(11): 944-5.
We describe the anaesthetic management of the first reported cholecystectomy by laparoscopic laser in the United Kingdom. The implications of the development of laser surgery in a district general hospital are discussed.

Grinenko, T. F., I. Lapshina, et al. (1997). “Sravnitel'naia otsenka primeneniia mivakrona i trakriuma v anesteziologicheskom posobii pri laparoskopicheskikh kholetsistektomiiakh.  Anesteziologiia i Reanimatologiia(6): 4-6.
Two nondepolarizing myorelaxants: tracrium, with medium-long duration of action, and a new short-acting drug mivacron were used in combined anesthesia of 50 patients with gastrointestinal diseases subjected to laparoscopic cholecystectomy. Both drugs can be used for anesthesia of laparoscopic operations; mivacron should be preferred due to its shorter action.

Gurmarnik, S., M. Poreda, et al. (1996). “A combination of low dose spinal and general anaesthesia for laparoscopic cholecystectomy [letter].  Canadian Journal of Anaesthesia 43(1): 95.

Gutt, C., H. Voepel, et al. (1996). “Instrumente fur die gaslose laparoskopische Chirurgie.  Zentralblatt fur Chirurgie 121(7): 578-83.
Specially designed instruments for laparoscopic surgery with a pneumoperitoneum are expensive and delicate, and surgeons are initially not familiar with their handling. Beside restrictions of the surgeon's intraabdominal range of motion they lead to a loss of tactile sensation. In gasless laparoscopic procedures not only special laparoscopic instruments, but the standard conventional instruments, used in open surgery, can also be employed with simple valveless trocars. Still using these instruments can put up some difficulties, because ergonomic factors were not considered in their development. With regard to the instrument's length, shape and joint-position we developed a special instrument-set under the ergonomic criteria of gasless laparoscopy.

Gutt, C. N., P. Heinz, et al. (1997). “The phagocytosis activity during conventional and laparoscopic operations in the rat. A preliminary study.  Surgical Endoscopy 11(9): 899-901.
BACKGROUND: Numerous experimental and clinical investigations indicate that the mononuclear phagocyte system (MPS) has a relevant function in terms of physiological defense against tumor metastasis and bacterial infection. Consequently, a point of major interest is the influence of surgical techniques on the MPS function. METHOD: The model investigation examines the phagocytosis activity of the rat's MPS during conventional fundoplication (group 1, n = 10), laparoscopic fundoplication using a pneumoperitoneum (group 2, n = 10), and gasless laparoscopic fundoplication (group 3, n = 10). The MPS function is evaluated by an intravascular carbon clearance test (G. Biozzi). RESULTS: The fastest carbon elimination half-life was found in group 3. By way of contrast, there was a significant increase of carbon half-life in group 2 (p < 0.005). Even group 1 caused less MPS depression (p < 0.1) than group 2. CONCLUSION: Gasless laparoscopic procedures have a favorable effect on phagocytosis activity. The CO2 pneumoperitoneum seems to be the main reason for a decreased antigen elimination in laparoscopic treatments.

Gutt, C. N., V. Riemer, et al. (1999). “Impact of laparoscopic colonic resection on tumour growth and spread in an experimental model.  British Journal of Surgery 86(9): 1180-4.
BACKGROUND: The influence of surgical manipulation and carbon dioxide pneumoperitoneum on intraperitoneal tumour growth and port-site metastasis during laparoscopic colon resection is still unknown. METHODS: Some 33 male WAG/Rij rats were randomized into three experimental groups: a laparoscopy group with carbon dioxide pneumoperitoneum (n = 11), a gasless laparoscopy group (n = 11) and a laparotomy group (n = 11). After transanal injection of a tumour cell suspension (1 x 106 CC 531 cells) into the distal colon, a colon segment resection and an end-to-end anastomosis (laparoscopy; intra-abdominal technique) were performed. Tumour growth was scored semiquantitatively 24 days after the operation. Data were analysed by the Kruskal-Wallis test. RESULTS: The tumour indices from the four locations with the greatest tumour growth were significantly decreased in the laparoscopy group with carbon dioxide pneumoperitoneum compared with the gasless laparoscopy and laparotomy groups (P < 0.01). Port-site metastases were significantly decreased in the carbon dioxide pneumoperitoneum group compared with the gasless laparoscopy group (P = 0.05). CONCLUSION: A full laparotomy incision promotes greater tumour growth than does carbon dioxide pneumoperitoneum. Surgical manipulation stimulates local tumour spread more than the establishment of a carbon dioxide pneumoperitoneum.

Hall, T. J., D. R. Donaldson, et al. (1980). “The value of laparoscopy under local anaesthesia in 250 medical and surgical patients.  British Journal of Surgery 67(10): 751-3.
This study reports our experience of laparoscopy under local anaesthesia in 250 patients; the procedure was safe, quick and easy to perform with minimal inconvenience to the patient. We advocate the early use of laparoscopy in patients with ascites and when there is difficulty in the diagnosis of patients with jaundice and hepatomegaly, an accurate histological diagnosis being obtained in the majority. In patients with intra-abdominal malignancy, in whom surgery is planned, laparoscopy can detect disseminated disease and so avoid an unnecessary laparotomy. Laparoscopy may also provide a diagnosis in patients presenting with a variety of vague symptoms such as abdominal pain, weight loss, lethargy etc. We have found laparoscopy an excellent investigation if positive but, as if only allows the surface inspection of viscera, when negative, we recommend caution in its interpretation.

Hall, D., A. Goldstein, et al. (1993). “Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry.  Anesthesiology 79(1): 173-4.

Hammarqvist, F., B. Westman, et al. (1996). “Decrease in muscle glutamine, ribosomes, and the nitrogen losses are similar after laparoscopic compared with open cholecystectomy during the immediate postoperative period.  Surgery 119(4): 417-23.
BACKGROUND: The purpose of the study was to compare the postoperative muscle amino acid pattern, the ribosome concentration and size distribution, and postoperative nitrogen balance in patients who underwent either laparoscopic or open cholecystectomy. METHODS: Patients who underwent cholecystectomy by means of either laparoscopy (n=8;LAP) or laparotomy (n=8;OPEN) were studied. The concentrations of amino acids, ribosomes, and polyribosomes, reflecting protein synthesis, were determined in skeletal muscle tissue before operation and on postoperative day 2. The cumulated nitrogen balance was determined. RESULTS. Decreases in muscle glutamine (26.7% +/- 8.4% in the LAP group and 30.3% and +/- 4.5% in the OPEN group) and in polyribosomes (28.7% +/- 6.5% in the LAP group and 23.6% +/- 8.5% in the OPEN group) were observed without differences between the groups (mean +/- SEM). The nitrogen losses were similar in both groups (15.2 +/-1.6 gm in the LAP group and 15.5 +/- 1.2 gm in the OPEN group). CONCLUSION: A stress++ response with effects on amino acid and protein metabolism in muscle in present also after laparoscopic cholecystectomy. On postoperative day 2 this response is of similar magnitude after both the laparoscopic and the open procedures.

Hammond, J. E. (1984). “Anaesthesia for laparoscopy: alfentanil and fentanyl compared [letter].  Annals of the Royal College of Surgeons of England 66(2): 148-9.

Hanley, E. S. (1992). “Anesthesia for laparoscopic surgery.  Surgical Clinics of North America 72(5): 1013-9.
The anesthesiologist's goals during laparoscopic surgery are hemodynamic and respiratory stability, appropriate muscle relaxation, control of diaphragmatic excursion, intraoperative and postoperative patient analgesia, and a quick postanesthesia recovery. One must also consider that 3% to 5% of all laparoscopic procedures require conversion to an open laparotomy. Whatever the choice of anesthetic technique, it is important to maintain cooperation and communication among the members of the operating room team in order to ensure a successful patient outcome.

Hannon, J. K., W. B. Faircloth, et al. (2000). “Comparison of insufflation vs. retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine.  Surgical Endoscopy 14(3): 300-4.
Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs. 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.

Harris, M. N., O. M. Plantevin, et al. (1984). “Cardiac arrhythmias during anaesthesia for laparoscopy.  British Journal of Anaesthesia 56(11): 1213-7.
Fifty-six patients undergoing elective laparoscopy were allocated randomly to two groups. Group H received alcuronium and were ventilated artificially using 0.5% halothane and nitrous oxide in oxygen. Group E breathed spontaneously a mixture of enflurane and nitrous oxide in oxygen. Arterial pressure, heart rate, tidal volume, respiratory rate and end-tidal carbon dioxide tension (PECO2) were monitored. The electrocardiogram (ECG) was recorded continuously using magnetic tape, from before induction until the patient left the recovery area. The incidence of arrhythmias was similar in the two groups. No arrhythmias occurred after the insufflated carbon dioxide had been removed from the abdomen. Spontaneous ventilation with enflurane anaesthesia is a simple and safe, technique for routine laparoscopy, providing the intra-abdominal pressure does not exceed 25 mm Hg.

Hasel, R., S. K. Arora, et al. (1993). “Intraoperative complications of laparoscopic cholecystectomy.  Canadian Journal of Anaesthesia 40(5 Pt 1): 459-64.
We report a series of intraoperative complications of laparoscopic cholecystectomy. Three cases are presented in which subcutaneous emphysema associated with pneumomediastinum, pneumoscrotum, and pneumothorax with pneumomediastinum and ocular emphysema, respectively, developed intraoperatively. These events resulted in no major morbidity to these patients. Use of N2O and monitoring of airway and intraabdominal pressures are discussed.

Hashizume, M., K. Tanoue, et al. (1998). “Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism.  Journal of the American College of Surgeons 187(3): 263-70.
BACKGROUND: The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices. STUDY DESIGN: Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints. RESULTS: The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months). CONCLUSIONS: The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.

Hatasaka, H. H., H. T. Sharp, et al. (1997). “Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 7(5): 295-9.
OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

Hateboer, N., C. Spargo, et al. (1995). “Bilateral laparoscopic nephrectomy in a patient with renal transplant [letter].  American Journal of Nephrology 15(6): 533-4.

Healey, D. E., R. C. Newman, et al. (1993). “Laparoscopically assisted percutaneous renal biopsy.  Journal of Urology 150(4): 1218-21.
We performed laparoscopically assisted percutaneous renal biopsy on 4 patients with azotemia or renal dysfunction who were believed to be unsuitable candidates for percutaneous renal biopsy. Tissue adequate for diagnosis was obtained in all 4 cases. Complications included subcutaneous emphysema in 1 patient and a small splenic capsular tear in 1, which was managed laparoscopically and did not require transfusion. Bleeding from the renal biopsy occurred in 1 patient and was easily managed laparoscopically. We recommend laparoscopically assisted percutaneous renal biopsy as an alternative method of renal biopsy in patients who can tolerate general anesthesia and who are not candidates for percutaneous renal biopsy.

Hegarty, J. H. and T. G. Brennan (1983). “Laparoscopy under local anaesthesia: our experience in 400 non-gynaecological patients.  Irish Journal of Medical Science 152(7): 276-8.

Heikkinen, T. J., K. Haukipuro, et al. (1998). “A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. A randomized prospective study [see comments].  Surgical Endoscopy 12(10): 1199-203.
BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.

Hellinger, M. D., S. A. Martinez, et al. (1999). “Gasless laparoscopic-assisted intestinal stoma creation through a single incision.  Diseases of the Colon & Rectum 42(9): 1228-31.
Intestinal stoma creation has been performed using both open and laparoscopic surgery. However, each technique still has disadvantages. We created the intestinal stoma through one incision, with the use of the laparoscope in a gasless fashion. This method has not been reported previously. Fourteen adult patients underwent this technique between February 1996 and December 1998. Indications for stoma creation were for various anorectal disease processes, most commonly for purposes of hygiene in patients with spinal cord injury. The average operative time to perform the stoma was 58 (range, 15-78) minutes, with minimal blood loss (<35 ml). Follow-up ranged from 1 to 22 months. Two cases (14 percent) were converted secondary to severe adhesions. All nonconverted patients were able to tolerate a regular diet within two days of surgery. There was only one stoma-related complication. Two patients (14 percent) died of comorbidities during follow-up. In conclusion, the initial experience with gasless laparoscopic-assisted intestinal stoma creation through a single incision is encouraging. Patients requiring ostomy creation as a single intervention may benefit from this approach.

Helmy, S. A. (1999). “Prophylactic anti-emetic efficacy of ondansetron in laparoscopic cholecystectomy under total intravenous anaesthesia. A randomised, double-blind comparison with droperidol, metoclopramide and placebo.  Anaesthesia 54(3): 266-71.
The prophylactic anti-emetic efficacy and safety of pre-operative intravenous ondansetron was evaluated in a randomised, double-blind, comparison with droperidol, metoclopramide and placebo in 160 ASA grade 1 and 2 patients undergoing laparoscopic cholecystectomy under total intravenous anaesthesia. The patients were randomly allocated to receive ondansetron (4 mg), droperidol (1.25 mg), metoclopramide (10 mg) or placebo given as a single intravenous dose immediately before induction of a standardised general anaesthetic. There were no significant differences between the four study groups with regard to the demographic and anaesthetic data, postoperative analgesia, postoperative sedation scores, duration of postoperative hospital stay and incidence of adverse events. The incidence of nausea and vomiting was significantly lower (p < 0.05) between 1 h and 4 h after surgery in the ondansetron group compared with the droperidol, metoclopramide and placebo groups. The incidence of nausea was similar in the four groups in the other study periods: 0-1 h and 4-24 h. The incidence of vomiting was lower in the ondansetron, droperidol and metoclopramide groups than in the placebo group between 1 and 4 h but was the same between 4 and 24 h. As a result of the lower incidence of nausea and vomiting between 1 h and 4 h in the ondansetron group, the overall incidence of nausea and vomiting was lower during the first 24 h after surgery in this group than in the other three groups.

Hin, P. C. (1996). “Laparoscopic-assisted gastrostomy in 26 patients: indications and outcome at 2 years.  Journal of Laparoendoscopic Surgery 6(1): 25-8.
Laparoscopic-assisted gastrostomy using an original technique was successfully performed in 26 patients referred for nutritional support. The indications were neurological disorders of swallowing in 15, head and neck cancer in 4, and head injuries in 7. No major complications were seen in this group. One episode of temporary peritubal leakage settled after catheter change. One tube blocked after 4 months of feeding and temporary loss to follow-up. At follow-up, the tube continued to function in 7 patients, a mean of 130 days (range 45-667 days). In 7 patients recovery was sufficient to allow catheter removal at a mean of 134 days (range 56-450 days). Twelve patients died of their disease, a mean of 76 days after insertion (range 43-300). Patient tolerance and ease of care have been excellent. There is a suggestion that recovery specially in head injury patients may be enhanced. Laparoscopic-assisted gastrostomy should be considered in all patients referred for medium or long-term nutritional support.

Hirsch, H. A., K. Decker, et al. (1979). “Laparoskopische Tubensterilisation in Lokalanasthesie.  Archives of Gynecology 228(1-4): 282-3.

Hirsch, I. H., J. G. Moreno, et al. (1995). “Noninsufflative laparoscopic access.  Journal of Endourology 9(6): 483-6.
Standard laparoscopic surgery requires maintenance of the working cavity by continual carbon dioxide insufflation and exaggerated Trendelenburg positioning. Both cardiopulmonary and metabolic adverse effects may result from these maneuvers, which may be avoided by a gasless approach to laparoscopic surgery. We investigated a new mechanical retraction system designed to maintain exposure of either intraperitoneal or retroperitoneal contents in a gasless laparoscopic cavity and assessed its performance in both laparoscopic approaches. Gasless laparoscopic surgery was attempted using the Laprolift/Laparofan system for retroperitoneal procedures: left varicocele ligation (three cases), renal biopsy (one case), extraperitoneal pelvic lymph node dissection (one case), and intraperitoneal bilateral varicocelectomy (two cases). Renal biopsy and varicocelectomy were accomplished successfully with the gasless approach and with technical ease comparable to that of the standard insufflative laparoscopic approach. Gasless pelvic lymph node dissection and intraperitoneal varicocelectomy were converted to insufflative laparoscopic or open procedures because of inadequate exposure of the pelvic contents. This early experience with gasless laparoscopy indicates that it may best be reserved for retroperitoneal urologic procedures.

Hirsch, I. H., T. Abdel-Meguid, et al. (1997). “Gasless laparoscopic varicocele ligation: experience with new instrumentation and technique for retroperitoneal and intraperitoneal approaches.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 7(4): 221-6.
Laparoscopic access to the retroperitoneum without abdominal insufflation has recently been made possible by devices designed to create a dilated laparoscopic cavity maintained by a fixed retraction system. This technique was applied in 10 patients undergoing laparoscopic ligation of the internal spermatic vein via extraperitoneal and intraperitoneal approaches. Gasless laparoscopic varicocelectomy was completed in 7 of 8 men by the extraperitoneal route and in neither of the 2 men approached intraperitoneally. The mean operative time was 170+/-55 min and postoperative pain exceeded the norm for standard insufflative laparoscopic varicocelectomy. Whereas certain theoretical advantages are offered by the gasless extraperitoneal approach to varicocele ligation, exposure through the gasless technique is currently suboptimal. Further development of "retraction" technology is required, prior to its routine application for varicocele ligation.

Hirsch, I. H., T. A. Abdel-Meguid, et al. (1998). “Postsurgical outcomes assessment following varicocele ligation: laparoscopic versus subinguinal approach.  Urology 51(5): 810-5.
OBJECTIVES: To prospectively compare and objectively assess the postsurgical outcome parameters of both laparoscopic and open subinguinal techniques for varicocele ligation in infertile men. METHODS: A total of 41 evaluable patients with a history of infertility, abnormal semen analysis, and clinically diagnosed varicoceles underwent surgical ligation either by the insufflative intraperitoneal laparoscopic (n = 15), gasless laparoscopic (n = 7), or the open subinguinal (n = 19) approach. Most procedures (39 of 41) were performed in the outpatient setting, and patients were followed postoperatively for a minimum of 6 months. Postsurgical outcome was assessed by physical examination and review of a patient questionnaire quantifying the graded pain severity, analgesic requirements, and number of days to return to work. RESULTS: The average operative time was 82.3 +/- 26.5 minutes for insufflative intraperitoneal laparoscopic varicocelectomy, 170 +/- 55 minutes for gasless laparoscopic varicocelectomy, and 35.6 +/- 13.5 minutes for the open subinguinal approach. The analgesic requirement was 13.7 +/- 9.9 tablets for the insufflative laparoscopic group, 22.5 +/- 11 tablets for the gasless laparoscopic group, and 10.9 +/- 10.3 tablets for the open subinguinal group. The average number of days to return to work was 4.9 +/- 2.7 for the insufflative group, 6.6 +/- 2.6 for the gasless group, and 5.1 +/- 3.7 for the open subinguinal group. CONCLUSIONS: These results show no superiority of laparoscopic techniques over the standard open subinguinal technique with respect to hospital stay, analgesic requirements, or return to work. Laparoscopic techniques require excessive operative time, may have attendant complications, and require general anesthesia, limitations that preclude their routine application in varicocele ligation. However, the laparoscopic approach may have a role in the setting of other concurrently performed laparoscopic procedures.

Hirvonen, E. A., E. O. Poikolainen, et al. (2000). “The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy.  Surgical Endoscopy 14(3): 272-7.
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 degrees) 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 mm Hg), 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.

Hodgson, C., J. Newton, et al. (1970). “Peritoneal transfer of carbon dioxide.  Anaesthesia 25(1): 128-9.

Hodgson, C., R. M. McClelland, et al. (1970). “Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy.  Anaesthesia 25(3): 382-90.

Horgan, S., M. Sinanan, et al. (1997). “Use of laparoscopic techniques improves outcome from adrenalectomy.  American Journal of Surgery 173(5): 371-4.
BACKGROUND: Laparoscopic adrenalectomy is a promising alternative to open approaches but safety and efficacy remain unproven. METHODS: A recent experience with laparoscopic adrenalectomy at the University of Washington was analyzed for efficacy, complications, evolution of technical steps, and clinical outcome. RESULTS: Nineteen adrenalectomies were performed in 16 patients with a mean age of 52 years. Indications included pheochromocytoma (4), functional adenoma (12), and uncontrolled Cushing's disease (3). All patients had computed tomography scans. Meta-iodo-benzyl-guanidine (MIBG) or iodocholesterol scans were done in selected patients. Three patients had bilateral procedures, 7 were on the left and 6 on the right, all via a transperitoneal flank approach. There were no conversions and all procedures were successful. Complications included subcapsular liver hematomas (2), one transfusion, and a bleeding port site requiring repeat laparoscopy. Except for 1 patient with COPD, the mean length of stay was 2.9 days. CONCLUSIONS: Laparoscopic adrenalectomy in appropriate patients is safe and effective. For endocrine surgeons with advanced laparoscopic skills, it should be considered a new standard therapy for benign adrenal tumors.

Horvath, K. D., R. L. Whelan, et al. (1997). “A prospective comparison of laparoscopic exposure techniques for rectal mobilization and sigmoid resection.  Journal of the American College of Surgeons 184(5): 506-12.
BACKGROUND: We determined the efficacy of a pneumoperitoneum and a gasless abdominal wall lifting device in providing exposure for low rectal mobilization and sigmoid resection in a swine model. The results of these laparoscopic techniques were compared with those obtained using standard open surgical methods. STUDY DESIGN: We conducted a prospective randomized nonblinded trial. Twenty-four adult female pigs were randomized into three groups depending on exposure technique: group 1, open (n = 6); group 2, carbon dioxide (n = 6) or helium (n = 6) pneumoperitoneum; and group 3, a mechanical abdominal wall lifting device (n = 6). A low rectal mobilization and sigmoid resection with a double-stapled, circular, end-to-end anastomosis was performed in all pigs. In group 2, a laparoscopic-assisted approach was used. Parameters assessed included length of operation, length of the colonic specimen, number of lymph nodes per specimen, and extent of anterior and posterior rectal mobilization (centimeters from the anal verge). RESULTS: Operative times were significantly shorter for group 1 than for group 2; no significant differences were found between the two laparoscopic subgroups. No significant difference was found in length of the colonic specimen or in number of lymph nodes harvested for each group. Extent of anterior and posterior rectal mobilization was also not significantly different for the three groups. Although mean mobilization lengths for each group were not significantly different, the range of values was broader in the laparoscopic groups. CONCLUSIONS: A comparable mobilization and bowel resection can be performed laparoscopically, regardless of the exposure technique used. Gasless laparoscopy may prove useful in patients in whom pneumoperitoneum is contraindicated; it will not replace pneumoperitoneum as the only method for obtaining laparoscopic exposure because of the ease of use and frank superiority of the pneumoperitoneum in most circumstances. Abdominal wall lifting devices seem to be a reasonable alternative to pneumoperitoneum for sigmoid resection and rectal mobilization.

Hovorka, J., A. M. Lehtinen, et al. (1983). “Recovery after general anaesthesia for laparoscopy.  Acta Anaesthesiologica Scandinavica 27(5): 396-9.
Recovery after two methods of light general anaesthesia for gynaecological laparoscopy was studied. For this purpose, 30 patients were divided into two equal groups (A and B). The patients in group A were anaesthetized with thiopentone, fentanyl and suxamethonium infusion, while the patients in group B received inhalation anaesthesia with enflurane and suxamethonium infusion. Both groups were normoventilated with nitrous-oxide and oxygen mixture. A battery of recovery tests was applied in the recovery room. The patients who received inhalation anaesthesia with enflurane scored better in the recovery tests, and reached preoperative values after 3 h in the recovery room. Inhalation anaesthesia with enflurane was accepted well by the patients and provided good working conditions for the surgeons. It is suitable for outpatient gynaecological laparoscopy because it ensures rapid recovery.

Howard, J. G., M. A. Barone, et al. (1992). “The effect of pre-ovulatory anaesthesia on ovulation in laparoscopically inseminated domestic cats.  Journal of Reproduction & Fertility 96(1): 175-86.
Laparoscopic intrauterine artificial insemination (AI) of electroejaculated spermatozoa was used to compare embryo development and conception rates in domestic cats inseminated either before or after ovulation. Females were given a single (100 iu) injection of pregnant mares' serum gonadotrophin (PMSG) followed by either 75 or 100 iu human chorionic gonadotrophin (hCG) 80 h later. Cats were anaesthetized (injectable ketamine HCl/acepromazine plus gaseous halothane) 25-50 h after administration of hCG for laparoscopic assessment of ovarian activity and for transabdominal AI into the proximal aspect of the uterine lumen. At the time of AI, 23 cats were pre-ovulatory (25-33 h after hCG injection) and 30 were post-ovulatory (31-50 h after hCG injection). Pre-ovulatory females produced 10.5 +/- 1.1 follicles and no corpora lutea compared with 1.9 +/- 0.5 follicles and 7.5 +/- 0.9 corpora lutea for the post-ovulatory group (P < 0.05). Six days later, the ovaries of nine pre-ovulatory and 12 post-ovulatory females were re-examined and the reproductive tracts flushed. On this day, pre-ovulatory cats produced fewer corpora lutea (2.8 +/- 1.5; P < 0.05) and embryos (0.4 +/- 0.3; P < 0.05) than post-ovulatory females (18.9 +/- 3.3 corpora lutea; 4.6 +/- 1.2 embryos). Two of the 14 cats (14.3%) inseminated before ovulation and not flushed became pregnant compared with 9 of 18 cats (50.0%) inseminated after ovulation and up to 41 h after hCG injection (P < 0.05). These results indicate that ovulation in cats is compromised by pre-ovulatory ketamine HCl/acepromazine/halothane or laparoscopy or by both and that electroejaculated spermatozoa deposited by laparoscopy in utero, after ovulation, result in a relatively high incidence of pregnancy. Because ovulation usually occurs 25-27 h after injection of hCG, the lifespan for fertilization of the ovulated ovum appears to be at least 14 h in vivo in cats.

Iafrati, M. D., R. Yarnell, et al. (1995). “Gasless laparoscopic cholecystectomy in pregnancy.  Journal of Laparoendoscopic Surgery 5(2): 127-30.
Although laparoscopic cholecystectomy has become the surgical procedure of choice for most patients with cholecystitis, the safety of carbon dioxide (CO2) pneumoperitoneum during pregnancy has not been fully elucidated. Pregnancy causes many physiologic changes, resulting in compromised cardiac, pulmonary, and metabolic reserves. The use of CO2 pneumoperitoneum during laparoscopy may cause further physiologic stress to both the parturient and the fetus. A case of gasless laparoscopic cholecystectomy is presented. This procedure avoids potential risks of both absorbed CO2 and increased intraabdominal pressure.

Iglesias Gonzalez, J. L., A. Alaejos Estebanez, et al. (2000). “Anestesia en un caso de reparacion laparoscopica de hernia de Morgagni.  Revista Espanola de Anestesiologia y Reanimacion 47(3): 135-7.

Intra, M., M. P. Viani, et al. (1996). “Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis.  Journal of Laparoendoscopic Surgery 6(4): 263-70.
Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function. Laparoscopy for surgical treatment of hepatic diseases is at an early stage. Laparoscopy has been often proposed for diagnosis, staging of hepatic malignancy, treatment of hepatic cyst or benign tumors, but very few laparoscopic treatments of hepatic malignancies have been reported at present and always using conventional CO2 laparoscopy. We describe herein the operative treatment of a single subglissonian HCC of segment III in a child, HCV (hepatitis C virus)-related cirrhosis. A nonanatomical wedge resection was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. The technique, in selected cases, is a simple, safe, and effective surgical method. The gasless technique guarantees a clear vision, it makes possible the continuous suction of smoke and fluids, it allows the use of conventional instruments for classic maneuvers of the liver surgery (Pringle maneuver), and the easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless minimally invasive surgery.

Jakobsson, J., K. Rane, et al. (1997). “Anaesthesia during laparoscopic gynaecological surgery: a comparison between desflurane and isoflurane.  European Journal of Anaesthesiology 14(2): 148-52.
Desflurane is a new inhalation anaesthetic with a low blood/gas solubility which should allow a fast emergence from anaesthesia. In a prospective open randomized study, desflurane was compared with isoflurane paying special attention to recovery and the quality of the post-operative period. The occurrence of pain and post-operative nausea and vomiting (PONV) was recorded during the first 20 post-operative hours. Seventy women ASA Grade I-II scheduled for elective gynaecological laparoscopic procedures were studied. Patients receiving desflurane were extubated earlier than patients receiving isoflurane, 5 +/- 1 and 9 +/- 1 min respectively (P < 0.05) and the patients anaesthetized with desflurane were able to tell their name and date on average 5 min earlier than those who had received isoflurane; however, time in the recovery room was the same for both groups of patients. Twenty-two of 35 patients receiving desflurane, and 18 of 35 receiving isoflurane required analgesia. PONV was recorded in 18 patients anaesthetized with desflurane and 12 patients anaesthetized with isoflurane. In both groups PONV was more frequently observed in patients after leaving the recovery room. PONV in the recovery room was associated with a delayed discharge, 139 vs. 114 min respectively. Desflurane seems to be an useful alternative to isoflurane for laparoscopic procedures.

Jandali, S. T., A. B. Mofti, et al. (1999). “Anesthesia for laparoscopic gastroplasty in morbid obesity.  Middle East Journal of Anesthesiology 15(1): 63-72.

Jensen, O. H. and E. Lindbaek (1980). “Laparoskopisk sterilisering i lokalanestesi.  Tidsskrift for Den Norske Laegeforening 100(34-36): 2036-7.

Jeon, H. M., J. S. Kim, et al. (1999). “Late development of umbilical metastasis after laparoscopic cholecystectomy for a gallbladder carcinoma.  Oncology Reports 6(2): 283-7.
A periumbilical mass developed 47 months after laparoscopic cholecystectomy. Pathologic examination of this mass showed features of moderately differentiated papillary adenocarcinoma, similar to that identified within the previously removed early stage (pT1b) gallbladder carcinoma. The cause of this <late type recurrence> at the laparoscope port is unclear. <Late type recurrence> after laparoscopic cholecystectomy for gallbladder carcinoma has not been reported previously. We reported a case with late periumbilical tumor seeding at the navel trocar insertion site in a 65-year-old female. A review of the preventative information of tumor recurrence and management is discussed. The use of gasless laparoscopy, slow desufflation, trocar site washout, wound protector and specimen bags are recommended.

Johannsen, G., M. Andersen, et al. (1989). “The effect of general anaesthesia on the haemodynamic events during laparoscopy with CO2-insufflation.  Acta Anaesthesiologica Scandinavica 33(2): 132-6.
Sixteen women were studied during elective diagnostic laparoscopy with CO2-insufflation to an intraabdominal pressure (IAP) of 2 kPa and Trendelenburg tilt to 30 degrees. They were allocated to either a halothane (Group I) or a balanced (Group II) anaesthesia with relaxation and controlled ventilation. Heart rate (HR), arterial pressure, stroke volume, CO2-elimination, end-tidal CO2 vol.% and total respiratory compliance (TRC) were the parameters measured, and mean arterial pressure (MAP), total peripheral resistance (TPR), stroke index (SI) and cardiac index (CI) were calculated. At maximum haemodynamic strain, SI and CI were on average reduced by 42% in both groups, without significant changes in HR and MAP. TPR increased by 50% in Group I and 100% in Group II. The reduction in SI was related to the changes in TRC. A small increment in CO2-elimination after CO2-insufflation was most pronounced in Group II. SI and CI did not reach the pre-insufflation values after return to the horizontal position and CO2-exsufflation. The haemodynamic differences between the two groups were small compared to the effects of the laparoscopy procedures.

Johnson, P. L. and K. S. Sibert (1997). “Laparoscopy. Gasless vs. CO2 pneumoperitoneum.  Journal of Reproductive Medicine 42(5): 255-9.
OBJECTIVE: To compare gasless laparoscopy with conventional laparoscopy using CO2 pneumoperitoneum. STUDY DESIGN: Women undergoing bilateral laparoscopic tubal coagulation (LTC) were randomly assigned to one of two laparoscopy procedures: (1) a gasless laparoscopy system consisting of an intraabdominal fan retractor and electrically powered mechanical arm, and (2) standard CO2 pneumoperitoneum laparoscopy. The two laparoscopic procedures were compared on the basis of intraoperative visualization, operation duration, procedural difficulty, ventilatory parameters, hemodynamic stability, and postoperative pain and nausea. RESULTS: Significant disadvantages for the surgeon (increased technical difficulty, poorer visualization, longer operative times) and patient (greater postoperative pain and nausea) were seen with the gasless system. Because of these findings, the study was prematurely terminated after only 18 patients had participated. Intraoperative ventilatory and hemodynamic parameters were more stable in the gasless laparoscopy groups; however, the differences were not clinically significant in this population of healthy patients. CONCLUSION: The markedly increased technical difficulty and absence of clear clinical benefits for the healthy patient led to the conclusion that laparoscopy with CO2 pneumoperitoneum is preferable for routine LTC and most laparoscopic procedures in the pelvis. Gasless laparoscopy may be of benefit for the fragile patient with a compromised cardiovascular system who may suffer complications from hypercarbenemia.

Jones, D. B., D. L. Dunnegan, et al. (1995). “The influence of intraoperative gallbladder perforation on long-term outcome after laparoscopic cholecystectomy.  Surgical Endoscopy 9(9): 977-80.
During laparoscopic cholecystectomy, gallbladder perforation with leakage of bile and/or gallstones into the abdominal cavity occurs frequently. When this occurs, our practice has been to lavage the operative field and retrieve as many gallstones as possible. We were concerned, however, that complications secondary to infection or adhesions might develop. To address this issue, our first 250 consecutive patients undergoing laparoscopic cholecystectomy were surveyed by postal questionnaire. In the 35-48 months (mean, 41 months) since operation, six patients (2.6%) died of nonbiliary causes. Of the 225 patients (90%) who completed the questionnaire, 73 (33%) suffered intraoperative gallbladder perforation. There were no late wound or intraabdominal infectious complications and no patient has required reoperation for intraabdominal sepsis or bowel obstruction. In the entire group, gastrointestinal symptoms were prevalent and included flatulence (40%), loose stools or fecal urgency (35%), belching (23%), and nausea (4%). The prevalence of these complaints was similar in patients with and without gallbladder perforation. Intraoperative gallbladder perforation during laparoscopic cholecystectomy, therefore, does not cause adverse long-term complications when accompanied by operative lavage and stone removal.

Jones, D. B., R. W. Thompson, et al. (1996). “Development and comparison of transperitoneal and retroperitoneal approaches to laparoscopic-assisted aortofemoral bypass in a porcine model.  Journal of Vascular Surgery 23(3): 466-71.
PURPOSE: Transperitoneal and retroperitoneal approaches to video-assisted aortofemoral bypass were developed and compared using gasless laparoscopic techniques in a porcine model. METHODS: Ten pigs were randomized to either a transperitoneal or retroperitoneal approach. Aortic clamp time, total operative time, and complications were recorded. Both operations used an external lift device to maintain the working space. Retroperitoneal operations first used serial balloon inflation to dissect the retroperitoneum. After exposure of the infrarenal aorta, a graft was tunneled under endoscopic visualization. End-to-side aortic and femoral anastomoses were created with conventional instruments through 4 cm incisions. RESULTS: Mean +/- SEM aortic clamp time, operative duration, and graft patency rates were similar for both approaches (difference not significant by unpaired t test). Intraoperative complications related to the use of the laparoscopic technique included injury to the bladder and small bowel (n=2) and occurred only in the transperitoneal group. CONCLUSIONS: The use of a gasless technique allowed direct visualization, standard instrumentation, and conventional anastomotic techniques. The retroperitoneal approach used the peritoneal sac to exclude the bowel, simplifying the aortic dissection. Gasless laparoscopic-assisted aortofemoral bypass can be performed by both transperitoneal and retroperitoneal approaches and holds promise as a minimally invasive treatment for aortoiliac occlusive disease.

Joris, J. L., D. P. Noirot, et al. (1993). “Hemodynamic changes during laparoscopic cholecystectomy.  Anesthesia & Analgesia 76(5): 1067-71.
Hemodynamics during laparoscopic cholecystectomy under general anesthesia (isoflurane in N2O/O2 (50%)) were investigated in 15 nonobese ASA Class I patients by using invasive hemodynamic monitoring including a flow-directed pulmonary artery catheter. During surgery, intraabdominal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator, and minute ventilation was controlled and adjusted to avoid hypercapnia. Hemodynamics were measured before anesthesia, after the induction of anesthesia, after tilting into 10 degrees head-up position, 5 min, 15 min, and 30 min after peritoneal insufflation, and 30 min after exsufflation. Induction of anesthesia decreased significantly mean arterial pressure and cardiac index (CI). Tilting the patient to the head-up position reduced cardiac preload and caused further reduction of CI. Peritoneal insufflation resulted in a significant increase (+/- 35%) of mean arterial pressure, a significant reduction (+/- 20%) of CI, and a significant increase of systemic (+/- 65%) and pulmonary (+/- 90%) vascular resistances. The combined effect of anesthesia, head-up tilt, and peritoneal insufflation produced a 50% decrease in CI. Administration of increasing concentrations of isoflurane, via its vasodilatory activity, may have partially blunted these hemodynamic changes. These results demonstrate that laparoscopy for cholecystectomy in head-up position results in significant hemodynamic changes in healthy patients, particularly at the induction of pneumoperitoneum.

Juckenhofel, S., C. Feisel, et al. (1999). “TIVA mit Propofol/Remifentanil oder balancierte Anasthesie mit Sevofluran/Fentanyl bei laparoskopischen Operationen. Hamodynamik, Aufwachverhalten und Nebenwirkungen.  Anaesthesist 48(11): 807-12.
OBJECTIVE: This study was designed to investigate the differences between TIVA with propofol/remifentanil (P/R) and balanced anaesthesia with sevoflurane/fentanyl (S/F) in gynaecological laparoscopic surgery. Emphasis was put on haemodynamic reaction, recovery profile, postoperative side effects and patient satisfaction. METHODS: Sixty patients were randomly assigned to receive either total intravenous anaesthesia with propofol/remifentanil or anaesthesia with sevoflurane/fentanyl. After premedication (midazolam) and induction of anesthesia (propofol, atracurium) in both groups, either 1 microgram/kg fentanyl (S/F) or 1 microgram/kg remifentanil (P/R) was injected. Anaesthesia was maintained with 0.5 microgram/kg/min remifentanil (reduced to 50% after 5 min) and 0.06 microgram/kg/min propofol (P/R) or 1.7 vol % sevoflurane (S/F). Both groups were mechanically ventilated with 30% oxygen in air. The administration of sevoflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. For postoperative analgesia 1 g paracetamol was administered rectally prior to surgery. After recovery 20 mg/kg metamizol was given intravenously. At the end of surgery the anaesthetics were discontinued and haemodynamics, early emergence from anaesthesia, pain level, frequency of analgesic demand, incidence of PONV, shivering and patient satisfaction were assessed. Parameters were recorded for 24 h postoperatively. RESULTS: Recovery time after propofol-remifentanil anaesthesia was significantly shorter than after administration of sevoflurane and fentanyl (spontaneous ventilation 4.1 vs. 6.3 min, extubation 4.3 vs. 9.3 min, eye opening 4.4 vs 8.2 min, stating name 5.3 vs. 13.2 min, stating date of birth 5.4 vs. 13.3 min). There were no significant differences between the groups in shivering, pain score, analgesic demand and PONV. The S/F group responded to tracheal intubation with significantly higher blood pressure than the P/R group. During maintenance of anaesthesia heart rate in patients with S/F was significantly higher (P/R:HR max +16/-10; S/F:HR max +24/-0.). Measured on a scale (S/F 62%). CONCLUSION: Compared with patients given balanced anaesthesia with sevoflurane and fentanyl, TIVA with propofol and remifentanil proved to be particularly suited for gynaecological laparoscopic surgery. Its major advantages are haemodynamic stability, significantly shorter times of emergence, and the exceptional acceptance by the patients.

Junghans, T., B. Bohm, et al. (1997). “Effects of pneumoperitoneum with carbon dioxide, argon, or helium on hemodynamic and respiratory function.  Archives of Surgery 132(3): 272-8.
OBJECTIVE: To evaluate the effects of pneumoperitoneum with carbon dioxide, argon, and helium; different abdominal pressures (ie, 8, 12, and 16 mm Hg); and different positions (ie, head up, head down, supine) on hemodynamic and respiratory function in a porcine model. DESIGN: Prospective randomized trial. SETTING: Animal research laboratory. ANIMALS: Eighteen pigs weighing 25.5 +/- 6.9 kg (mean +/- SD). INTERVENTIONS: General anesthesia with endotracheal intubation. Implantation of pulmonal artery catheter and central venous line in jugular vein and catheters in femoral artery and vein. Carbon dioxide, argon, or helium was insufflated through a cannula in the left upper quadrant. The type of gas was randomly assigned to each animal. After recording baseline values at the beginning and at the end without pneumoperitoneum, each animal was placed in 1 of the 3 positions and under 1 of the 3 pressures kept by the insufflator. After 15 minutes of adaptation to the new circumstances, all factors were recorded. This procedure was repeated until all 9 combinations of pressures and positions were evaluated. MAIN OUTCOME MEASURES: Cardiac output; heart rate; stroke volume; right ventricular stroke work; pressures in the pulmonal artery, vena cava, and femoral artery and vein; systemic vascular resistance; respiratory pressure; tidal volume; pH; base excess; oxygen partial pressure; and carbon dioxide partial pressure. RESULTS: The type of gas did not affect cardiac output. Only carbon dioxide demonstrated negative effects on respiratory function. Argon markedly increased afterload. Carbon dioxide increased central venous and mean arterial pressure, which was only moderate using helium. A head-up position decreased cardiac output and central venous pressure and increased mean arterial and peripheral venous pressures, which were partly compensated in a head-down position. An intraperitoneal pressure of 16 mm Hg increased peripheral and central venous pressures, heart rate, and respiratory pressure, and decreased cardiac output, tidal volume, and pH. CONCLUSIONS: Helium may be an alternative gas to establish pneumoperitoneum because it does not have any effect on respiratory function and has only a moderate effect on hemodynamic function. Argon insufflation has some hemodynamic disadvantages. An intraperitoneal pressure greater than 12 mm Hg and a head-up position should be avoided because both have a markedly negative effect on respiratory and hemodynamic factors.

Kald, A., B. Anderberg, et al. (1997). “Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up.  European Journal of Surgery 163(7): 505-10.
OBJECTIVE: To compare outcome and costs between laparoscopic and open hernia repair. DESIGN: Prospective randomised study. SETTING: One university and two district hospitals in Sweden. SUBJECTS: 200 men aged 25-75 years. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option. RESULT: The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364). CONCLUSIONS: Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.

Kamolz, T., T. Bammer, et al. (2000). “Quality of life and surgical outcome after laparoscopic Nissen and Toupet fundoplication: one-year follow-up.  Endoscopy 32(5): 363-8.
BACKGROUND AND STUDY AIMS: Quality of life data are becoming widely accepted as a measure of surgical outcome, but the multifaceted symptoms in patients with gastrointestinal disorders are a challenge for this type of evaluation. The aim of the present study was to determine any potential differences in quality of life, specifically in patients undergoing either laparoscopic "floppy" Nissen fundoplication or Toupet fundoplication. PATIENTS AND METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data for 175 consecutive patients undergoing laparoscopic "floppy" Nissen (n=107) or Toupet (n=68) fundoplication at our department of surgery over a period of 30 months were evaluated prospectively. The patients included 97 men and 78 women, with a mean age of 52 years. The GIQLI creates a general score for quality of life by classifying five different subscales: gastrointestinal symptoms, emotional status, physical and social functions, and stress of medical treatment. This questionnaire was given to the patients preoperatively, and on three occasions after surgery -- at six weeks, three months, and one year. RESULTS: The analysis showed that the patients had a low GIQLI preoperatively in comparison with healthy individuals (mean 90.4 vs. 122.6 points), with all subscales being affected. The general score improved significantly six weeks postoperatively (mean: 118.2 points; P<0.05), showed further improvement at three months (mean: 124.2 points), and remained stable at one year (mean: 123.1 points; P<0.01) postoperatively. There were no differences in the quality of life or side effects between patients with a Nissen or Toupet fundoplication, except regarding the frequency of mild, transient dysphagia. CONCLUSIONS: Patients with gastroesophageal reflux disease suffer from a poor quality of life. After laparoscopic fundoplication, the quality of life improves and becomes comparable to that of healthy individuals. In our view, quality of life data should be evaluated as a major factor in determining the role of surgical interventions. Patients should receive consultation and advice regarding quality of life questions prior to surgery.

Kane, R. L., N. Lurie, et al. (1995). “The outcomes of elective laparoscopic and open cholecystectomies [see comments].  Journal of the American College of Surgeons 180(2): 136-45.
BACKGROUND: The demand for evidence of effectiveness for medical care has prompted the development of epidemiologic approaches to relating the outcomes of care to treatment. This study compares the outcomes of care for patients undergoing the newly introduced laparoscopic cholecystectomy with the results from conventional open cholecystectomies. METHODS: Consecutive cases of elective cholecystectomy from 35 hospitals (all of the metropolitan and selected rural hospitals in Minnesota) were enrolled in the study. Patients were interviewed on admission to establish baseline symptoms and functional status and to confirm risk factors. Their medical records were abstracted to yield information on risk factors, treatment, and hospital complications. To establish outcomes, patients were sent a questionnaire about their symptoms and functional status six months postoperatively. RESULTS: Of 3,448 patients studied, 2,490 (72 percent) had a laparoscopic procedure, including 195 cases that were converted to open cholecystectomies. Functional status data were obtained on 2,481 cases (76 percent). Laparoscopic operation was associated with more operative complications (odds ratio 3.02, p < 0.001), but with fewer general complications (odds ratio 0.32, p < 0.001). The mean time to return to work was 15 days for laparoscopic cases compared to 31 days for open procedures (p < 0.001). The only functional outcome difference between the two procedures was that patients who underwent laparoscopic cholecystectomies were more likely than those with conventional cholecystectomies to be able to perform their usual activities at follow-up evaluation (p < .001). There was evidence of a learning curve; the more laparoscopic procedures a surgeon performed, the fewer the operative (p < 0.01) and general (p < 0.0001) complications. There was no indication that the availability of laparoscopic operation was associated with more operations being performed. CONCLUSIONS: Laparoscopic operation seems to represent a significant advance in getting patients back to a normal life sooner. More attention needs to be given to which patients are most likely to benefit from cholecystectomy of either type. Epidemiologic approaches can be useful in assessing the effectiveness of care. Partnerships between providers and researchers can produce useful effectiveness data by supplementing available clinical records with more detailed outcome data.

Kanski, A., E. Plocharska, et al. (1999). “Transient left vocal cord paralysis during laparoscopic surgery for an oesophageal hiatus hernia.  European Journal of Anaesthesiology 16(7): 495-9.
A 45-year-old male, with symptoms of many years standing of gastro-oesophageal reflux disease, was subjected, under general anaesthesia, to laparoscopic fundoplication. Tracheal intubation yielded no problems but great difficulties were encountered during tube insertion into the oesophagus. After surgery, aphonia developed. Laryngological examination demonstrated paralysis of the left vocal cord. Voice strength returned to the pre-operative status after 3 months, and laryngological examination confirmed normal mobility of both cords. The possible cause of the complication was damage to the left recurrent laryngeal nerve which occurred during insertion of the tube into the oesophagus. Gastro-oesophageal reflux disease causing 'acid laryngitis' can create conditions favouring this type of complication.

Karayiannakis, A. J., G. G. Makri, et al. (1997). “Systemic stress response after laparoscopic or open cholecystectomy: a randomized trial.  British Journal of Surgery 84(4): 467-71.
BACKGROUND: Surgical injury induces a systemic endocrine-metabolic response which is proportional to the severity of surgical stress. Laparoscopic cholecystectomy is associated with a favourable clinical outcome compared with open cholecystectomy suggesting that surgical injury is reduced. METHODS: In a randomized clinical trial of 41 patients undergoing laparoscopic cholecystectomy and 42 patients undergoing open cholecystectomy, the neuroendocrine and metabolic stress responses were compared. Plasma levels of cortisol, adrenaline, noradrenaline, glucose, interleukin (IL) 6 and C-reactive protein (CRP) were measured before, during and at 4, 8 and 24 h after operation. RESULTS: Plasma levels of cortisol and catecholamines increased during and after both laparoscopic and open cholecystectomy; however, their postoperative responses during and after both laparoscopic and open cholecystectomy; however, their postoperative responses were significantly higher (P < 0.05) after open cholecystectomy. Glucose, IL-6 and CRP levels also increased after operation and were significantly higher (P < 0.05) in the open cholecystectomy group. CONCLUSION: The neuroendocrine stress response and inflammatory response following laparoscopic cholecystectomy were significantly reduced compared with those after open cholecystectomy.

Kawamura, Y. J., E. Sunami, et al. (1999). “Transmesenteric hernia after laparoscopic-assisted sigmoid colectomy.  JSLS: Society of Laparoendoscopic Surgeons 3(1): 79-81.
BACKGROUND AND OBJECTIVES: Laparoscopic-assisted surgery has been applied for a variety of colonic surgery. The objective of this paper is to demonstrate a possible and avoidable complication of laparoscopic colonic surgery. CASE PRESENTATION: A 47-year-old woman underwent gasless laparoscopic-assisted sigmoid colectomy. On the 20th postoperative day, she developed bowel obstruction. Decompression with a long tube failed to resolve the bowel obstruction. Open laparotomy was performed. Abdominal exploration revealed a loop of the small bowel incarcerated in the mesenteric defect caused by the previous operation. Adhesiolysis was performed, and the postoperative course was uneventful. DISCUSSION: Despite technical difficulty, complete closure of the mesentery after bowel resection is strongly recommended for prevention of transmesenteric incarcerated hernia after laparoscopic surgery.

Kawamura, Y. J., T. Sawada, et al. (1999). “Gasless laparoscopically assisted colonic surgery.  American Journal of Surgery 177(6): 515-7.
BACKGROUND: Laparoscopic technique has been applied to a variety of colonic and rectal operations, generally using carbon dioxide insufflation (CDI). However, CDI is inevitably associated with cardiopulmonary loading and can cause complications. The objective of this study was to determine the feasibility of gasless laparoscopic colonic surgery. METHODS: The abdominal wall was lifted up using an originally designed retractor. A small incision, 3 to 5 cm in length, was made at the start of the operation. The surgeon operated through this incision using both conventional and laparoscopic instruments. RESULTS: Operations were undertaken in 67 patients. In 6 patients (9%), conversion to open surgery was necessitated. In the remaining 61 patients, operations were completed with gasless laparoscopically assisted technique. Four reoperations (7%) were performed because of postoperative bleeding, anastomotic rotation, anastomotic stricture, and transmesenteric hernia. Fifty-three patients with colonic cancer were operated on with potentially curative intent. Of these, 1 (2%) developed hepatic recurrence during the mean follow-up period of 23.8 months. There was no port site recurrence. CONCLUSIONS: Gasless laparoscopic colonic surgery is technically feasible. CDI is not necessary to perform minimal access surgery.

Kay, B., A. T. Cohen, et al. (1983). “Anaesthesia for laparoscopy: alfentanil and fentanyl compared.  Annals of the Royal College of Surgeons of England 65(5): 316-7.
A double blind comparison was made between alfentanil and fentanyl as analgesic components of anaesthesia. Sixty-six women undergoing laparoscopy received methohexitone, alcuronium, nitrous oxide and oxygen, with either alfentanil 0.75 mg or fentanyl 0.25 mg. Ten of the patients who received alfentanil and 1 patient who received fentanyl required supplementation of anaesthesia by enflurane. Recovery from anaesthesia was similar in the two groups of patients though the onset of spontaneous breathing occurred more quickly after alfentanil (P less than 0.002). The injection of fentanyl was followed by a fall in BP (P less than 0.05) and the mean minimum value for pulse rate occurring after fentanyl was slower than after alfentanil (P less than 0.05).

Kelly, D., P. A. Kraus, et al. (1995). “Laparoscopic pelvic lymphadenectomy during epidural anesthesia.  Journal of Clinical Anesthesia 7(8): 648-51.
This report describes the perioperative management of a 70-year-old man undergoing bilateral pelvic lymphadenectomy. Because of concerns regarding this patient's high risk for myocardial ischemia, the four-hour surgical procedure, which included the formation of pneumoperitoneum, was performed during epidural anesthesia with minimal sedation. The anesthetic implications of pneumoperitoneum during regional anesthesia are discussed.

Kemeter, P., W. Feichtinger, et al. (1982). “Influence of laparoscopic follicular aspiration under general anaesthesia on corpus luteum progesterone secretion in normal and clomiphene-stimulated cycles.  British Journal of Obstetrics & Gynaecology 89(11): 948-50.
In 32 patients with unstimulated normal cycles and 24 with cycles stimulated with clomiphene and human chorionic gonadotrophin (hCG) all visible follicles were punctured laparoscopically under general anaesthesia for the purpose of in vitro fertilization. In unstimulated cycles the time of surgery was between 24 and 32 h after the first luteinizing hormone (LH) increase in the urine; in the cycles stimulated with hCG (5000 i.u.) laparoscopy was between 35 and 37 h after injection. Blood samples for progesterone determination were taken about 7 days later. Progesterone levels were compared with those in a control group not subjected to surgery, in which the progesterone levels were determined 7 days after the LH increase. There was no statistically significant difference in the progesterone levels in the unstimulated subjects after laparoscopy compared with those in the control subjects but progesterone levels in the stimulated subjects were significantly higher (p less than 0.01). Durations of the luteal phases showed no significant differences thus laparoscopy under general anaesthesia does not impair luteal function.

Kernick, D. P. and D. Reinhold (1999). “Laparoscopic verses open mesh repair of inguinal hernia. Costs and outcomes should always be presented in disaggregated form [letter] [see comments].  BMJ 318(7177): 190.

King, M. R., D. A. Hendrickson, et al. (1998). “Laparoscopic ovariectomy in two standing llamas.  Journal of the American Veterinary Medical Association 213(4): 523-5.
Laparoscopic ovariectomy was performed in 2 llamas that were sedated but remained standing, avoiding possible complications associated with general anesthesia. All incisions were made in the left paralumbar fossa. The only intraoperative complications encountered were difficulty in maneuvering the laparoscope ventral to the uterine body in 1 llama because of distension of the urinary bladder, and a tendency to lean on the sidebar of the stocks in the other llama. The only postoperative complication was subcutaneous emphysema, which could be minimized by suctioning excess CO2 from the abdomen at completion of surgery. Laparoscopic ovariectomy was successful in these llamas and allowed direct examination and manipulation of the ovaries even though llamas were standing during surgery.

Kjer, J. J. (1991). “Laparoskopisk sterilisation af kvinder i lokal anaestesi.  Ugeskrift for Laeger 153(38): 2619-20.
Ten women were sterilized via a laparoscope under local anaesthesia (paracervical blockade and periumbilical infiltration anaesthesia). Sterilization was carried out with simultaneous video monitoring. One patient, in whom termination of pregnancy was performed simultaneously at the end of the first trimester, experienced discomfort. The remaining nine sterilized women were extremely satisfied with the procedure. Laparoscopic sterilization of women in local anaesthesia is a rapid, safe and pleasant procedure for the patients.

Klockgether-Radke, A., V. Piorek, et al. (1996). “Nausea and vomiting after laparoscopic surgery: a comparison of propofol and thiopentone/halothane anaesthesia.  European Journal of Anaesthesiology 13(1): 3-9.
Sixty ASA I and II patients scheduled for laparoscopic cholecystectomy or inguinal herniotomy were randomly assigned to one of two groups: Group one (n = 30): induction with thiopentone 4-6 mg kg-1, fentanyl 2 micrograms kg-1, pancuronium 0.03 mg kg-1, and succinylcholine 1 mg kg-1, maintainance with halothane (0.8-1.5%), and N2O in O2 (FiO2 = 0.33). Group two (n = 30): induction with propofol 2-3 mg kg-1, fentanyl 2 micrograms kg-1, pancuronium 0.03 mg kg-1, and succinylcholine 1 mg kg-1, maintainance with propofol 6-10 mg kg-1 h-1, and O2 in N2 (FiO2:0.33). Seven of the patients experienced nausea in each group with group one having higher emetic scores. Six patients in group one vomited compared to none in group two (P < 0.05). The overall incidence of emetic sequelae (nausea or vomiting) was 43% in group one and 23% in group two (P = 0.17). Patients with propofol anaesthesia had lower emetic scores and higher recovery scores compared with those after thiopentone/halothane anaesthesia.

Klopfenstein, C. E., G. Gaggero, et al. (1995). “Laparoscopic extraperitoneal inguinal hernia repair complicated by subcutaneous emphysema.  Canadian Journal of Anaesthesia 42(6): 523-5.
The case of a healthy 59-yr-old man who underwent elective laparoscopic extraperitoneal inguinal hernia repair and general anaesthesia is presented. After one hour of surgery, a sudden increase in the FETCO2 from 5.0% to 9.4% in relation to a massive subcutaneous emphysema, but without any haemodynamic instability, was noticed. The acute rise of FETCO2 was the first sign of an abnormal event. Nevertheless, subcutaneous emphysema was diagnosed with chest wall examination and palpation. Subcutaneous emphysema and hypercarbia are potential complications of laparoscopic surgery, but are more likely to occur in extraperitoneal surgery, since insufflated CO2 can diffuse easily into the surrounding tissues. High insufflation pressures will increase chances of this occurring and was the most likely cause of this complication. This case encouraged us to make recommendations for the management of laparoscopic extraperitoneal surgery which included: monitoring of CO2 insufflation pressure, routine examination and palpation of chest wall, use of N2O with caution, adjusting ventilation to physiological FETCO2 and excluding other causes of subcutaneous emphysema and hypercarbia.

Koetsawang, S., S. Srisupandit, et al. (1984). “A comparative study of topical anesthesia for laparoscopic sterilization with the use of the tubal ring.  American Journal of Obstetrics & Gynecology 150(8): 931-3.
A study of 300 women undergoing sterilization via standard or open laparoscopy was conducted at Siriraj Hospital in Bangkok, Thailand; one aspect of the study was designed to determine whether application of topical anesthesia to the fallopian tubes reduces the degree of pain experienced by the patient. The use or nonuse of topical anesthesia was randomized for all cases. Overall, data from this study indicate that application of topical anesthesia to the fallopian tubes tends to diminish surgical pain of patients sterilized by use of either the standard laparoscopy or the open laparoscopy approach and that pain in the recovery period is also reduced for open laparoscopy patients.

Koga, Y. (1994). “[Anesthesia for laparoscopic surgery].  Masui - Japanese Journal of Anesthesiology 43 Suppl: S166-73.

Koivusalo, A. M., I. Kellokumpu, et al. (1996). “Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique.  British Journal of Anaesthesia 77(5): 576-80.
We have compared, in a randomized study in 26 patients, immediate and late postoperative recovery after elective laparoscopic cholecystectomy using the gasless, mechanical abdominal wall lift method with conventional carbon dioxide pneumoperitoneum. After the gasless method, tracheal extubation was performed significantly earlier than after the conventional method (P < 0.01). End-tidal carbon dioxide concentrations were significantly higher after pneumoperitoneum for 30 min after operation (P < 0.01). In the conventional group, deviation in Maddox-Wing recordings from preoperative values remained at a significantly higher level during the 3-h recovery room period (P < 0.01). There was a positive correlation between the total amount of carbon dioxide used and duration of drowsiness (r = 0.61, P < 0.001) and the Maddox-Wing deviation (r = 0.62, P < 0.001). Postoperative nausea and vomiting, and right shoulder pain occurred less often after the gasless method (P < 0.05). Late recovery criteria (ability to drink, void and walk) in patients in the gasless group were fulfilled approximately 7 h earlier than in those in the pneumoperitoneum group (P < 0.01). Gasless laparoscopic cholecystectomy resulted in more uneventful and faster immediate and late postoperative recovery than conventional carbon dioxide pneumoperitoneum.

Koivusalo, A. M., I. Kellokumpu, et al. (1996). “Randomized comparison of the neuroendocrine response to laparoscopic cholecystectomy using either conventional or abdominal wall lift techniques [see comments].  British Journal of Surgery 83(11): 1532-6.
Increase in plasma renin activity and noradrenaline concentration occur in response to carbon dioxide insufflation during laparoscopic cholecystectomy. In a randomized study the conventional carbon dioxide pneumoperitoneum was compared with the abdominal wall lift method for laparoscopic cholecystectomy, with special reference to neuroendocrine changes and renal function. The total mean(s.d.) volume of carbon dioxide insufflated was 42(23) litres with the conventional method and 9(7) litres with abdominal wall lift (P < 0.001). Mean(s.d.) intra-abdominal pressure after 15 min of insufflation was 11(2) and 3(9) mmHg respectively (P < 0.01). In the conventional group mean(s.d.) plasma renin activity increased slightly from 5.5(2.1) to 6.1(2.0) ng ml-1 during the first 55 min of laparoscopic cholecystectomy. In the abdominal wall lift group plasma renin activity decreased from 5.3(2.7) to 3.8(0.9) ng ml (P < 0.01 between the groups). Plasma antidiuretic hormone concentration increased similarly in both groups. Diuresis was significantly less with conventional pneumoperitoneum during the first 35 min of the operation compared with the abdominal wall lift method (P < 0.001). There were significant increases in plasma noradrenaline concentration in both groups (P < 0.001), but the increase was slightly higher in the conventional group during the first 15 min of insufflation. The abdominal wall lift method with minimal carbon dioxide insufflation was associated with smaller neuroendocrine responses and better preservation of renal function compared with conventional carbon dioxide pneumoperitoneum.

Koivusalo, A. M., I. Kellokumpu, et al. (1996). “Randomized comparison of the neuroendocrine response to laparoscopic cholecystectomy using either conventional or abdominal wall lift techniques [see comments].  British Journal of Surgery 83(11): 1532-6.
Increase in plasma renin activity and noradrenaline concentration occur in response to carbon dioxide insufflation during laparoscopic cholecystectomy. In a randomized study the conventional carbon dioxide pneumoperitoneum was compared with the abdominal wall lift method for laparoscopic cholecystectomy, with special reference to neuroendocrine changes and renal function. The total mean(s.d.) volume of carbon dioxide insufflated was 42(23) litres with the conventional method and 9(7) litres with abdominal wall lift (P < 0.001). Mean(s.d.) intra-abdominal pressure after 15 min of insufflation was 11(2) and 3(9) mmHg respectively (P < 0.01). In the conventional group mean(s.d.) plasma renin activity increased slightly from 5.5(2.1) to 6.1(2.0) ng ml-1 during the first 55 min of laparoscopic cholecystectomy. In the abdominal wall lift group plasma renin activity decreased from 5.3(2.7) to 3.8(0.9) ng ml (P < 0.01 between the groups). Plasma antidiuretic hormone concentration increased similarly in both groups. Diuresis was significantly less with conventional pneumoperitoneum during the first 35 min of the operation compared with the abdominal wall lift method (P < 0.001). There were significant increases in plasma noradrenaline concentration in both groups (P < 0.001), but the increase was slightly higher in the conventional group during the first 15 min of insufflation. The abdominal wall lift method with minimal carbon dioxide insufflation was associated with smaller neuroendocrine responses and better preservation of renal function compared with conventional carbon dioxide pneumoperitoneum.

Koivusalo, A. M., I. Kellokumpu, et al. (1997). “Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method.  Anesthesia & Analgesia 85(4): 886-91.
Carbon dioxide (CO2) pneumoperitoneum together with an increased intraabdominal pressure (IAP) induces a hemodynamic stress response, diminishes urine output, and may compromise splanchnic perfusion. A new retractor method may be less traumatic. Accordingly, 30 ASA physical status I or II patients undergoing laparoscopic cholecystectomy were randomly allocated to a CO2 pneumoperitoneum (IAP 12-13 mm Hg) (control) or to a gasless abdominal wall lift method (retractor) group. Anesthesia and intravascular fluids were standardized. Direct mean arterial pressure (MAP), urine output, urine-N-acetyl-beta-D-glucosaminidase (U-NAG), arterial blood gases, gastric mucosal PCO2, and intramucosal pH (pHi) were measured. Normoventilation was instituted in all patients. MAP increased (P < 0.001) only with CO2 pneumoperitoneum. Minute volume of ventilation had to be increased by 35% with CO2 insufflation. PaCO2 was significantly higher (P < 0.05) for 3 h postoperatively in the control group. Diuresis was less (P < 0.01) and U-NAG levels (P < 0.01) higher in the control group. The pHi decreased after induction of pneumoperitoneum up to three hours postoperatively and remained intact in the retractor group. We conclude that the retractor method for laparoscopic cholecystectomy ensures stable hemodynamics, prevents respiratory acidosis, and provides protection against biochemical effects, which reveal the renal and splanchic ischemia caused by CO2 insufflation. Implications: A mechanical retractor method (gasless) was compared with conventional CO2 pneumoperitoneum for laparoscopic cholestectomy. The gasless method ensured stable hemodynamics, prevented respiratory acidosis, and provided protection against the renal and splanchnic ischemia seen with CO2 pneumoperitoneum.

Koivusalo, A. M., I. Kellokumpu, et al. (1998). “A comparison of gasless mechanical and conventional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy.  Anesthesia & Analgesia 86(1): 153-8.
Carbon dioxide (CO2) insufflation with increased intraabdominal pressure (IAP) has adverse hemodynamic, pulmonary, and renal effects. To avoid these problems, an abdominal wall lift method with a retractor was used to provide the surgical view without CO2 insufflation. Twenty-six patients undergoing elective laparoscopic cholecystectomy were randomly allocated to either the gasless, retractor group, or conventional CO2 pneumoperitoneum group (CPP). Hemodynamic data, ventilatory variables, urine output, urine oxygen tension, and blood samples for determining stress hormones were collected throughout the perioperative period. Patients in the retractor group had lower mean arterial pressure, heart rate, and central venous pressure (P < 0.001). They also had higher pulmonary dynamic compliance and needed a lower minute volume of ventilation to achieve normocarbia (P < 0.001). Urine output and oxygen tension in urine were higher (P < 0.05) with the retractor method than with CPP. Increase in plasma renin activity (P < 0.05) and decrease in core temperature (P < 0.001) were smaller with the gasless method than with CPP. The gasless method for laparoscopic cholecystectomy might be beneficial, especially in patients with compromised cardiorespiratory or renal function. Implications: Totally gasless laparoscopic cholecystectomy was compared with conventional pressure pneumoperitoneum with CO2 insufflation. The gasless method resulted in more stable hemodynamics and pulmonary function, as well as higher urine, output than conventional pressure pneumoperitoneum. No changes in renal oxygenation was seen with the gasless method, compared with conventional pressure pneumoperitoneum.

Kozol, R., P. M. Lange, et al. (1997). “A prospective, randomized study of open vs laparoscopic inguinal hernia repair. An assessment of postoperative pain.  Archives of Surgery 132(3): 292-5.
OBJECTIVE: To compare postoperative pain after laparoscopic hernia repair and conventional open hernia repair. DESIGN: Prospective, randomized study. SETTING: Veterans Affairs Medical Center. PATIENTS: Sixty-two patients scheduled for elective inguinal hernia repair. INTERVENTIONS: Patients were randomized in the operating room to have a laparoscopic hernia repair (30 patients) or a conventional open hernia repair (32 patients). All operations were performed while the patient was under general anesthesia to avoid anesthesia as a confounding variable. MEASURES: Postoperative pain following laparoscopic hernia repair and open hernia repair were compared using the McGill Pain Score, the McGill Visual Analogue Pain Scale score, and the number of acetaminophen with 30-mg codeine sulfate (Tylenol 3) tablets needed for pain during the first and second 24-hour periods postoperatively. All of the patients were interviewed and the postoperative pain was evaluated by a special study nurse (P.M.L.) who was blinded to the repair technique. RESULTS: At 24 hours, the patients with laparoscopic hernia repair had 26% less pain by the McGill Pain Score (P = .02) and 31% less pain by the McGill Visual Analogue Scale (P = .006) than those who underwent an open hernia repair. At 48 hours the patients who underwent laparoscopic hernia repair had 28% less pain by the McGill Pain Score (P = .03), 42% less pain by the McGill Visual Analogue Scale (P = .002), and used 42% fewer analgesic tablets (P = .004). CONCLUSION: Patients with a laparoscopic hernia repair had significantly less pain postoperatively than those with standard open hernia repairs.

Krahenbuhl, L. and E. Frei (1995). “Fruhresultate der ersten 100 laparoskopischen Hernienoperationen in Periduralanasthesie.  Schweizerische Medizinische Wochenschrift. Journal Suisse de Medecine 125(26): 1279-85.
From November 1992 to March 1994 we performed 100 transabdominal laparoscopic herniographies in 84 patients. The mean age was 54.6 years. 83% of all hernias were primary, 17% recurrent and 16% bilateral. All hernias were classified according to Nyhus and individually repaired. Except in type 2 hernias, a large polypropylene mesh was inserted (15 x 12 cm) and the peritoneum closed with a running suture. During a mean follow-up time of 14 months no recurrent hernias, infections or bowel adhesions were observed. The mean postoperative hospital stay was 4.1 days and the mean time off work 16.4 days. Intraoperative complications were found in 11.9%, early postoperative complications in 25% and late postoperative complications in 3.6%.

Krahenbuhl, L., M. Feodorovici, et al. (1998). “Laparoscopic partial hepatectomy in the rat: a new resectional technique.  Digestive Surgery 15(2): 140-4.
BACKGROUND: Rats are widely used for basic research in laparoscopic surgery. We have developed a new technique of laparoscopic partial hepatectomy in the rat. METHODS: 40 American Cancer Institute rats were randomized into 3 groups. Group A (n = 14) underwent laparoscopic liver resection using a CO2 pneumoperitoneum. Group B (n = 14) was operated on with a gasless laparoscopic technique using a lifting device. A control group C (n = 12) underwent conventional open liver resection. In each group half of the animals underwent single lobectomy and the other half bilobectomy. RESULTS: The liver resection was performed successfully in all 40 rats. No conversion to open surgery was necessary. No mortality or morbidity was observed. CONCLUSIONS: This new technique of laparoscopic partial hepatectomy proved to be feasible and safe. It is the first description of a laparoscopic hepatic resection in the rat that could prove valuable in further investigations of liver physiology and pathology.

Kruger, P. and P. Moran (1998). “Anaesthesia for laparoscopic cholecystectomy in a patient with Eisenmenger's syndrome [letter; comment].  British Journal of Anaesthesia 81(2): 296; discussion 297-8.

Lacy, A. M., J. C. Garcia-Valdecasas, et al. (1995). “Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer.  Surgical Endoscopy 9(10): 1101-5.
The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients. The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.

Leong, H. T., W. T. Siu, et al. (1996). “Gasless laparoscopic excision of bleeding gastric polyp.  Journal of Laparoendoscopic Surgery 6(3): 189-91.
A case of bleeding gastric polyp in an elderly woman with compromised respiratory function was treated successfully as an emergency by the gasless laparoscopic technique after endoscopic means failed to control the bleeding. The application of laparoscopic mechanical stapling devices allows rapid gastrotomy and resection, with simultaneous hemostasis that is beneficial in acute bleeding condition. The use of gasless laparoscopy also allows continuous suction to be applied for identification of the bleeding pathology and it also reduces the risk of pneumoperitoneum in patients with poor cardiorespiratory reserve. The operative approach and technique are fully discussed.

Lessin, M. S., F. I. Luks, et al. (1999). “Primary laparoscopic placement of peritoneal dialysis catheters in children and young adults.  Surgical Endoscopy 13(11): 1165-7.
BACKGROUND: Primary placement of peritoneal dialysis catheters in children often requires suturing of the catheter into the pelvis. We describe our experience with a gasless laparoscopy technique in children and young adults. METHODS: During an 18-month period, 12 patients (mean age, 14 years) underwent primary laparoscopic placement of peritoneal dialysis catheters. A single umbilical port was used for abdominal wall elevation, telescope, and catheter. A needleholder was introduced via an accessory port at the future catheter exit site or through the umbilical port. Omentectomy was performed through the umbilical incision. The catheter was tunneled to the lateral abdominal wall. Follow-up data (>/= 15 months) included time to initiation of dialysis, hospitalization, and outcome. End points were cure, transplantation, or death. RESULTS: Diet was started on the day of surgery and dialysis on the following day. Four patients had seven complications, including leakage and entanglement of the catheter in tubal fimbriae. Long-term revision-free catheter survival was 67% at 24 months. CONCLUSIONS: This minimal access technique for primary placement of peritoneal dialysis catheters includes securing of the catheter tip in a dependent location and omentectomy. It allows nearly immediate use of the catheter, leads to a minimal hospital stay, and has acceptable long-term patency.

Leung, T. Y. and P. M. Yuen (2000). “Small bowel herniation through subumbilical port site following laparoscopic surgery at the time of reversal of anesthesia.  Gynecologic & Obstetric Investigation 49(3): 209-10.
Incisional hernias through laparoscopic trocar sites are unusual complications of laparoscopy. Two cases of small bowel herniation at subumbilical port site occurred at the time of withdrawal of the trocar sheath at the end of the laparoscopic procedure are reported. The herniations were precipitated by the coughing movements of the patients as a result of too early reversal of the general anesthesia. Awareness of the complication, precaution at time of sheath withdrawal and a well-timed reversal of the general anesthesia are important in avoiding such a complication. Copyright 2000 S. Karger AG, Basel

Lewin, A., E. J. Margalioth, et al. (1985). “Comparative study of ultrasonically guided percutaneous aspiration with local anesthesia and laparoscopic aspiration of follicles in an in vitro fertilization program.  American Journal of Obstetrics & Gynecology 151(5): 621-5.
Twenty patients from our in vitro fertilization program were randomly divided into two groups. Ten women underwent follicular aspiration during laparoscopy while they were under general anesthesia and 10 women had an ultrasonically guided follicular aspiration with local anesthesia. All patients had mechanical infertility, and ovulation was induced with human menopausal gonadotropins. In both groups the same aspiration system with a needle of 1.4 mm inner diameter and a continuous suction at 120 mm Hg were used. In the laparoscopy group the oocyte recovery rate was 82.5% and the fertilization rate 62.5%, with one twin pregnancy; in the ultrasound group the oocyte recovery rate was 75%, and the fertilization rate 61.9%, with a singleton pregnancy. Implications of these results are discussed.

Liberman, M. A., E. H. Phillips, et al. (1996). “Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs [see comments].  Surgical Endoscopy 10(1): 15-8.
BACKGROUND: The aim of this study was to evaluate the outcome of patients undergoing laparoscopic colectomy for diverticulitis. METHODS: Fourteen consecutive patients undergoing laparoscopic sigmoid colectomy (LSC) for diverticulitis were evaluated. Medical records from a control group of 14 matched patients undergoing traditional open sigmoid colectomy (OSC) for diverticulitis were reviewed for comparison. RESULTS: Mean age, operative time, morbidity, and mortality of the LSC and OSC groups were not significantly different. However, the mean estimated blood loss (171cc vs 321cc), days to p.o. liquids (2.9 vs 6.1), and postoperative stay (6.3 vs 9.2 days) were all significantly less in the LSC patients. Although the mean operating room charges were greater in the LSC patients ($10,589 vs $8,207) the mean total hospital charges ($29,981 vs $36,745) and costs ($11,528 vs $13,426) were markedly less. CONCLUSIONS: Compared with OSC for diverticulitis, LSC results in a more rapid return of bowel function and shortened hospital stay. Despite the greater operating room charges of LSC, the total hospital charges and costs are lessened.

Lipscomb, G. H., T. G. Stovall, et al. (1992). “Comparison of silastic rings and electrocoagulation for laparoscopic tubal ligation under local anesthesia.  Obstetrics & Gynecology 80(4): 645-9.
OBJECTIVE: To compare objectively the pain associated with tubal occlusion by Silastic rings versus electrocoagulation during laparoscopic tubal ligation under local anesthesia. METHODS: Consecutive patients scheduled for laparoscopic tubal ligation under local anesthesia were randomized to Silastic rings (N = 50) or electrocoagulation (N = 52) as the method of tubal occlusion. Sterilization was performed under local anesthesia in a standard fashion. Bupivacaine 0.5% was used as the local anesthetic agent. Operative pain was measured based on intraoperative anesthesia requirements and a modified McGill pain questionnaire. This questionnaire was used to assess pain at 15 minutes, 1 hour, and 24 hours postoperatively. RESULTS: Demographics were similar for the two groups. Operative time was shorter in the Silastic-ring group (16.7 versus 21.8 minutes; P = .001), and this group also required less intraoperative anesthesia (P = .004). There were no statistical differences between the groups in self-reported pain intraoperatively or postoperatively. No patient in either group required antiemetics or pain medication in the recovery room. CONCLUSION: Silastic rings appear preferable to bipolar electrocoagulation for laparoscopic tubal sterilization under local anesthesia when long-acting local agents are used for tubal anesthesia.

Lipscomb, G. H., R. L. Summitt, Jr., et al. (1994). “The effect of nitrous oxide and carbon dioxide pneumoperitoneum on operative and postoperative pain during laparoscopic sterilization under local anesthesia.  Journal of the American Association of Gynecologic Laparoscopists 2(1): 57-60.
STUDY OBJECTIVE: To compare carbon dioxide and nitrous oxide pneumoperitoneum with respect to intraoperative and postoperative pain during laparoscopic sterilization under local anesthesia. DESIGN: Randomized, double-blind study of pain during surgery and at 15 minutes, 1 hour, and 24 hours postoperatively. SETTING: Regional Medical Center, Memphis, Tennessee. PATIENTS: Women scheduled for laparoscopic sterilization under local anesthesia. Interventions. Forty-nine patients were randomized to carbon dioxide and 56 to nitrous oxide pneumoperitoneum. MEASUREMENTS AND MAIN RESULTS: Pain was assessed using a modified McGill pain questionnaire. Intraoperative pain was measured by the amount of supplemental narcotic required. Analgesic use in the recovery room and during the first 24 hours postoperatively was compared. Demographics for both groups were similar. The groups had no statistical differences in pain during surgery or at any of the postoperative time periods. Recovery room analgesia requirement was similar, but the nitrous oxide group used fewer pain tables (0.98 vs 0.42 tablets) in the first 24 hours. CONCLUSIONS: There is no difference in intraoperative and postoperative pain between nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic sterilization when used in conjunction with a protocol such as ours.

Lipscomb, G. H., R. L. Summitt, Jr., et al. (1994). “Serum bupivacaine levels during laparoscopic sterilization using local anesthesia.  Journal of the American Association of Gynecologic Laparoscopists 2(1): 27-30.
STUDY OBJECTIVE: To determine the serum levels of bupivacaine during laparoscopic sterilization when bupivacaine 0.5% without epinephrine is used as the sole local anesthetic agent. DESIGN: Case series. SETTING: Regional medical center and primary teaching hospital of Ob/Gyn Department of the University of Tennessee, Memphis. PATIENTS; Thirty women undergoing laparoscopic sterilization with bupivacaine for local anesthesia. INTERVENTIONS: Venous serum bupivacaine levels were measured, with samples drawn at 45, 60, 90, and 120 minutes after injection in 25 patients. Five additional patients had sampling at 15 and 30 minutes as well as at the above times. MEASUREMENTS AND MAIN RESULTS: The highest concentration of bupivacaine was detected at 15 minutes. The mean concentrations at 15, 30, 45, 60, and 120 minutes were 0.86, 0.74, 0.31, 0.27, 0.23, and 0.22 microg/ml, respectively. This is well below the level of serious toxicity. Only four patients received 2.5 mg/kg or greater of bupivacaine. In these patients, mean serum levels were 1.1, 1.0, 0.28, 0.43, 0.9, and 0.29 microg/ml, respectively. CONCLUSION: Serum bupivacaine levels during sterilization using bupivacaine 0.5% without epinephrine for local anesthesia are well below the threshold for serious toxicity.

Lipscomb, G. H. and F. W. Ling (1995). “Development of a program teaching laparoscopic sterilization using local anesthesia.  Obstetrics & Gynecology 86(4 Pt 1): 609-12.
A program teaching laparoscopic sterilization using local anesthesia was developed and implemented in a large residency program in which sterilization using general anesthesia was already being taught in a traditional fashion. Important steps for the development of such a program included the designation of an individual with overall responsibility for the program, identification of potential obstacles along with feasible solutions, and training of residents and staff in the new techniques. The major obstacles to implementation included opposition from anesthesia personnel, the need for additional training in the new techniques for both residents and faculty, nursing staff resistance, and the uncertainty of patient acceptance. Solutions included involving anesthesia personnel in program planning as well as in the ultimate performance of the procedures, practicing local techniques during cases under general anesthesia, limiting initial cases to candidates anticipated to be uncomplicated, and using nondirective counseling of patients. Similar strategies can be useful both to other residency programs and individuals wishing to offer local anesthesia as an option for laparoscopic sterilization at their hospitals.

Lipscomb, G. H., J. R. Dell, et al. (1996). “A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting.  Journal of the American Association of Gynecologic Laparoscopists 3(2): 277-81.
OBJECTIVE: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance. DESIGN: A retrospective review of charges. SETTING: The Regional Medical Center, Memphis, Tennessee. PATIENTS: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization. MEASUREMENTS AND MAIN RESULTS: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment. CONCLUSION: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Lonie, D. S. and N. J. Harper (1986). “Nitrous oxide anaesthesia and vomiting. The effect of nitrous oxide anaesthesia on the incidence of vomiting following gynaecological laparoscopy [published erratum appears in Anaesthesia 1986 Oct;41(10):1083].  Anaesthesia 41(7): 703-7.
Eighty-seven patients undergoing routine laparoscopy were divided randomly into two groups to study the effect of nitrous oxide anaesthesia on the incidence of postoperative vomiting. Patients in group A received nitrous oxide as part of their anaesthetic, while in group B nitrous oxide was omitted. Significantly fewer patients in group B vomited when compared with group A (17 percent and 49 percent respectively; p less than 0.005). We suggest that an anaesthetic technique which avoids nitrous oxide may be especially indicated in patients undergoing laparoscopy.

Low, D. E. (1995). “Examination of outcome and cost data of open and laparoscopic antireflux operations at Virginia Mason Medical Center in Seattle.  Surgical Endoscopy 9(12): 1326-8.

Lowham, A. S., C. J. Filipi, et al. (1996). “Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery.  Surgical Endoscopy 10(10): 979-82.
BACKGROUND: This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention. METHODS: Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports. RESULTS: Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%. CONCLUSION: Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anesthesiologist and safe techniques of dilator insertion.

Luchetti, M., R. Palomba, et al. (1996). “Effectiveness and safety of combined epidural and general anesthesia for laparoscopic cholecystectomy.  Regional Anesthesia 21(5): 465-9.
BACKGROUND AND OBJECTIVES: The aim of this study was to compare the efficacy and safety of two anesthesia techniques, combined epidural/general anesthesia (CEGA) versus total intravenous anesthesia (TIVA), for laparoscopic cholecystectomy. METHODS: Forty patients were randomly assigned to one of two different groups: group A received TIVA and group B received CEGA. At preset times during the operation, systolic and diastolic arterial pressure, heart rate, oxygen saturation (SaO2) and end-tidal carbon dioxide (Etco2) were monitored. Postoperatively, recovery (Steward's test) and analgesia (visual analog scale [VAS] pain scores) were assessed, as well as the incidence of adverse effects. RESULTS: The groups were comparable as to demographic data and duration of surgery and of anesthesia. Intraoperative parameters also showed no statistical differences. Both groups had a rapid recovery (Steward score of 6 within 12 minutes), but group B showed better recovery scores at 4 minutes. Postoperative pain was well controlled in both groups, but group B exhibited better scores at postoperative hour 2. The incidence of postoperative side effects was low in both groups. CONCLUSIONS: The use of CEGA for laparoscopic cholecystectomy seems to be effective and safe and to offer some advantages as compared to TIVA alone. CEGA can control pain due to CO2-induced peritoneal irritation, providing excellent intra- and postoperative analgesia. CEGA does not require the use of intraoperative intravenous opioids and shortens recovery time, without increasing the incidence of side effects.

MacKenzie, I. Z., E. Turner, et al. (1987). “Two hundred out-patient laparoscopic clip sterilizations using local anaesthesia.  British Journal of Obstetrics & Gynaecology 94(5): 449-53.
Female sterilization using clips applied laparoscopically under local anaesthesia was used in 200 women. Apart from two patients in whom there were technical difficulties, the operation was completed without complication and without immediate or delayed morbidity. The technique, which avoids the risks of general anaesthesia, is commended as a safe, simple method of sterilization suitable for, and acceptable to, the majority of women.

Madrigal, V., D. A. Edelman, et al. (1977). “Laparoscopic sterilization as an outpatient procedure.  Journal of Reproductive Medicine 18(5): 261-4.
Since June 1972, more than 2,000 laparoscopic sterilizations have been performed as outpatient procedures using neuroleptanalgesics. Electrocoagulation, spring-loaded clips or tubal rings were the methods used for tubal occlusion. All laparoscopies were performed in a family planning clinic. The surgical facilities were minimal and did not include general anesthesia equipment or a blood bank. The nearest hospital was about one-half mile from the clinic. The procedures were performed by a physician assisted by two paramedical personnel and a technician. Patients were scheduled to be at the clinic on the morning of the procedure and were discharged three to six hours after the procedure. Only one patient required hospitalization for treatment of a complication: her aorta was punctured during placement of the Tuohy needle. The patient was admitted to a local hospital and underwent laparotomy for repair; her subsequent recovery was uneventful. No bowel or bladder burns have occurred. Minor complications (emphysema of the abdominal wall, bleeding from the tubes, infections) have occurred in less than 4% of the patients. The results of this study indicate that laparoscopy in an outpatient clinic is safe and presents minimal additional risks to the patient if the surgeon is experienced.

Marchisio, M., E. Romairone, et al. (1995). “L'anestesia nelle colecistectomie per via laparoscopica. Contributo clinico e revisione.  Minerva Anestesiologica 61(1-2): 15-9.
The authors compare the problems arising during the course of 280 cases of anesthesia in videolaparoscopic cholecystectomy with 265 cases of laparotomic cholecystectomy. Ventilatory mechanics and intraoperative respiratory function were analysed together with respiratory function and postoperative pain. The authors also examined the possible complications linked to the endoscopic technique and underline the anesthesiological contraindications for videolaparoscopic cholecystectomy.

Marco, A. P., C. J. Yeo, et al. (1990). “Anesthesia for a patient undergoing laparoscopic cholecystectomy.  Anesthesiology 73(6): 1268-70.

Martinez, J. M., A. Halverson, et al. (1997). “Laparoscopic versus open Nissen fundoplication: outcome of surgery in monozygotic twins.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 7(5): 323-6.
Differences in outcome and cost of laparoscopic and open surgery are continuously being evaluated. Two-year-old monozygotic twin boys with a previous history of prematurity, severe gastroesophageal reflux disease, and intractable reactive airway disease were each scheduled to undergo a laparoscopic Nissen fundoplication (LNF) on the same day. Current medications for both patients included albuterol, cromolyn sodium, dexamethasone, ranitidine, and metoclopramide. In the first case, the laparoscopic procedure was converted to an open Nissen fundoplication (ONF) to gain expeditious control of bleeding from a short gastric vessel close to the spleen. The second patient underwent LNF without complication. Operative time for each patient was 3.5 h. The postoperative length of stay for each patient was 6 days (ONF) and 4 days (LNF). The total hospital charges were $21,931 (ONF) and $19,108 (LNF). The first patient (ONF) was readmitted later on the day of discharge (postoperative day 6) for vomiting and was discharged after 24 h with no further treatment. The subsequent course of each patient was similar. At a 6-week follow-up visit, both patients were tolerating a regular diet with weight gain and dramatic improvement in pulmonary symptoms.

Massouda, D. and D. Muram (1986). “Laparoscopic tubal ligation under local anesthesia.  Journal of the Tennessee Medical Association 79(2): 75-6.

Matthews, B. D. and G. B. Williams (1999). “Laparoscopic cholecystectomy in an academic hospital: evaluation of changes in perioperative outcomes.  JSLS: Society of Laparoendoscopic Surgeons 3(1): 9-17.
OBJECTIVE: Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital. METHODS: A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer's exact test. RESULTS: Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group. CONCLUSION: Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct supervision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same.

Mazzanti, T., P. Baldi, et al. (1991). “Intervento di colecistectomia per via laparoscopica: studio di due protocolli di anestesia, risultati preliminari.  Minerva Anestesiologica 57(9): 725.

McCahill, L. E., C. A. Pellegrini, et al. (1996). “A clinical outcome and cost analysis of laparoscopic versus open appendectomy [see comments].  American Journal of Surgery 171(5): 533-7.
BACKGROUND: Benefits of laparoscopic appendectomy are controversial, and the results of recent clinical studies have contradictory conclusions. We performed a cost analysis comparing laparoscopic and open appendectomies to assess potential efficacy of the laparoscopic approach. METHODS: All patients operated on for suspected acute appendicitis at the University of Washington Medical Center (UWMC) from January 1, 1991 through January 1, 1995 were analyzed. Potential benefits of the laparoscopic approach were examined in five major categories: hospital length of stay, total hospital charges, operative time, operating room charges, and postoperative complications. Patients were stratified according to the presence or absence of perforation for outcome analysis. RESULTS: There were 163 appendectomies performed in 82 men and 81 women. Twenty-seven (17%) patients had laparoscopic evaluation, of which 21 underwent attempted laparoscopic appendectomy. Among nonperforated patients, laparoscopic appendectomy did not reduce hospital stay compared with open appendectomy, but did lead to greater hospital charges ($7760 vs $5064; P < 0.001). Operating times were longer in the laparoscopic group (104 vs 74 minutes; P < 0.001) compared with open appendectomies. Operating room charges for laparoscopic appendectomies exceeded charges for the open approach ($4740 vs $1870; P < 0.001). Complication rates were similar (laparoscopic, 19% vs open, 16%; NS). The false diagnostic rate for women was four times greater than for men among patients undergoing open appendectomy (31% vs 8%; P < 0.01). Patients with perforation undergoing a midline incision had a longer hospital stay (9.5 vs 5.9; P < 0.02) than patients operated on through a right lower quadrant incision. CONCLUSIONS: In our analysis, laparoscopic appendectomy, while safe, was more expensive and was not associated with better clinical outcome compared with open appendectomy patients.

McDermott, J. P., M. C. Regan, et al. (1995). “Cardiorespiratory effects of laparoscopy with and without gas insufflation.  Archives of Surgery 130(9): 984-8.
BACKGROUND: Patients who are undergoing laparoscopic procedures can present with a number of ventilatory and circulatory problems. The use of a gasless technique for performing a laparoscopy by using a mechanical lifting device may potentially avoid such problems. OBJECTIVE: To compare the cardiorespiratory effects of laparoscopy with and without gas insufflation. METHODS: Twelve adult pigs were randomized to undergo a laparoscopy by using either carbon dioxide insufflation or mechanical elevation. Full invasive monitoring was performed preoperatively and at 10-minute intervals throughout the operative period. Parameters that were measured included blood gas determinations, mean arterial pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac output, stroke volume, and total peripheral resistance. RESULTS: Carbon dioxide insufflation unlike mechanical elevation led to a fall in PO2 and absorption of a significant quantity of CO2, resulting in hypercapnia, acidosis, and a consequent hyperdynamic circulation. CONCLUSION: These findings have significant implications for the use of CO2 insufflation for laparoscopy in patients with a compromised respiratory or cardiac status.

McGrath, B. J., J. E. Zimmerman, et al. (1989). “Carbon dioxide embolism treated with hyperbaric oxygen [see comments].  Canadian Journal of Anaesthesia 36(5): 586-9.
We report a case of suspected carbon dioxide embolism occurring during laparoscopy. Among the sequelae was neurological dysfunction felt to be secondary to paradoxical embolization. The patient was treated with hyperbaric oxygen therapy. Hyperbaric oxygen should be considered when confronted with a clinically important gas embolism.

McMahon, A. J., I. T. Russell, et al. (1994). “Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing postoperative pain and pulmonary function.  Surgery 115(5): 533-9.
BACKGROUND. Upper abdominal surgery is associated with severe postoperative pain and a concomitant reduction in pulmonary function and oxygen saturation. Laparoscopic cholecystectomy is said to result in less postoperative pain compared with open cholecystectomy. METHODS. In a pragmatic, randomized trial, postoperative pain, opiate analgesic consumption, oxygen saturation, and pulmonary function (forced vital capacity, forced expiratory volume in 1 second, and peak expiratory flow rate) were assessed after laparoscopic (n = 67) and minilaparotomy (n = 65) cholecystectomy. RESULTS. Compared with minilaparotomy cholecystectomy, laparoscopic cholecystectomy was associated with lower linear analogue pain scores (median 40 vs 59, p < 0.001), lower patient-controlled morphine consumption (median 22 vs 40 mg, p < 0.001), a smaller reduction in postoperative pulmonary function (mean peak expiratory flow rate 64% of preoperative value vs 49%, p < 0.001), and better oxygen saturation (mean 92.9% vs 91.2%, p = 0.008). CONCLUSIONS. This study confirms that the postoperative pain and pulmonary changes associated with upper abdominal surgery are significantly reduced by the laparoscopic technique. These findings suggest that laparoscopic cholecystectomy may result in a reduced risk of postoperative pulmonary complications.

Meltomaa, S. S., J. I. Makinen, et al. (1999). “One-year cohort of abdominal, vaginal, and laparoscopic hysterectomies: complications and subjective outcomes.  Journal of the American College of Surgeons 189(4): 389-96.
BACKGROUND: In the past decade, changes in operative approaches to hysterectomy have resulted in needs to renew study of postoperative morbidity. STUDY DESIGN: This prospective observational study, performed in a university teaching hospital in Finland, was conducted to determine the overall number of complications and subjective outcomes after hysterectomy for benign conditions. The population studied during a 1-year period consisted of 687 women, who underwent 516 abdominal hysterectomies, 105 vaginal hysterectomies, and 66 laparoscopic hysterectomies. Complications arising within 1 year of operations were recorded, and subjective complaints and outcomes were assessed using two questionnaire-based evaluations, the first following a convalescence period of 4 to 6 weeks, the second after 1 year. RESULTS: Intraoperative complications occurred in 16 patients (2.3%), in 9 patients in the abdominal hysterectomy group (1.7%), and in 4 (3.9%) and 3 patients (4.5%) in the vaginal and laparoscopic hysterectomy groups, respectively. During the hospital stay postoperative complications were found in 28.5% of patients, in the vaginal hysterectomy group (41.9%) more often than in the abdominal and laparoscopic hysterectomy groups (28.3% and 9.1%, respectively). Postoperative infection, including urinary infection, was the main problem, during both the stay in the hospital and the convalescence period at home. It was also the principal reason for readmission to the hospital. Despite an increase in incidence of subjective complaints, from 14.9% during the first evaluation to 37.0% during the second (p < 0.001), 95% of respondents remained satisfied with their operation after 1 year. CONCLUSIONS: Vaginal hysterectomy was more often associated with some adverse event, mainly postoperative infection, than abdominal and laparoscopic hysterectomy. Subjective outcomes were not influenced by the type of hysterectomy. Most patients were satisfied with the operation on both short- and longterm followup.

Merefield, D. C. and M. T. Haines (1997). “Anaesthesia for laparoscopic surgery in myotonic dystrophy [letter].  Anaesthesia & Intensive Care 25(1): 93-4.

Milki, A. A., R. I. Hardy, et al. (1992). “Local anesthesia with conscious sedation for laparoscopic intrafallopian transfer.  Fertility & Sterility 58(6): 1240-2.
Local anesthesia with conscious sedation is well accepted by patients and provides scheduling flexibility, cost containment, patient safety, and ease of recovery. We believe the technique should be offered to selected patients undergoing intrafallopian transfer. By adhering to specific guidelines for surgical technique and monitoring, the procedure is a safe and acceptable alternative to general anesthesia for laparoscopic intrafallopian transfers.

Mimica, Z., M. Biocic, et al. (2000). “Laparoscopic and laparotomic cholecystectomy: a randomized trial comparing postoperative respiratory function.  Respiration 67(2): 153-8.
BACKGROUND: The fact that pulmonary complications occur in 20-60% of the patients subjected to abdominal operations clearly indicates that the lungs are the most endangered organ during the postoperative period. OBJECTIVE: The aim of this study was to demonstrate the impact of cholecystectomy on postoperative respiratory disturbances by comparing the laparotomic cholecystectomy with laparoscopic gallbladder removal. PATIENTS AND METHODS: A hundred cholecystectomized patients were included in the prospective randomized clinical trial. Half of the patients were operated on by the laparotomic procedure, whereas the other half underwent laparoscopic cholecystectomy. Spirometric parameters, arterial blood gases, and acid-base balance were determined before the operation, and at 6, 24, 72 and 144 h postoperatively. Abdominal distension was assessed by auscultating intestinal peristaltics, abdominal circumference measurement, and time interval to restitution of defecation. RESULTS: Six hours postoperatively, the values of ventilation parameters decreased on average by 40-50% from the baseline preoperative values in both groups of patients. The group of patients submitted to laparotomic cholecystectomy had significantly lower spirometric values and slower recovery of the ventilation parameters than the laparoscopic cholecystectomy group. Abdominal circumference was significantly greater and the time needed for restitution of peristaltics and defecation was significantly longer in the laparotomic cholecystectomy group compared to the group of laparoscopic cholecystectomy. CONCLUSIONS: Statistically significant impairments including hypoxia, hypocapnia and hyperventilation were observed in the patients submitted to laparotomic cholecystectomy, indicating the presence of objective respiratory risk, especially in elderly patients and patients with obstructive pulmonary diseases or cardiac insufficiency. Copyright 2000 S. Karger AG, Basel

Minne, L., D. Varner, et al. (1997). “Laparoscopic vs open appendectomy. Prospective randomized study of outcomes.  Archives of Surgery 132(7): 708-11; discussion 712.
OBJECTIVE: To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. DESIGN: Prospective randomized clinical trial of patients with acute appendicitis. SETTING: Tertiary care, urban teaching hospital. PATIENTS: A population-based sample of patients (aged > or = 12 years; weight, > 49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up. INTERVENTIONS: Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group. MAIN OUTCOME MEASURES: Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. RESULTS: Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P < .002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P < .001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P < .001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group). CONCLUSIONS: Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.

Mintz, M. (1976). “Le risque et la prophylaxie des accidents en coelioscopie gynecologique. Enquete portant sur 100,000 cas.  Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 5(5): 681-95.
The author having learned the true character and the value for teaching of his own complications set out a questionnaire which would draw a line distinguishing between complications that seemed in retrospect to have been inevitable and those that could be attributed to the inexperience or lack of care of the operator. The analysis of 194 severe complications occurring in 100,000 laparoscopies performed over 20 years includes 53 cardio-respiratory complications, of which 15 were fatal, 122 injuries or burns due to the instrument, of which 4 were fatal and 18 different complications. No statistical conclusions can be drawn because the figures are approximate and probably below the true levels. But a calculated comparison of the risks can be significant, so long as one avoids mixing up the operators who are well trained, careful and personnally responsible for their actions with those who work hurriedly without proper estimation of the difficulties and dangers. Most opinions agree that apart from the risk of embolus and of general anaesthesia there is no risk of a fatal complication due to laparoscopy. This is particularly true of cardio-respiratory complications, which can be avoided if empirically proven prophylactic measures are taken which take into account the various theories of the aetiology and pathology, which are still being studies. From the results of this enquiry it emerges that certain criteria of care have to be followed which are too often neglected, but they should be applied systematically even when they appear to be unnecessary.

Morimoto, Y., S. Matsumoto, et al. (1997). “[Total intravenous anesthesia with propofol and fentanyl for laparoscopic cholecystectomy].  Masui - Japanese Journal of Anesthesiology 46(9): 1242-5.
The postoperative antiemetic effect of total intravenous anesthesia with propofol and fentanyl was evaluated in 40 patients for laparoscopic cholecystectomy. Patients were divided into 2 groups. In group P, anesthesia was induced with intravenous fentanyl 0.1 mg and propofol 2 mg.kg-1 and maintained with continuous infusion of propofol. In group I, anesthesia was induced with intravenous thiopental 5 mg.kg-1 and maintained with nitrous oxide 60% in oxygen and isoflurane. Post-operative nausea and vomiting were recorded for 8 h after surgery. Nausea scores (range 1-4) were significantly lower in group P as compared with group I at 0 h after surgery, but no difference between the groups at 2 h, 4 h, 8 h after surgery. No significant differences were found in the incidence of vomiting between the groups. These results suggest that total intravenous anesthesia with propofol and fentanyl is superior to inhalational anesthesia with nitrous oxide and isoflurane in postoperative nausea. This antiemetic effect is, however, limited in the early period after anesthesia.

Morimoto, Y., T. Tamura, et al. (1998). “[Carbon monoxide in the expiratory gas during laparoscopic surgery].  Masui - Japanese Journal of Anesthesiology 47(7): 879-81.
One of the complications of laparoscopic surgery is carbon monoxide (CO) production under the use of electrocautery. We experienced a case in which high levels of CO were detected in the expiratory gas. An 80-year old, 33 kg female was scheduled for laparoscopic nephrectomy. Anesthesia was induced with thiopental and vecuronium and maintained with nitrous oxide 60% in oxygen and isoflurane. The concentrations of CO in the anesthetic circuit were examined with CO sensor (XC-341, Shinkosumosudenshi, Tokyo). The CO concentrations were not detected at the start of operation. About 140 minutes after carbon dioxide pneumoperitoneum, the CO concentration increased up to 170 ppm accompanying a high Paco level. The high concentrations, however, decreased immediately after ending of pneumoperitoneum. The HbCO levels were unchanged. Subcutaneous emphysema was noted at the end of surgery. This is because CO is more absorbable in the subcutaneous tissue than in the peritoneal cavity. We consider that CO was absorbed in subcutaneous emohysema during pneumoperitoneum and exhausted in the expiratory gas. When subcutaneous emphysema occurred during laparoscopic surgery, we should be aware of absorption of CO.

Moriya, K., N. Sakakibara, et al. (1997). “[Clinical study of gasless laparoscopic adrenalectomy in 17 cases--comparison between laparoscopic adrenalectomy with and without pneumoperitoneum].  Nippon Hinyokika Gakkai Zasshi - Japanese Journal of Urology 88(12): 1021-7.
PURPOSE: To determine the efficiency of gasless laparoscopic adrenalectomy, this procedure was compared to that with pneumoperitoneum. PATIENTS AND METHODS: Between February 1994 and December 1996, 17 gasless laparoscopic adrenalectomy were performed in 5 men and 12 women, 36 to 79 years old. Clinical diagnosis was primary aldosteronism in 8, pheocromocytoma in 2, incidentaloma in 4 and adrenal cyst in 3. When gasless laparoscopic adrenalectomy was performed, the laparoscope was inserted through the upper margin of the umbilicus by open laparotomy. To create a workable space, a 1.2 mm Kirschner wire was advanced subcutaneously below the costal arch and attached to a retractor. Operating time, estimated blood loss, changes of the end tidal CO2 concentration during operation, operative complications and postoperative course were compared to those with pneumoperitoneum in 12 cases. RESULTS: In both procedures, satisfying workable spaces were created in all cases. The mean operating time and estimated blood loss were 245 min and 201 ml without pneumoperitoneum, 317 min and 274 ml with pneumoperitoneum, respectively. The mean changes of end tidal CO2 concentration during operation were 3.2 mmHg without pneumoperitoneum and 5.1 mmHg with pneumoperitoneum. As operative complications, open operations were required in 2 cases (1 without pneumoperitoneum and another with pneumoperitoneum) to control intraoperative bleeding. They had the histories of transabdominal operations. Postoperative bleeding was observed in 2 cases (1 without pneumoperitoneum and another with pneumoperitoneum). One of them (with pneumoperitoneum) needed surgical management for hemostasis. Fever over 38 degrees C that occurred in 1 case with pneumoperitoneum appeared to be absorption fever. No differences were observed in the number of the days to the start of oral intake and for postoperative hospitalization between the two groups. CONCLUSIONS: Gasless laparoscopic adrenalectomy is available for most adrenal tumors. Suction could be used unrestrictedly and there were no hemodynamic or ventilatory effects due to pneumoperitoneum. This procedure appears to be safe and advantageous for the treatment of most adrenal tumors.

Munk, T. and J. J. Kjer (1994). “Laparoscopic sterilization under local anesthesia.  Acta Obstetricia et Gynecologica Scandinavica 73(4): 347-8.
Fifty-two women were sterilized through laparoscope under local anesthesia with Filshieclips. The majority (94%) were satisfied with the method. During the operation three patients were submitted to general anesthesia due to adhesions (two) and inadequate relaxation (one). Admission period and sick leave were reduced to a minimum.

Muzii, L., R. Marana, et al. (1996). “Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy.  Journal of the American Association of Gynecologic Laparoscopists 3(2): 229-34.
STUDY OBJECTIVE: To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy. DESIGN: Prospective study. SETTING: A tertiary care university hospital. PATIENTS: Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis. INTERVENTIONS: Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH. MEASUREMENTS AND MAIN RESULTS: The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached. CONCLUSIONS: Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

Myatt, J. K., M. Smith, et al. (1986). “Anaesthesia for day-stay laparoscopy [letter].  British Journal of Anaesthesia 58(10): 1200-1.

Nakamura, H., Y. Kobori, et al. (1996). “Fishing-rod-type abdominal wall lifter for gasless laparoscopic surgery.  Surgical Endoscopy 10(9): 944-6.
We have designed a new abdominal wall lifter for gasless laparoscopic surgery which consists of stainless steel rods and iron lifters. They elevate the abdominal wall up like a dome-type camping tent, which does not disturb any manipulation of scope or X-ray camera. We received a good view of the peritoneal cavity without CO2 gas insufflation in ten patients with cholecystitis. This will be helpful for general laparoscopic surgery or laparoscopic assisted surgery with the use of conventional forceps or extracorporeal suturing through a valveless trocar.

Nakamura, C., T. Terai, et al. (1998). “[A case of endotracheal tube obstruction caused by pneumoperitoneum during laparoscopic cholecystectomy].  Masui - Japanese Journal of Anesthesiology 47(12): 1490-2.
A 56-year-old man with cholecystolithiasis was scheduled for laparoscopic cholecystectomy. Anesthesia was induced with pentazocine and propofol i.v., and the trachea was intubated using vecuronium i.v. Anesthesia was maintained with 70% nitrous oxide and 1-3% sevoflurane in oxygen, and vecuronium was used for muscle relaxation. The lungs were mechanically ventilated with a tidal volume of 600 ml and a respiratory rate of 8 cycles.min-1. Following induction of carbon dioxide pneumoperitoneum, blood pressure, PETCO2 and peak inspiratory pressure gradually increased. PETCO2 increased from 33 mmHg to 48 mmHg despite increase in the respiratory rate to 20 cycles.min-1. By 45 minutes after the beginning of surgery, PETCO2 had increased to 60 mmHg, and ventilation of the lungs was impossible. Bronchofiberscopy revealed obstruction of the endotracheal tube by tracheal mucosa. The endotracheal tube was then drawn out by 2 cm with slight recovery of ventilation. After 1 h 16 min of surgery, it was observed that the patient had developed pneumoscrotum and subcutaneous emphysema extending from femoral area, abdomen, and thorax to the right neck. Chest rentogenography revealed a slight tracheal shift and subcutaneous emphysema. One hour after the end of surgery, PaCO2 was 48.9 mmHg under spontaneous respiration. We speculate that the pneumoperitoneum shifted the tracheal carina cephalad, causing obstruction of the endotracheal tube. Our findings show that displacement of the endotracheal tube must be carefully monitored during laparoscopic cholecystectomy.

Nanashima, A., H. Yamaguchi, et al. (1998). “Physiologic stress responses to laparoscopic cholecystectomy. A comparison of the gasless and pneumoperitoneal procedures.  Surgical Endoscopy 12(12): 1381-5.
BACKGROUND: Differences in the physiological stress response to pneumoperitoneal (PP) and gasless abdominal wall-lifting (AWL) procedures used for laparoscopic cholecystectomy have not been properly evaluated. METHODS: We compared leukocyte count, interleukin-6 (IL-6) levels, arterial blood gases, creatinine clearance, plasma renin activity, cardiothoracic ratio, and clinical outcome in 27 patients without systemic complications who underwent laparoscopic cholecystectomy, including 11 by AWL and 16 by PP. RESULTS: Transient leukocytosis and high IL-6 levels were observed at POD 1 (postoperative day) in both groups, but both values returned to baseline by POD 2. IL-6 levels correlated significantly with operation time (p < 0.01). Changes in blood gases, creatinine clearance, plasma renin activity, and cardiothoracic ratio were not different for the two groups. The clinical outcome was similar for both groups. CONCLUSIONS: Our results indicate that both PP and AWL are appropriate for patients without serious complications.

Naude, G. P., M. K. Ryan, et al. (1996). “Comparative stress hormone changes during helium versus carbon dioxide laparoscopic cholecystectomy.  Journal of Laparoendoscopic Surgery 6(2): 93-8.
Laparoscopic surgery has been termed minimally invasive surgery by advocates of this technology. It has been demonstrated previously that using carbon dioxide for insufflation produces a respiratory acidosis due to transperitoneal absorption of gas. Insufflation with helium does not create this acidosis. We questioned whether laparoscopic surgery would elicit a stress response and whether the absence of acidosis with helium might prevent or reduce the levels of stress hormones. Sixteen female patients undergoing laparoscopic cholecystectomy were randomly assigned to helium (n = 8) or CO2 (n = 8) insufflation. Serum cortisol, epinephrine, and norepinephrine were measured preoperatively, after induction of anesthesia but before insufflation, at 45 min of surgery, and after desufflation. There were increases in epinephrine, norepinephrine, plasma cortisol, and urine cortisol at 45 min and at the conclusion of the procedure over the preoperative value. With ANOVA, each variable showed significant increases from preoperative values, at 45 min, and at the end of the case. Except for the increased epinephrine when helium was used, there were no significant differences in the other variables between helium and CO2. Laparoscopic cholecystectomy produces significant increases in stress hormone levels. Prevention of acidosis with helium insufflation does not appear to protect against increases in stress hormones. Epinephrine levels with helium insufflation are higher than with CO2, and elevations in stress hormones suggest that laparoscopic cholecystectomy is not physiologically minimally invasive.

Neeser, E. and H. A. Hirsch (1979). “Vergleich von 2- und 5% iger Lidocainlosung zur Lokalanasthesie beider Tuben bei der laparoskopischen Sterilisation.  Archives of Gynecology 228(1-4): 279.

Negrin Perez, M. C., P. De La Torre Fdz, et al. (1999). “Ureteral complications after gasless laparoscopic hysterectomy.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 9(4): 300-2.
Laparoscopic hysterectomy is becoming a more common operation. Gasless laparoscopy initially seems to be a better technique, reducing CO2 complications and allowing the use of conventional instruments rather than more expensive laparoscopic tools. We report our experience with 50 cases of laparoscopic hysterectomies, 5 of which were performed using a gasless technique. Of these five cases, there were two cases of ureteral stenosis. Ureteral injuries are common with hysterectomy, even in nonlaparoscopic procedures, and the literature is replete with recommendations to avoid this damage. In the gasless procedure, the ureters cannot be repositioned completely from the cervix after the hydrodissection. Extreme caution must be taken when applying bipolar or monopolar energy. The abdominal cavity shape does not allow complete avoidance of the ureters using the gasless technique. We have decided not to use a gasless technique with hysterectomy. We believe that the actual complication rate may be higher than reported, due to investigators' reluctance to report such complications. Our hope is that this report will encourage other investigators to help establish a more accurate rate of possible complications associated with this procedure.

Negro, P., F. Gossetti, et al. (1997). “Laparoscopic vs open hernioplasty. Which open technique for a correct comparison of outcomes? [letter; comment].  Surgical Endoscopy 11(12): 1228-31.

Nelskyla, K., H. Eriksson, et al. (1997). “Recovery and outcome after propofol and isoflurane anesthesia in patients undergoing laparoscopic hysterectomy.  Acta Anaesthesiologica Scandinavica 41(3): 360-3.
BACKGROUND: Laparoscopic hysterectomy (LH) is expected to provide fast and comfortable recovery, plus an early return to normal daily activities. This study was carried out to compare the outcome after LH in patients anesthetized with isoflurane or propofol. METHODS: Sixty-two patients undergoing LH were randomized to receive either isoflurane-N2O or propofol-N2O anesthesia. The times when the patients could drink, void and walk were recorded. Recovery was also evaluated by the Digit Symbol Substitution Test in the postanesthesia care unit (PACU) 60 and 120 min after the operation. The patients were also given a questionnaire on their further recovery (return to daily activities, pain and nausea) to be filled out at home. RESULTS: Early recovery was significantly (P < 0.05) faster in the isoflurane group (eye opening within 3 min, orientation in 6 min) when compared to the propofol group (eye opening within 7 min, orientation in 14 min), but there was no significant difference in the other parameters of recovery. Most of the patients were discharged from the hospital on the first postoperative day in both groups. Twenty-five percent of the patients, however, stayed two nights in hospital, mainly for social reasons. No difference was found regarding the recovery at home: the patients resumed their normal daily activities on about the sixth postoperative day (median). CONCLUSIONS: It is concluded that both isoflurane and propofol are suitable anesthetics for LH. In this study recovery was not fast enough to make the patients suitable for same-day surgery.

Neuhaus, S. J., M. Texler, et al. (1998). “Port-site metastases following laparoscopic surgery.  British Journal of Surgery 85(6): 735-41.
BACKGROUND: Application of laparoscopy to the resection of malignancy has been followed by a literature describing cases of metastatic involvement at laparoscopic port sites. These include patients who underwent surgery for early stage carcinoma and instances following laparoscopic procedures during which tumours were not dissected. METHODS: Recently published clinical and experimental studies, and case reports related to this problem are reviewed; their relevance is discussed. RESULTS: Experimental studies incorporating bench top and large animal models have confirmed that tumour cells may be redistributed to port sites during laparoscopic surgery either directly from contaminated instruments or indirectly via the insufflation gas. Small animal models suggest that the incidence of wound metastasis is increased following conventional laparoscopic surgery, and that it may be decreased by gasless laparoscopy or helium insufflation. This evidence suggests that the development of port-site metastases depends not only on the physical redistribution of tumour cells but also on the specific insufflation gas used, possibly because of influences on local metabolic or immune factors acting at the wound site. CONCLUSION: Further research in this area is urgent. Until the issue is better understood, patients undergoing laparoscopic surgery for malignancy should be entered into clinical trials.

Neuhaus, S. J., T. S. Ellis, et al. (1999). “In vitro inhibition of tumour growth in a helium-rich environment: implications for laparoscopic surgery.  Australian & New Zealand Journal of Surgery 69(1): 52-5.
BACKGROUND: The recent results of several experimental studies have suggested that tumour implantation after laparoscopic surgery for intra-abdominal malignancy may be partly related to the chemical composition of the insufflation gas used during surgery. These studies have demonstrated that the use of helium as a laparoscopic insufflation agent for cancer surgery results in less tumour implantation and growth at port sites. To further investigate these findings, the present study was performed to compare the growth of cultured tumour cells after exposure to simulated laparoscopic environments, rich in helium, carbon dioxide (CO2), or air. METHODS: A rat mammary adenocarcinoma cell suspension was exposed to a simulated laparoscopic environment for 40 min in one of the following groups: (i) control (atmospheric air, equivalent to a 'gasless' laparoscopic environment); (ii) a CO2-rich environment; and (iii) a helium-rich environment. Cells were then cultured for 18 h and optical density readings were used to assess the number of viable tumour cells at the end of this period. The experiment was performed twice using an identical protocol to ensure consistency in the results. In a further study, pH was continuously measured using an antimony probe during a 40 min insufflation period and for 10 min after insufflation. RESULTS: Cell growth was significantly lower after incubation in the helium-rich environment compared to both the CO2 and control groups (P < 0.001). There was a significant decrease in pH in the CO2 group which was not observed during exposure to either air or helium. CONCLUSIONS: The inhibition of tumour growth in a helium-rich environment demonstrated by this study, and the reduced incidence of port-site metastases seen in other experimental studies, suggests that the clinical use of helium as an insufflation gas may have important advantages over CO2.

Newman, L. d., J. P. Luke, et al. (1993). “Laparoscopic herniorrhaphy without pneumoperitoneum.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 3(3): 213-5.
To study the feasibility of gasless laparoscopy using the Laparolift device (Origin Medsystems), appropriate animal studies were carried out using a porcine model. After preliminary success in the laboratory, a petition was made to the institutional review boards of our hospitals. A laparoscopic herniorrhaphy was performed successfully in a consenting male patient with a right indirect inguinal hernia. To further delineate the role of mechanical planar lifting in surgical procedures, further investigation appears safe and is warranted.

Ninomiya, K., S. Kitano, et al. (1998). “Comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy [see comments].  Surgical Endoscopy 12(2): 124-8.
BACKGROUND: Impairments in hemodynamics during pneumoperitoneum (PP) have been noted. This study compared changes in hemodynamics and surgical stress response with PP and abdominal wall lifting (AWL) during laparoscopic cholecystectomy. METHODS: Twenty patients with symptomatic cholecystolithiasis were assigned to PP (n = 10) or AWL (n = 10). Cardiac output (CO), stroke volume (SV), and ejection fraction (%EF) were measured by transesophageal echocardiography. Clearances of para-aminohippurate (CPAH) and sodium thiosulfate (CSTS) were determined as measures of renal function. Levels of interleukin-6, C-reactive protein, white cell count, and neutrophil elastase were evaluated as indicators of surgical stress. RESULTS: In the PP group, CO, SV, and %EF were depressed significantly during pneumoperitoneum. Immediately after and 15 min after insufflation, the CPAH and CSTS were decreased by 78.0% and 73.8%, respectively. None of the hemodynamic parameters changed significantly in the AWL group. Surgical stress response was not different significantly between the two groups. CONCLUSIONS: In contrast to pneumoperitoneum, AWL did not alter cardiac function or renal hemodynamics. AWL may be useful in patients with cardiovascular or renal disorders.

Nishio, S., H. Takeda, et al. (1999). “Changes in urinary output during laparoscopic adrenalectomy.  BJU International 83(9): 944-7.
OBJECTIVE: To better understand the physiological effects of pneumoperitoneum, by examining changes in urinary output during gaseous and gasless laparoscopic adrenalectomy. PATIENTS AND METHODS: Laparoscopic adrenalectomy was performed with gas in six patients and without in three. Urinary output was measured during insufflation and after desufflation. RESULTS: In all patients who received gas, the urinary output was significantly decreased during insufflation and significantly increased after desufflation. However, there were no changes in urinary output in patients who did not receive gas. CONCLUSION: For the safety of laparoscopic surgery it is important to recognise that oliguria occurs during pneumoperitoneum, although the changes in urinary output caused no complications in renal function.

Niville, E. and A. Dams (1999). “Late pouch dilation after laparoscopic adjustable gastric and esophagogastric banding: incidence, treatment, and outcome.  Obesity Surgery 9(4): 381-4.
BACKGROUND: Pathologic late pouch dilation is the most frequent complication following gastric banding procedures for morbid obesity. In this study, possible predictive factors were sought. The treatment of these complications and the final outcome are discussed. METHODS: Between December 1994 and December 1997, 171 patients underwent laparoscopic adjustable banding for morbid obesity. 40 patients underwent classic gastric banding (Group 1), and 131 patients underwent esophagogastric banding (Group 2). RESULTS: Pouch dilation developed in 6 patients (15%) in Group 1 and 12 patients (9.2%) in Group 2. There were no significant predictive factors, although the complication occurred more frequently in patients with presurgical hiatus hernia. The type of dilation was different for each group, as was the surgical treatment. Laparoscopic repositioning of the band was always possible and was uncomplicated. The long-term outcome has been good, and weight loss has been maintained. CONCLUSIONS: A frequent complication following banding procedures for morbid obesity is pathologic late pouch dilation. In experienced hands, when appropriate surgical treatment is carried out, this is not a major problem. Nevertheless, efforts should be made to decrease the number of late dilations.

Noguchi, J., H. Takagi, et al. (1993). “[Severe subcutaneous emphysema and hypercapnia during laparoscopic cholecystectomy].  Masui - Japanese Journal of Anesthesiology 42(4): 602-5.
A 41-year old, 50 kg female was scheduled for laparoscopic cholecystectomy. Anesthesia was induced with thiopental 250 mg IV and endotracheal intubation was performed using succinylcholine 60 mg IV. Anesthesia was maintained with N2O (67%)-oxygen-sevoflurane (1.5-2%) and pancuronium was used for muscle relaxation. The lungs were mechanically ventilated with TV 500 ml and RR 12.min-1. Immediately after the start of incision, PECO2 was 30 mmHg. But about thirty minutes after introducing carbon dioxide pneumoperitoneum, subcutaneous emphysema and high PECO2 (60 mmHg) were noted and arterial blood gas analysis showed PaCO2 63.2 mmHg, PaO2 135.4 mmHg and pH 7.32. Generally in laparoscopic cholecystectomy, subcutaneous emphysema is more common than in gynecologic laparoscopy and especially with severe subcutaneous emphysema, there is a risk of hypercapnia. This is because carbon dioxide in subcutaneous tissue is more absorbable than that in peritoneal cavity. As carbon dioxide in subcutaneous tissue is absorbed continuously after the operation, the patient should be carefully observed postoperatively.

Nogueira, J. M., C. B. Cangro, et al. (1999). “A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy.  Transplantation 67(5): 722-8.
BACKGROUND: Laparoscopic donor nephrectomy (laparoNx) has the potential to increase living kidney donation rates by reducing the pain and suffering of the donor. However, renal function outcomes of a large series of recipients of laparoNx have not been studied. METHODS: We retrospectively reviewed the records of 132 recipients of laparoNx done at our center between 3/96 and 11/97 and compared them to 99 recipients of kidneys procured by the open technique (openNx) done between 10/93 and 3/96. RESULTS: Significantly more patients in the laparoNx group (25.2%) were taking tacrolimus within the first month than those in the openNx group (2.1%). Mean serum creatinine was higher in laparoNx compared with openNx at 1 week (2.8+/-0.3 and 1.8+/-0.2 mg/dl, respectively; P=0.005) and at 1 month (2.0+/-0.1 and 1.6+/-0.1 mg/dl, P=0.05) after transplant. However, by 3 and 6 months, the mean serum creatinine was similar in the two groups (1.7+/-0.1 versus 1.5+/-0.05 mg/dl, and 1.7+/-0.1 versus 1.7+/-0.1, respectively). By 1 year posttransplant, the mean serum creatinine for laparoNx was actually less than that for openNx (1.4+/-0.1 and 1.7+/-0.1 mg/dl, P=0.03). Although patients in the laparoNx compared to the openNx group were more likely to have delayed graft function (7.6 versus 2.0%) and ureteral complications (4.5 versus 1.0%), the rate of other complications, as well as hospital length of stay, patient and graft survival rates were similar in the two groups. CONCLUSION: Although laparoNx allografts have slower initial function compared with openNx, there was no significant difference in longer term renal function.

Norlen, K., P. Essen, et al. (1993). “Laparoskopisk kirurgi. Kunskap om pneumoperitoneum och anestesi kan forhindra peroperativa komplikationer.  Lakartidningen 90(40): 3428-9.

Novick, A. C. (1999). “A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy.  Journal of Urology 162(3 Pt 1): 963-4.

O'Leary, E., K. Hubbard, et al. (1996). “Laparoscopic cholecystectomy: haemodynamic and neuroendocrine responses after pneumoperitoneum and changes in position [see comments].  British Journal of Anaesthesia 76(5): 640-4.
We have assessed the potential for myocardial ischaemia during laparoscopic cholecystectomy in 16 otherwise healthy patients. Continuous ambulatory ECG monitoring was commenced 12 h before operation and continued for 24 h after operation. The neuroendocrine stress response was assessed by measuring plasma concentrations of adrenaline and noradrenaline, human growth hormone, cortisol, renin and aldosterone, and prolactin, at specified times during surgery. Acute ST segment changes in the ECG occurred in only two patients. These episodes were independent of creation of pneumoperitoneum and changes in position. Acute intraoperative increases in MAP were noted during insufflation of carbon dioxide and reverse Trendelenburg positioning (P < 0.05). A four-fold increase in plasma concentrations of renin and aldosterone was noted after pneumoperitoneum and reverse Trendelenburg positioning (P > 0.05). There was a linear correlation between changes in plasma renin and aldosterone concentrations and MAP (r = 0.97 and r = 0.85, respectively). Prolactin concentrations increased four-fold after induction of anaesthesia. Cortisol, HGH, adrenaline and noradrenaline concentrations increased after deflation of the pneumoperitoneum. The time profile-concentration changes of increased MAP and renin-aldosterone suggests a cause-effect relationship. Increased intra-abdominal pressure and reverse Trendelenburg positioning may reduce cardiac output and renal blood flow. The early increase in prolactin concentration was probably secondary to the effect of the opioid fentanyl.

Odeberg, S., O. Ljungqvist, et al. (1994). “Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery.  Acta Anaesthesiologica Scandinavica 38(3): 276-83.
The laparoscopic operating technique is being applied increasingly to a variety of intra-abdominal operations. Intra-abdominal gas insufflation, i.e. pneumoperitoneum (PP), is then used to allow surgical access. The haemodynamic effects of PP in combination with different body positions have not been fully examined. Eleven patients without signs of cardiopulmonary disease were studied before and during laparoscopic cholecystectomy under propofol-fentanyl anaesthesia with controlled ventilation. Swan-Ganz and radial arterial catheterization were used to determine haemodynamic data in the horizontal position, with a 15-20 degree head-down tilt and a 15-20 degree head-up tilt. The measurements were repeated after insufflation of carbon dioxide to an intraabdominal pressure of 11-13 mmHg, as well as during surgery. The ventricular filling pressures of the heart were strictly dependent on body position. PP in the horizontal position increased pulmonary capillary wedge pressure by 32% (P < 0.01), central venous pressure by 58% (P < 0.01), and mean arterial pressure by 39% (P < 0.01). When PP was combined with a head-down tilt, there was a further increase in filling pressures by approximately 40% (P < 0.01), while the reduction in filling pressures during the head-up tilt was counteracted by PP. During PP with a head-up tilt, the filling pressures did not differ from those in the horizontal position without PP. CI showed a certain dependency on filling pressures. It is concluded that PP causes signs of elevated preload and afterload. The combination of PP and a head-up tilt is associated only with signs of an elevated afterload.(ABSTRACT TRUNCATED AT 250 WORDS)

Odeberg, S., O. Ljungqvist, et al. (1998). “Lack of neurohumoral response to pneumoperitoneum for laparoscopic cholecystectomy.  Surgical Endoscopy 12(10): 1217-23.
BACKGROUND: Pneumoperitoneum (PP) for laparoscopic surgery induces prompt changes in circulatory parameters. The rapid onset of these changes suggests a reflex origin, and the present study was undertaken to evaluate whether release of vasopressor substances could be responsible for these alterations. The influence of two different anesthesia techniques was also evaluated. METHODS: American Society of Anesthesiologists (ASA) class I patients, scheduled for laparoscopic cholecystectomy, were investigated. The first group (n = 10) was anesthetized intravenously. The second group (n = 6) had inhalation anesthesia. Plasma vasopressin, catecholamines, and plasma renin activity were investigated as neurohumoral vasopressor markers of circulatory stress. The general stress response to surgery was assessed by analysis of plasma cortisol. RESULTS: Induction of pneumoperitoneum caused no apparent activation of vasopressor substances, although several hemodynamic parameters responded promptly. CONCLUSION: The hemodynamic alterations, seen at the establishment of PP during stable anesthesia, cannot be explained by elevation of vasopressor substances in circulating blood.

Ogihara, Y., A. Isshiki, et al. (1999). “Abdominal wall lift versus carbon dioxide insufflation for laparoscopic resection of ovarian tumors.  Journal of Clinical Anesthesia 11(5): 406-12.
STUDY OBJECTIVE: To evaluate and compare changes in pulmonary mechanics and stress hormone responses between abdominal wall lift (gasless) and carbon dioxide (CO2) insufflation laparoscopic surgery during controlled general anesthesia. DESIGN: Prospective, randomized clinical study. SETTING: Operating rooms at a university medical center. PATIENTS: 12 ASA physical status I and II female patients undergoing laparoscopic resection of ovarian tumors. INTERVENTIONS: Patients were divided into two groups of six each: the abdominal wall lift group and the CO2 pneumoperitoneum laparoscopic group. Following induction of anesthesia, patients were paralyzed and the trachea was intubated. Anesthesia was maintained with isoflurane and nitrous oxide (N2O) in oxygen. Throughout the procedure, patients were mechanically ventilated with a tidal volume of 10 ml/kg and a respiratory rate of 10 breaths per minute. MEASUREMENTS AND MAIN RESULTS: During the laparoscopic procedure, arterial blood gases, acid-base balance, pulmonary mechanics, stress-related hormones, and urine output were measured and recorded. In the CO2 pneumoperitoneum group, arterial CO2 tension increased (p < 0.01), dynamic pulmonary compliance decreased (p < 0.01), peak inspiratory airway pressure increased (p < 0.01), and plasma epinephrine (p < 0.05), norepinephrine (p < 0.05), dopamine (p < 0.01), and antidiuretic hormones (p < 0.05) increased significantly during the laparoscopic procedure as compared to the abdominal lift group. Adrenocorticotropic hormone and cortisol increased as compared to baseline value in both groups (p < 0.05). Urine output was significantly less (p < 0.01) in the CO2 pneumoperitoneum group than in the abdominal wall lift group. CONCLUSIONS: Abdominal wall lift laparoscopic surgery is physiologically superior to CO2 pneumoperitoneum laparoscopic surgery as seen during the conditions of this study. Abdominal wall lift laparoscopic surgery provides normal acid-base balance and a lesser degree of hormonal stress responses, it maintains urine output, and it avoids derangement of pulmonary mechanics.

Ohta, J., I. Kodama, et al. (1997). “Abdominal wall lifting with spinal anesthesia vs pneumoperitoneum with general anesthesia for laparoscopic herniorrhaphy.  International Surgery 82(2): 146-9.
BACKGROUND: Laparoscopic herniorrhaphy has generally been very successful since any postoperative inguinal pain or tension is considerably less troublesome than after other open methods. The conventional laparoscopic approach in the treatment of inguinal hernia involves the use of pneumoperitoneum and general anesthesia. Nevertheless, some complications can be encountered and the procedure is costly. We, therefore, examined the possibility of using a more practical and cost efficient method. MATERIALS AND METHODS: Based on our findings, we propose the use of a Kirschner lifting wire as a means of separating the abdominal wall during laparoscopic herniorrhaphy. Two Kirschner wires are introduced through the subcutaneous tissue, between the umbilicus and inguinal ligament, and parallel to the inguinal ligament. Furthermore, we recommend the use of spinal anesthesia as a means by which the problems associated with general anesthesia and the potential cardiopulmonary complications of carbon dioxide insufflation, are circumvented. Fifteen cases of inguinal hernia have been treated with this new method and compared to the more conventional procedure of pneumoperitoneum under general anesthesia. RESULTS: Visibility of the operative field when used in the inguinal region was not limited at all, and Kirschner wire is considerably less expensive. The postoperative course for the patients who were operated by the new method was uneventful. CONCLUSIONS: Our results indicate that this new method can be useful for the treatment of inguinal hernia.

Olsen, M. F., K. Josefson, et al. (1997). “Respiratory function after laparoscopic and open fundoplication.  European Journal of Surgery 163(9): 667-72.
OBJECTIVE: To compare respiratory function in the immediate postoperative period in patients undergoing open or laparoscopic fundoplication. DESIGN: Prospective non-randomised open study. SETTING: University hospital, Sweden. SUBJECTS: A consecutive series of 32 patients who underwent a conventional open fundoplication and a further 25 consecutive patients who had a similar procedure done laparoscopically. MAIN OUTCOME MEASURES: Respiratory function, oxygen saturation, body temperature, analgesic consumption, rate of mobilisation, and postoperative stay in hospital. RESULTS: In the early postoperative period the respiratory function deteriorated less in the laparoscopy group as reflected by higher oxygen saturation (mean (SEM) 95.8 (0.6)% compared with 94.0 (0.6)%) on the first postoperative day (p < 0.05) and less reduction in forced vital capacity and peak expiratory flow (2.3 (0.2) L compared with 1.8 (0.1) L and 279.8 (19.7) L/min compared with 207 (19.8) L/min respectively) (p < 0.05). Patients had significantly less fever after the laparoscopic procedure (37.5 (0.1) C degrees compared with 38.0 (0.1) C degrees) (p < 0.001) and left hospital earlier (median 2 (range 1-5) days compared with 6 (3-9) (p < 0.001). CONCLUSION: All fundoplication procedures impair respiratory function but significantly less if the procedure is done laparoscopically.

Ongaro, L., F. A. Compostella, et al. (1991). “Variazioni emodinamiche e respiratorie in corso di colecistectomia per via laparoscopica condotta in anestesia epidurale.  Minerva Anestesiologica 57(9): 462-3.

Ortega, A. E., J. H. Peters, et al. (1996). “A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy.  Journal of the American College of Surgeons 183(3): 249-56.
BACKGROUND: In a relatively short period of time, therapeutic laparoscopy has become an everyday part of the general surgeon's life. Although laparoscopy provides distinct clinical advantages, it is not yet clear that it lessens the stress response typical of elective surgical procedures, and as such, the morbidity of surgery. The hypothesis that laparoscopic cholecystectomy produces less of a metabolic and stress hormonal response than open cholecystectomy was tested in a prospective randomized trial. STUDY DESIGN: Twenty otherwise healthy women between 18 and 45 years of age with a history of uncomplicated symptomatic cholelithiasis undergoing either laparoscopic (n = 10) or open cholecystectomy (n = 10) were studied. The hormonal response of the adrenocortical (serum adrenocorticotropic hormone, cortisol, and urinary free cortisol), adrenomedullary (plasma and urinary epinephrine and norepinephrine), thyroid (thyroid-stimulating hormone, thyroxine, and triiodothyronine), pituitary (antidiuretic hormone and growth hormone), and glucose (serum glucose, glucagon, and insulin) homeostatic axes were measured serially over a 24-hour period. RESULTS: No difference was seen between the laparoscopic and open groups in operative time (mean plus or minus standard error of the mean, 70 +/- 6 minutes compared with 77 +/- 6.3 minutes) or hospital stay 1.3 +/- 0.2 compared with 1.1 +/- 0.1 days). Assessment of postoperative pain using an analog pain score was less in the laparoscopic group (4.9 +/- 1.3 compared with 12.3 +/- 2.5, p = 0.01). The response of the adrenocortical, adrenomedullary, thyroid, and glucose axes were similar or identical in both groups. Antidiuretic hormone levels were greater in the laparoscopic group at one hour intraoperatively (281 +/- 79 pg/mL compared with 54 +/- 18 pg/mL, p < 0.01), and at extubation (122 +/- 18 pg/mL compared with 36 +/- 7 pg/mL, p < 0.01). Serum glucose levels were greater immediately following laparoscopic cholecystectomy. Glucose and insulin levels were greater at four, 12, and 24 hours after open cholecystectomy. CONCLUSIONS: Elective laparoscopic and open cholecystectomy for uncomplicated cholelithiasis result in similar degrees of perioperative hormonal stimulation. The different hormonal responses in the immediate and later postoperative periods after laparoscopic and open cholecystectomy suggest differential stressful stimuli between the two procedures.

Otani, T., T. Kaji, et al. (1998). “A flower-shaped cannula for three-incision laparoscopic cholecystectomy.  Surgical Endoscopy 12(2): 179-80.
A simple flower-shaped cannula, in which up to three laparoscopic instruments can be inserted and manipulated freely, is described. Using this cannula, a three-incision gasless laparoscopic cholecystectomy can be performed easily.

Padilla, S. L., K. Dugan, et al. (1996). “Laparoscopically assisted gamete intrafallopian transfer with local anesthesia and intravenous sedation.  Fertility & Sterility 66(3): 404-7.
OBJECTIVE: To determine the length of procedure, length of recovery, patient tolerance, complications, and pregnancy rate (PR) of laparoscopically assisted GIFT performed during local anesthesia with i.v. sedation. DESIGN: A retrospective study. SETTING: Freestanding private ambulatory surgical center. PATIENTS: Thirty-one consecutive couples with infertility. INTERVENTIONS: Laparoscopically assisted GIFT during local anesthesia with i.v. sedation. MAIN OUTCOME MEASURES: Surgery time, recovery time, patient tolerance, PR, miscarriage rate, and complications. RESULTS: Cannulation of at least one fallopian tube was achieved successfully in all patients. The average surgery time was 64 +/- 12 minutes (mean +/- SD). The average recovery time was 92 +/- 30 minutes. The PR was 39% with an ongoing PR of 32%. There were no intraoperative or postoperative complications. CONCLUSION: Local anesthesia with IV sedation for GIFT using a two-puncture laparoscopic technique was well tolerated by the patients. Our ongoing PR of 32% compares very favorably with other series using general anesthesia.

Pannen, F. and H. Frangenheim (1975). “Die "chirurgische" Laparoskopie. Indikationen und Aussagewert.  Chirurg 46(9): 405-10.
From 1971-1973, 1046 patients underwent laparoscopy in the gynecological department; 256 of the cases were surgical problems. In contrast to gastroenterological laparoscopy, surgical laparoscopy was performed in the operating room under general anaesthesia and everything prepared for immediate surgery. Major surgical interventions--if necessary--were performed immediately after laparoscopy. Indications for surgical laparoscopy were the following: preoperative evaluation of nature, extent and eventual metastases of tumors. Preoperative differentiation of acute and chronic appendicitis from other affections, particularly in younger female patients. Suspected intraabdominal hemorrhage of traumatic or non-traumatic origin. Evaluation of pathological palpatory findings in the abdominal cavity. Differential diagnosis of chronic relapsing intraabdominal complaints of unknown origin. Differential diagnosis of putrid, tuberculous or carcinomatous peritonitis with eventual biopsy. Preoperative evaluation of questions concerning surgery of liver, gallbladder or pancreas in connection with occlusive jaundice, hepatic cirrhosis or malignancy. The results of this study show, that by laparoscopy in over 50% of the patients, major surgical interventions could be avoided. Contraindications were primarily limited to pulmonal or cardiac insufficiency. The only complication (intestinal perforation), was adequately dealt with under the given operative conditions.

Paolucci, V., B. Schaeff, et al. (1994). “Die gaslose laparoskopische Cholezystektomie.  Zentralblatt fur Chirurgie 119(6): 383-7.
The pneumoperitoneum as a precondition of laparoscopic procedures represents a restriction of the surgeons freedom of movement and causes rare but typical complications. In July 1993 we started doing laparoscopic cholecystectomy without using a pneumoperitoneum. Under direct vision and digital control the retractor blades are introduced into the abdominal cavity via minilaparotomy. The retractor is attached to an electrically powered mechanical arm and raised. The scope is introduced through the same access and the laparoscopic cholecystectomy can be performed using the established technique without instilling a pneumoperitoneum. Both conventional and laparoscopic surgical instruments were introduced through valveless trocars and unlimited suction without loss of gas and exposure is possible. Metabolic and hemodynamic alterations associated with the intraperitoneal insufflation of carbon dioxide are omitted. So far we did gasless laparoscopic cholecystectomy in 22 patients. We didn't see any related complications. Four times we had to change the surgical procedure. In comparison to the traditional laparoscopic cholecystectomy with a CO2-pneumoperitoneum the results of the first gasless procedures demonstrate possible advantages.

Paolucci, V., B. Schaeff, et al. (1995). “The gasless laparoscopic cholecystectomy.  Endoscopic Surgery & Allied Technologies 3(1): 76-80.
The pneumoperitoneum, generally used for all laparoscopic procedures, can lead to specific disadvantages and result in complications, and it furthermore represents a restriction of the surgeon's freedom of movement. In July, 1993 we started doing laparoscopic surgery without the pneumoperitoneum. Under direct vision and digital control, a fan-shaped wall retractor, which is attached to an electric lift arm, is introduced into the abdominal cavity. After raising the abdominal wall, the scope is introduced through the same access and the laparoscopic procedure can be started without the technical and pathophysiological problems which may occur when using a pneumoperitoneum. In this gasless laparoscopic procedure, simple valveless trocars and instruments can be used. During anaesthesia, neither an increased ventilation nor an enlarged ventilation pressure is necessary in this way we performed gasless laparoscopic cholecystectomy in 50 patients. We observed 5 wound infections as related complications. We had to change the surgical procedure seven times. The retraction technique creates a sufficient but not optimal exposure to the gallbladder. Intraoperative changes of the instruments, suction and specimen removal appeared easier. Both conventional and laparoscopic surgical instruments were introduced through the valveless trocars. Our experience demonstrates the practicability of this technique and potential advantages.

Parris, W. C. and E. M. Lee (1991). “Anaesthesia for laparoscopic cholecystectomy [letter].  Anaesthesia 46(11): 997.

Patel, A. and G. J. Fuchs (1996). “Laparoscopic approaches to transitional cell carcinomas of the upper urinary tract.  Seminars in Surgical Oncology 12(2): 113-20.
Traditionally transitional cell tumors of the upper urinary tract are treated by nephroureterectomy. In circumstances where low functional renal reserve necessitates renal parenchymal preservation, endoscopic or percutaneous treatment may be an option for low grade and stage lesions. In this article, the role of laparoscopic surgery as an alternative modality to open surgery is discussed. Techniques of laparoscopic nephroureterctomy are described and different approaches (transperitoneal, retroperitoneal, and gasless hand-assisted) are contrasted. The limitations imposed on laparoscopic treatment by the requirement of adherence to oncological principles of tumor containment and excision of the intramural ureter, are outlined. Laparoscopic nephroureterectomy, although technically demanding, has been shown to be a feasible procedure. Benefits of the laparoscopic approach include shortened hospital stay and early return to daily activities. It is unclear at this time whether these immediate advantages over open surgery will yield comparatively efficacious long term outcomes.

Patel, S. I. (1998). “Anaesthesia for laparoscopic cholecystectomy in a patient with Eisenmenger's syndrome [letter; comment].  British Journal of Anaesthesia 81(2): 297; discussion 297-8.

Paterson, P. (1982). “Laparoscopic sterilisation with the Filshie clip under local anaesthesia.  Medical Journal of Australia 2(10): 476-7.
A technique for performing laparoscopic sterilisation under local anaesthesia and without systemic sedation is described. A mechanical tubalocclusion clip was employed. The procedure, and the technique of local anaesthesia are compared with other methods of sterilisation.

Pattinson, R. C., N. S. Louw, et al. (1983). “Complications in 8509 laparoscopic Falope ring sterilizations performed under local anaesthesia.  South African Medical Journal 64(25): 975-6.
During the 3-year period 1 January 1980-31 December 1982, 8509 laparoscopic Falope ring sterilizations were performed under local anaesthesia in rural areas of the Cape Province by the Sterilization Service of Tygerberg Hospital. Despite the fact that 476 of the patients had undergone previous lower abdominal surgery, major complications (anaphylactic shock after injection of lignocaine and inadvertent perforation of the bladder by the trocar) occurred in only 2 cases. It was not possible to complete the sterilization under local anaesthesia in 98 cases, resulting in a technical failure rate of 1.15%. A prospective study of the minor complications encountered among the 193 patients sterilized during November 1982 showed that torn tubes occurred in 3.1% and uterine perforation in 2.1%. This can be partially explained by the fact that evidence of previous pelvic infection was seen during laparoscopy in 9.3% of cases. The pregnancy rate after sterilization was 0.28% for the group as a whole.

Pendurthi, T. K., E. J. DeMaria, et al. (1995). “Laparoscopic bilateral inguinal hernia repair under local anesthesia.  Surgical Endoscopy 9(2): 197-9.
A case report of the laparoscopic repair of bilateral inguinal hernias performed under local anesthesia with intravenous sedation is presented. The combination of nitrous oxide for peritoneal insufflation and an ultrasonically activated scalpel for dissection made the procedure feasible. It is hoped that this technique can extend laparoscopic surgery to patients who are poor candidates for general anesthesia.

Penfield, A. J. (1974). “Laparoscopic sterilization under local anesthesia.  Journal of Reproductive Medicine 12(6): 251.

Penfield, A. J. (1974). “Laparoscopic sterilization under local anesthesia: a new service in a free-standing Planned Parenthood center.  Advances in Planned Parenthood 9: 56-8.

Penfield, A. J. (1977). “Laparoscopic sterilization under local anesthesia. 1200 cases.  Obstetrics & Gynecology 49(6): 725-7.
Laparoscopic tubal fulguration operations were performed on 1200 patients under local anesthesia in two free-standing surgical units in Syracuse, New York, between June 1972 and March 1976. No operative accidents occurred. However, because of increasing understanding of the risks to major blood vessels from needle and trocar insertion, all patients undergoing laparoscopy since March 15, 1976, have received the additional safeguards of an operating room with full anesthesia and laparotomy capabilities. The major technical innovation in this series of operations was the use of the 23-guage needle cannula, inserted through the Wolf operating laparoscope for preliminary Xylocaine infiltration of the fallopian tubes. The advantages of local over general anesthesia are summarized.

Peterson, H. B., J. F. Hulka, et al. (1987). “Local versus general anesthesia for laparoscopic sterilization: a randomized study.  Obstetrics & Gynecology 70(6): 903-8.
Despite the contention by some that local anesthesia is a preferred alternative to general anesthesia for laparoscopic sterilization, there have been no randomized studies comparing these techniques. To better characterize the relative safety and acceptability of these techniques for laparoscopic sterilization, we randomly assigned 100 women undergoing bipolar electrocoagulation or spring clip application to either local or general anesthesia. Of the 53 women assigned local anesthesia, four had their procedures completed using another technique because of technical problems related to obesity. Thirteen other obese women, however, underwent successful surgery with local anesthesia. Women undergoing local anesthesia had a slightly shorter anesthesia time (30 versus 36 minutes) and recovery room stay (65 versus 78 minutes). Women having general anesthesia were 2.3 and 1.5 times more likely to have maximum systolic and diastolic blood pressures above 160 and 90 mmHg, respectively. They were also 5.7 times more likely to have a maximum heart rate 110 or higher. Patient movement was reported to be a concern in five women undergoing general anesthesia, but in none having local anesthesia. An equal percentage (80%) of women in each group expressed satisfaction with their anesthetic technique.

Pfeifer, J., S. D. Wexner, et al. (1995). “Laparoscopic vs open colon surgery. Costs and outcome.  Surgical Endoscopy 9(12): 1322-6.

Philip, B. K., D. A. Scott, et al. (1991). “Butorphanol compared with fentanyl in general anaesthesia for ambulatory laparoscopy.  Canadian Journal of Anaesthesia 38(2): 183-6.
Butorphanol was compared with fentanyl as the narcotic component of general anaesthesia for ambulatory laparoscopic surgery. This double-blind, randomized study enrolled 60 healthy women who received equianalgesic doses of fentanyl 1 microgram.kg-1 (F, n = 30) or butorphanol 20 micrograms.kg-1 (B, n = 30) prior to induction of anaesthesia. Tracheal anaesthesia was maintained with nitrous oxide/oxygen, isoflurane, and succinylcholine by infusion. Intraoperatively, patients who received B demonstrated lower pulse rate before and after intubation (P less than 0.05, P less than 0.01) and lower diastolic blood pressure after intubation (P less than 0.01). Anesthesiologists judged the maintenance phase as satisfactory more often with B (P less than 0.05). Postoperatively, there were no differences in analgesic need. No major side-effects occurred in either group. Among minor side-effects, patients who received B reported postoperative sedation more often, 77% vs 37% (P less than 0.01), which occurred during the first 45 min of recovery (P less than 0.05). Discharge times were not different. On the first postoperative day, more subjects who received B were satisfied with their anaesthesia experience (P less than 0.05). Butorphanol 20 micrograms.kg-1 is an acceptable alternative analgesic in general anaesthesia for ambulatory laparoscopy.

Phillips, E. H. (1995). “Laparoscopic transcystic duct common bile duct exploration--outcome and costs.  Surgical Endoscopy 9(11): 1240-2.

Poen, A. C., M. de Brauw, et al. (1996). “Laparoscopic rectopexy for complete rectal prolapse. Clinical outcome and anorectal function tests.  Surgical Endoscopy 10(9): 904-8.
BACKGROUND: The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations. METHODS: Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography. RESULTS: No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p = 0.005) and the rectoanal inhibitory reflex improved in seven patients (p = 0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p = 0.02). CONCLUSIONS: Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.

Poindexter, A. N. d., M. Abdul-Malak, et al. (1990). “Laparoscopic tubal sterilization under local anesthesia [see comments].  Obstetrics & Gynecology 75(1): 5-8.
Laparoscopic tubal sterilization has been performed under local anesthesia in the United States since 1971. Pilot studies suggested that local anesthesia was as adequate and as safe as general anesthesia. Since 1980, the senior author has performed more than 3000 outpatient laparoscopic tubal sterilizations with the silastic ring under local anesthesia. A retrospective descriptive study was conducted on 2827 cases. The technical failure rate was 0.14%. There were no unintended laparotomies due to complications. The mean operative time was 10.0 +/- 5.1 minutes. The mean anesthesia time was 23.3 +/- 6.9 minutes. The hospital cost for the patient was reduced by 68-85%. This study demonstrates that laparoscopic tubal sterilization can be performed adequately, safely, and quickly under local anesthesia.

Puri, G. D. and H. Singh (1992). “Ventilatory effects of laparoscopy under general anaesthesia [see comments].  British Journal of Anaesthesia 68(2): 211-3.
We have studied 14 female patients undergoing elective laparoscopy under general anaesthesia with peritoneal insufflation of carbon dioxide in order to examine changes in physiological deadspace (VDphys), arterial to end-tidal carbon dioxide partial pressure difference (PaCO2-PE' CO2) and PaCO2. VCO2 increased after insufflation of carbon dioxide with a mean (SD) maximum increase of 32 (28)% compared with the preinsufflation value. PaCO2 increased also, with a mean (SD) maximum increase of 0.6 (0.58) kPa immediately before carbon dioxide deflation. VDphys and (PaCO2-PE' CO2) increased during laparoscopy, but this was not significant (P greater than 0.05).

Pursnani, K. G., Y. Bazza, et al. (1998). “Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease.  Surgical Endoscopy 12(8): 1082-4.
BACKGROUND: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). METHODS: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38-74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEB1/FVC was 0.52 (range, 0.4-0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. RESULTS: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2-4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including PO2 and pCO2, and no complications occurred either intra- or postoperatively. CONCLUSIONS: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.

Putensen-Himmer, G., C. Putensen, et al. (1992). “Comparison of postoperative respiratory function after laparoscopy or open laparotomy for cholecystectomy.  Anesthesiology 77(4): 675-80.
Cholecystectomy performed via laparotomy is associated with reduction of lung volumes including functional residual capacity that may lead to postoperative hypoxia and atelectasis. Laparoscopic cholecystectomy is associated with faster recovery compared to open laparotomy and cholecystectomy. To determine whether laparoscopic cholecystectomy was associated with less pulmonary dysfunction, 20 patients (ASA Physical Status I) undergoing elective cholecystectomy were randomly assigned to surgical teams performing either laparoscopy or open laparotomy for cholecystectomy. Patients in whom one or the other surgical technique had to be performed for medical or psychologic indications were excluded from the study. A standardized anesthetic technique and postoperative analgesic regimen were used. Forced vital capacity and forced expiratory volume in 1 s; functional residual capacity determined by a closed-circuit, constant volume helium dilution technique; and arterial O2 and CO2 tensions were measured preoperatively and at 6, 24, and 72 h postcholecystectomy. Forced vital capacity and forced expiratory volume in 1 s were significantly greater (P less than 0.05) in the laparoscopy compared to the laparotomy group at 6, 24, and 72 h postoperatively. Forced vital capacity relative to preoperative values was significantly (P less than 0.05) greater in patients with laparoscopy (24 h, 70 +/- 14%; 72 h, 91 +/- 6%) compared to open laparotomy (24 h, 57 +/- 23%; 72 h, 77 +/- 14%). Similarly, forced expiratory volumes in 1 s relative to preoperative values were significantly (P less than 0.05) greater in patients with laparoscopy (24 h, 85 +/- 13%; 72 h, 92 +/- 9%) compared to open laparotomy (24 h, 54 +/- 22%; 72 h, 77 +/- 11%).(ABSTRACT TRUNCATED AT 250 WORDS)

Raeder, J. C. and A. Hole (1986). “Out-patient laparoscopy in general anaesthesia with alfentanil and atracurium. A comparison with fentanyl and pancuronium.  Acta Anaesthesiologica Scandinavica 30(1): 30-4.
The effects of the new intravenous anaesthetic drugs alfentanil (50 micrograms/kg) and atracurium (0.5 mg/kg) on per- and post-operative function in out-patients clinics were compared with fentanyl (5 micrograms/kg) and pancuronium (0.07 mg/kg). Sixty-two healthy female patients submitted for out-patient sterilization by laparoscopy participated in the study. Thirty patients receiving alfentanil and atracurium (the AA-group) had significantly less pain during analgetic injection, less coughing during intubation, and faster and more pronounced muscle relaxation during induction of anaesthesia, compared with 32 patients receiving fentanyl and pancuronium (the FP-group). The AA-group had less adrenocortical stress-response judged by systolic blood pressure and pulse rate during anaesthesia. Reversal of anaesthesia and neuromuscular blockade were performed without differences in awakening parameters between the two groups. The AA-group had a significantly better score on P-deletion test 45 min after reversal of anaesthesia, a better street fitness score in the afternoon after the procedure and a better day-life function score at home in the evening. There was no difference between the groups in postoperative complaints and in function after the day of operation.

Raeder, J. C., P. E. Bordahl, et al. (1993). “Poliklinisk laparoskopisk sterilisering--bor lokalanalgesi og intravenos sedasjon erstatte generell anestesi? En sammenliknende klinisk undersokelse.  Tidsskrift for Den Norske Laegeforening 113(13): 1559-62.
A prospective, randomized study comprised 125 outpatient laparoscopic sterilization patients who had received either general anaesthesia or local anaesthesia together with intravenous sedation. The patients who had received local anaesthesia suffered significantly less postoperative pain and sore throat. Recovery and discharge were similar in the two groups, but those given a general anaesthetic were more drowsy in the evening on the day of operation. The time spent in the operating theatre was significantly shorter for the group given local anaesthesia, and the costs were lower. The majority of patients from both groups would prefer local anaesthesia and sedation for a similar procedure in the future. We conclude that local anaesthesia by intravenous sedation is the method of choice for laparoscopic sterilization.

Ramsey, D. E., N. Aldred, et al. (1993). “A simplified approach to the anesthesia of porcine laparoscopic surgical subjects.  Laboratory Animal Science 43(4): 336-7.
At a series of laparoscopic surgical workshops, 155 pigs were successfully anesthetised for up to 4 hours by using Profolol (Diprivan) as the anesthetic agent and without provision of positive pressure ventilation. On the basis of our findings, we believe this methodology presents a useful alternative to gaseous anesthesia and provides definite logistical and technical advantages.

Rantanen, T. K., J. A. Salo, et al. (1999). “Functional outcome after laparoscopic or open Nissen fundoplication: a follow-up study.  Archives of Surgery 134(3): 240-4.
OBJECTIVE: To compare the results of open and laparoscopic fundoplication. DESIGN: Nonrandomized controlled study with a 3-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. INTERVENTIONS: Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. RESULTS: Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. CONCLUSION: From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.

Rassweiler, J. J., T. O. Henkel, et al. (1993). “The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy.  European Urology 23(4): 425-30.
In the traditional kidney position three trocars are inserted after creation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm subcostal (port II) and 12/10 mm above the iliac spine (port III) in the mamillary line. After laterocolic incision the colon is dissected away from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) are inserted into the lateral abdominal wall parallel to parts II and III. Following clipping and dissection of the ovarian (spermatic) vein, the ureter is isolated and incised. Then the cranial part of the ureter is used as a retractor exposing the renal hilum for dissection of the renal vessels. The main renal artery and vein are dissected separately by use of an endoscopic stapling device (Endo-GIA, white magazine). Finally, the kidney including Gerota's fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performed with a specially designed bag (Lap-sac). The neck of the bag is brought out onto the surface of the abdomen (via port II/III) allowing digital morcellation with index finger inside the bag and removal of the organ in several pieces. We have applied this technique for 17 procedures in the upper retroperitoneum: 9 transperitoneal laparoscopic nephrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalectomy for renal cell carcinoma (T2G2), 1 adrenalectomy for a cortical adrenaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modified retroperitoneal lymphadenectomies for stage I testicular cancer. The mean operation time was 4 h (2-5), the mean postoperative hospital stay 6 days (4-12).(ABSTRACT TRUNCATED AT 250 WORDS)

Rassweiler, J., T. O. Henkel, et al. (1993). “Transperitoneal laparoscopic nephrectomy: training, technique, and results.  Journal of Endourology 7(6): 505-15; discussion 515-6.
Transperitoneal laparoscopic nephrectomy was integrated into our daily routine within a 6-month period by means of a step-by-step training program progressing from a pelvic trainer to animal studies (N = 15) to laptent-assisted surgery. The pneumoperitoneum is created with the patient in the flank position, enabling insertion of three trocars: 10-mm periumbilical (Port I), 5/12-mm subcostal (Port II), and 12/5-mm above the iliac spine (Port III). After medial mobilization of the colon, two additional 5-mm trocars (Ports IV and V) are inserted into the lateral abdominal wall parallel to Ports II and III. Once clipping and dissection of the ovarian (spermatic) vein has been carried out, the ureter is identified and dissected. Retraction of the proximal ureter exposes the renal hilum, allowing dissection of the renal vessels. The renal vein is dissected using an endoscopic stapling device, while accessory veins and the renal artery are clipped. Organ retrieval is achieved with a specially designed tissue pouch (Lapsac) and digital fragmentation of the kidney within the organ bag. Using this technique, we have treated 24 patients with benign (N = 20) and malignant (N = 4, including adrenalectomy) renal disease. The mean operative time was 239 (115-300) minutes. In four cases, open surgery was required because of bleeding (N = 2), severe perinephric inflammation (N = 1), or bowel injury (N = 1). For relief of wound pain, an average of 1.15 vials of analgesic (morphine derivatives)/patient were administered for 2.4 days. The postoperative hospital stay averaged 6.2 (4-10) days.

Reed, D. N., Jr. and P. Nourse (1998). “Untoward cardiac changes during CO2 insufflation in laparoscopic cholecystectomies in low-risk patients.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 8(2): 109-14.
In the past decade, laparoscopic cholecystectomy has become the gold standard treatment for gallbladder disease. A debate has arisen about using CO2 to distend the abdomen because of negative effects on venous return to the heart and declining cardiac output. Some authors have supported the use of pulmonary artery catheters for intraoperative monitoring while others have recommended gasless techniques to avoid these negative effects for high-risk patients. In this study, four cases of bradycardia and/or asystole during CO2 pneumoinsufflation at the beginning of planned, elective laparoscopic cholecystectomies are described. These patients were ASA category II, without history of cardiac disease. To determine the frequency and any underlying common denominators, we analyzed these laparoscopic cholecystectomies. Each patient experienced bradycardia shortly after the start of the laparoscopic cholecystectomy. None had known cardiac disease or symptoms. Two were on antihypertensive medications, and one had experienced an episode of unexplained bradycardia 6 years earlier. These cases occurred during 725 laparoscopic cholecystectomies (0.6% approximately). Using the senior author's conversion rate of 10% to open cholecystectomies, the entire group would be approximately 800, and the risk of bradycardia upon induction of CO2 is 4 per 800, or 0.5%. Although cardiovascular changes were noted during laparoscopic gynecologic surgery approximately 20 years ago, only in the last few years have cardiovascular changes been reported during laparoscopic cholecystectomies. This study reviews four cases of bradycardia during CO2 insufflation in patients that were considered to be low-risk. Surgeons should be prepared to encounter such cardiovascular changes even with low-risk patients.

Richards, K. F., K. S. Fisher, et al. (1996). “Laparoscopic Nissen fundoplication: cost, morbidity, and outcome compared with open surgery.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 6(2): 140-3.
We report a retrospective review of all patients undergoing both open and laparoscopic Nissen fundoplication from January 1990 through December 1993. Computer data were reviewed to determine the length of hospital stay, hospital costs, and perioperative complications. Questionnaires were sent to patients undergoing Nissen fundoplication. During the study period, 232 patients underwent Nissen fundoplication, and 72 patients underwent laparoscopic Nissen fundoplication. The open group had an average hospital stay of 6.1 days, the laparoscopy group, 1.5 days (p < < 0.001). Total hospital costs for the open group averaged $8,616 versus $4,331 for the group that underwent laparoscopic procedure (p < 0.001). Operating room time averaged 10 min longer for the laparoscopic procedure (p value, nonsignificant). In-hospital morbidity was significantly greater for the open group. In follow-up questionnaires, the laparoscopy group experienced an earlier return to "general health" (p < 0.005) and an earlier return to work.

Richardson, M. G., C. L. Wu, et al. (1997). “Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization.  Anesthesia & Analgesia 85(2): 301-5.
Preoperatively administered midazolam may contribute to postoperative sedation and delayed recovery from brief outpatient general anesthesia, particularly in patients who receive significant postoperative opioid analgesics. We evaluated the effects of midazolam premedication (0.04 mg/kg) on postoperative sedation and recovery times after laparoscopic tubal sterilization (Falope rings) in 30 healthy women in a randomized, double-blind, placebo-controlled study. Patients received midazolam or saline-placebo intravenously 10 min before anesthesia. General anesthesia was induced with fentanyl, propofol, and mivacurium and was maintained with N2O and isoflurane. Sedation was quantified before and after premedication and 15, 30, and 60 min after emergence from anesthesia, using the digit-symbol substitution (DSST) and Trieger dot (TDT) tests. Management of postoperative pain and nausea and discharge criteria were standardized. Groups were similar with respect to age, weight, and duration of surgery and anesthesia. Midazolam was associated with impairment of performance on the TDT and DSST after premedication administration and 15 (TDT and DSST) and 30 (DSST) min after postanesthesia care unit (PACU) arrival. There were no differences in PACU time and time to discharge-readiness. In conclusion, midazolam premedication augments postoperative sedation in this population but does not prolong recovery times.

Rigo, V. and A. Bartoloni (1991). “La colecistectomia per via laparoscopica. Tecniche di anestesia.  Annali Italiani di Chirurgia 62(4): 337-8.

Rishimani, A. S. and S. C. Gautam (1996). “Hemodynamic and respiratory changes during laparoscopic cholecystectomy with high and reduced intraabdominal pressure.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 6(3): 201-4.
Laparoscopic cholecystectomy (lapchole) is a safe procedure. Most of the complications are operation related. The complications related to increased intraabdominal pressure (IAP) are well recognized, but not emphasized enough. The changes in physiological parameters at different IAPs were studied to evaluate the usefulness of reduced IAP in minimizing these changes. Thirty consecutive patients consisting of 16 ASA III, 2 ASA IV, and the rest ASA I and II, underwent lapchole under high and reduced IAP. The mean arterial pressure (MAP), heart rate (HR), arterial oxygen saturation (SaO2), airway pressure (AWP), and end-tidal carbon dioxide (ETCO2) were recorded before insufflating carbon dioxide (T1), with IAP of 14 mm Hg (T2) and IAP of 6 mm Hg or less (T3). At T2, MAP increased by 41.15%, AWP by 44.3%, and ETCO2 by 20.5% as compared to T1 (p < 0.001). HR and SaO2 showed no significant changes. At T3 there was an increase in MAP by 24.94%, in AWP by 10%, and ETCO2 by 10.6% with no significant changes in HR and SaO2. Thus, operating under reduced IAP may be beneficial to the patients with decreased cardiopulmonary reserve, especially while undergoing long surgical procedures.

Root, B., M. N. Levy, et al. (1978). “Gas embolism death after laparoscopy delayed by "trapping" in portal circulation.  Anesthesia & Analgesia 57(2): 232-7.
A young woman died suddenly about 1 hour after instillation of CO2 for diagnostic larparoscopy. Post-mortem x-rays revealed large volumes of gas in the portal system, the heart, and the brain. In addition, autopsy revealed gas bubbles in the coronary arteries, pulmonary hemorrhage and edema, and a probe-patent foramen ovale. We postulated the "trapping" of gas in the portal circulation and affirmed this by experiments in 6 dogs. We further postulate the delayed and intermittent release of this gas and of platelet aggregates into the systemic circulation would occur in volumes which would be insufficient to produce hemodynamic signs yet sufficient to produce serious pulmonary insult.

Rose, D. K., M. M. Cohen, et al. (1992). “Laparoscopic cholecystectomy: the anaesthetist's point of view.  Canadian Journal of Anaesthesia 39(8): 809-15.
Although the surgical advantages of laparoscopic cholecystectomy (LC) have been reported, the anaesthetic problems associated with this new technique have not been well described. For the first 101 patients undergoing laparoscopic cholecystectomy at our institution, we prospectively documented intraoperative critical observations and adverse outcomes in the PACU (Post-Anaesthetic Care Unit). In order to put the magnitude of these problems into perspective, we compared, in an identical manner, the anaesthetic management and outcomes of two more familiar surgical groups, cholecystectomy by laparotomy (C), and laparoscopy for gynaecological examination (LG). For this new procedure LC, intraoperative hypotension (12.9%), and PACU hypothermia (31.4%), nausea and vomiting (12.9%) and desaturation (10.9%) were common but excessive pain (4.0%) was rare. Patients undergoing C, who were older and less healthy, tended to have fewer incidents of OR hypotension (3.4%) but in the PACU experienced more desaturation (25.9%) and excessive pain (12.9%) (P < or = 0.05). The younger and healthier LG group had fewer problems, less OR hypotension (0.4%), and less PACU nausea and vomiting (5.7%) and desaturation (1.3%) (P < or = 0.05). However, the LG group had a similar incidence of excessive pain (4.4%). We have documented considerable postoperative anaesthetic benefits for patients undergoing laparoscopic cholecystectomy compared with conventional cholecystectomy. However, there is still considerable perioperative morbidity compared with gynaecological laparoscopies. Now that specific problems have been identified, they may be amenable to specific anaesthetic interventions.

Rubio-Martinez, C. J., M. Lang-Lenton Leon, et al. (1996). “Anestesia en la colecistectomia laparoscopica con CO2: comparacion del comportamiento hemodinamico y ventilatorio con dos tecnicas anestesicas diferentes.  Revista Espanola de Anestesiologia y Reanimacion 43(1): 12-6.
OBJECTIVES: To study cardiopulmonary function in 30 ASA I and II patients undergoing laparoscopic cholecystectomy with CO2. PATIENTS AND METHODS: Fifteen patients were given total anesthesia with propofol (group PRO) and 15 inhaled isoflurane (group ISO). In addition to the usual monitoring, we used esophageal Doppler ultrasonogram (ED) to study the hemodynamic status after pneumoperitoneum (NP) at 15 mmHg, after the patient had been placed in anti-Trendelenburg (AT) position, and 10, 20 and 30 minutes after NP (series 1). We also studied response to reduction of NP from 15 mmHg to 12, 10, 8 and 6 mmHg (series 2), repeating this sequence when duration of surgery permitted (series 3). RESULTS: In group PRO, cardiac index (CI) decreased 17.96% (NS) after NP and 24.90% (p = 0.015; r = 0.71) after AT. In group ISO, the decreases were 15.86% (p = 0.02; r = 0.69) and 22.34% (p = 0.02; r = 0.80), respectively. Correlated flow time (FTc) and peak velocity (PV) decreased, while the index of total peripheral resistance (TPRI) increased with NP and AT. Recovery of CI was gradual and spontaneous (series 1). The decreases in NP pressure did not produce significant improvement in IC. CONCLUSIONS: Induction of NP and placement in AT position causes significant decreases in CI as measured by ED in ASA I and II patients, whether they inhale the anesthetic agent or are given total intravenous anesthesia. This effect seems to be related to the increase in afterload, measured in this study by TPRI and the ratio PV/FTc.

Rudkin, G. E. and G. J. Maddern (1995). “Peri-operative outcome for day-case laparoscopic and open inguinal hernia repair [see comments].  Anaesthesia 50(7): 586-9.
This study documents the results obtained in 30 day patients undergoing open hernia repair under local infiltration block with patient-controlled sedation (group A) and 29 day patients undergoing laparoscopic hernia repair under general anaesthesia (group B). The mean operating time was less in group A (44.8 min) compared with group B (66.6 min) (p < 0.0001). Similarly, stage 1 recovery room times were longer in group B (98.1 min) than group A (45.1 min) (p < 0.0001). Time to discharge for group A (139.1 min) was significantly shorter than group B (224.2 min) (p < 0.002), with more peri-operative complications occurring in group B and greater analgesic requirements. An open inguinal hernia repair under local infiltration block is the optimal approach for unilateral non-recurrent herniae as a day surgical procedure. These results have important cost and efficiency implications.

Rust, M., F. von Buquoy, et al. (1980). “Retroperitoneale Gefassverletzung bei gynakologischen Laparoskopien.  Anasthesie, Intensivtherapie, Notfallmedizin 15(4): 356-9.
Injury to retroperitoneal blood vessels is a rare, but very serious hazard of gynaecological laparoscopy. The role of anaesthesia in the diagnostic and therapeutic management of this iatrogenic complication is discussed. A typical case is reported.

Sabate, A. and C. Vila (1996). “Anestesia en la colecistectomia laparoscopica con CO2: comparacion del comportamiento hemodinamico y ventilatorio con dos tecnicas anestesicas diferentes.  Revista Espanola de Anestesiologia y Reanimacion 43(6): 227-8.

Safran, D., S. Sgambati, et al. (1993). “Laparoscopy in high-risk cardiac patients.  Surgery, Gynecology & Obstetrics 176(6): 548-54.
Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.

Safran, D. B. and R. Orlando, 3rd (1994). “Physiologic effects of pneumoperitoneum.  American Journal of Surgery 167(2): 281-6.
Laparoscopy requires the establishment of pneumoperitoneum in order to provide adequate surgical exposure and maintain operative freedom. Insufflation of carbon dioxide into the peritoneal cavity, however, can affect several homeostatic systems, leading to alterations in acid-base balance, blood gases, and cardiovascular and pulmonary physiology. Although these changes may be well tolerated by healthy individuals, they may increase physiologic stress in patients with pre-existing conditions, placing them at increased risk for perioperative complications. An understanding of the physiologic changes caused by carboperitoneum is therefore essential for identification of high-risk patients and formulation of appropriate treatment plans, which may include preoperative cardiorespiratory optimization and perioperative monitoring. Under optimal conditions, debilitated patients should be able to tolerate pneumoperitoneum safely and, thereafter, reap the benefits associated with minimally invasive surgery.

Salmi, A., A. Paterlini, et al. (1987). “Laparoscopia diagnostica ginecologica in anestesia locale.  Minerva Ginecologica 39(6): 437-40.

Samkoff, J. S. and B. Wu (1995). “Laparoscopic and open cholecystectomy outcomes in Medicare beneficiaries in member states of the Large State PRO Consortium.  American Journal of Medical Quality 10(4): 183-9.
To determine the incidence of laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) and some of their possible outcomes (complications, mortality, 30-day readmission) in the general population of senior citizens, we examined Medicare claims data for beneficiaries 65 years and older in eight states. Billing data for all cholecystectomies (ICD9-CM 51.22, 51.23) performed on an inpatient basis in those states on Medicare beneficiaries age 65 and older during fiscal year 1992 were examined. The incidence of LC in each state ranged from 2.1 to 3.2/1,000, whereas the incidence of OC ranged from 2.2 to 3.5/1,000. Eleven and one-half percent of LC patients suffered at least one perioperative complications, as did 21.5% of OC patients. There was considerable interstate variation in complication rates. In-hospital mortality was about five times greater of OC (4.5%) than for LC (0.9%). Patients who underwent OC were more likely (9.2%) to be readmitted within 30 days than were LC patients (7.0%). LC seems to be at least as safe as OC in the elderly population. Analyzing Medicare claims data can be useful in uncovering geographic variations in cholecystectomy practice.

Sammut, M. S. and M. L. Paes (1997). “Anaesthesia for laparoscopic cholecystectomy in a patient with Eisenmenger's syndrome [see comments].  British Journal of Anaesthesia 79(6): 810-2.
We describe the management of a patient with Eisenmenger's syndrome presenting for laparoscopic cholecystectomy. Of prime concern was maintenance of systemic vascular resistance and this was achieved using infusion of noradrenaline started before induction of anaesthesia and continued after operation. Avoidance of other factors that could potentially increase right to left shunt flow contributed to the successful outcome.

Sarac, A. M., A. O. Aktan, et al. (1996). “The effect and timing of local anesthesia in laparoscopic cholecystectomy.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 6(5): 362-6.
Although postoperative pain following laparoscopic cholecystectomy (LC) is less intense than that after open surgery, postoperative morbidity nonetheless increases with LC. The aim of this study was to investigate whether local anesthetic infiltration of trocar sites during LC decreased postoperative pain and, if so, to find the optimum timing for local anesthesia (LA). Seventy patients undergoing LC were randomized into three groups. In the first (control group, n = 25) 3 ml of 0.9% NaCl was subcutaneously infiltrated around each 5-mm trocar site, 4 ml around each 10-mm site. In the second group (n = 20), the same volume of local anesthetic was administered in the same manner prior to surgery, and in the third group (n = 25) an identical dose of local anesthetic was infiltrated at the end of surgery. A visual analog scale was given to all patients, who were asked to record their pain intensity at 1, 3, 5, 7, and 12 h postoperatively. Pethidine HCl 1 mg/kg i.m. was given to those whose pain intensities were greater than 5. The mean pain intensities were 7.6, 5.9, and 5.1 in the control, preoperative, and postoperative LA groups, respectively. In the preoperative LA group, 50% of patients and in the postoperative LA group 28% of patients required analgesics compared with 76% in the control group. The main pain intensities and analgesic requirements were significantly lower in the postoperative LA group compared with other groups. We conclude that local anesthesia during LC reduces postoperative pain and that infiltration of trocar sites following surgery offers better pain relief than local anesthetic given just before the incision.

Schirmer, B. D., J. Dix, et al. (1995). “The impact of previous abdominal surgery on outcome following laparoscopic cholecystectomy.  Surgical Endoscopy 9(10): 1085-9.
The first 1000 patients undergoing laparoscopic cholecystectomy (LC) at our institution were reviewed to investigate the impact of previous abdominal surgery on LC. The 454 patients having no previous abdominal surgery (NS) were compared to the 541 patients who had previous surgery (PS). PS patients were older, more likely to be female, and had a higher ASA risk category. PS patients had a higher incidence of wound infection, but in all other parameters of outcome, including operative duration and completion, length of hospitalization, and morbidity, there were no significant differences between PS and NS. When PS patients with previous upper abdominal surgery (PUAS, n = 59) were separately compared to the remainder of the entire patient group (NUAS, n = 936), the PUAS group was found to be older, to be more likely to be male, and to have a higher ASA risk category. PUAS patients had a longer postoperative hospitalization, and an increased incidence of intraoperative, postoperative, and total complications, readmissions to the hospital, and unrelated deaths. We conclude previous lower abdominal surgery has little impact on the outcome of patients undergoing LC while previous upper abdominal surgery is associated with increased morbidity.

Schlachta, C. M., J. Mamazza, et al. (2000). “Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections.  Surgical Endoscopy 14(3): 258-63.
BACKGROUND: To date, most large series of laparoscopic colorectal procedures have been descriptive reports that do not account for the potentially complex interaction of outcome predictors. The purpose of this study was to identify the preoperative factors that predict operative time, conversion to open surgery, and intraoperative and postoperative complications in laparoscopic colorectal surgery. METHODS: Multiple regression techniques were used to analyze 416 laparoscopic resections from a prospective database of laparoscopic colorectal procedures performed between April 1991 and April 1998. The preoperative factors considered were patient-specific (age, gender, weight) or disease-specific (diagnosis of cancer, Crohn's disease, diverticulitis, fistula). Surgical experience of < or =50 cases was also considered. Finally, all resections were represented by a combination of the following five procedure components: resections of the (a) hepatic flexure, (b) splenic flexure, (c) sigmoid, and (d) rectum, or (e) a perineal dissection. RESULTS: Patient weight, Crohn's disease, and each of the five individual procedure components incrementally lengthened operative time. Conversion to open surgery was influenced by the patient's weight, malignancy, and early experience of the surgeon. The risk of a postoperative complication was increased by the patient's age, resection of the perineum, and the presence of a fistula. No factors significantly influenced the risk of an intraoperative complication. CONCLUSIONS: Several preoperative factors that significantly affect outcomes in laparoscopic colorectal resections have been identified. Consideration of these factors may help in case selection and estimation of operating time; they should also be valuable when patients are informed of their risk of conversion and complications.

Schoeffler, P., J. E. Bazin, et al. (1993). “Anasthesie fur die laparoskopische Chirurgie.  Therapeutische Umschau 50(8): 559-63.
A thorough understanding of the physiological repercussions of the pneumoperitoneum is essential in order ot properly grasp the safety rules governing anesthesia for laparoscopic surgery. As a general rule systemic vascular resistance increases as the heart flow rate and venous return circulation decrease. Variations in the ventilation/perfusion ratio explain the origin of hypercapnia observed in patients. There is little reabsorption of CO2 from the peritoneal cavity. However, this increases considerably if CO2 is insufflated outside the peritoneum (for example during pelvic lymph-adenectomy). Anesthesia must therefore limit the intra-abdominal pressure by adequate curarization and adapt the ventilation according to the P and CO2 capnographic readings. When the surgical procedure is protracted, it may be of benefit ot the patient to reduce systemic vascular resistance by using halogenic anesthetics such as isoflurane.

Schoeffler, P. (1994). “Anesthesie pour coeliochirurgie.  Chirurgie 120(9): 518-23.

Schol, F. P., P. M. Go, et al. (1995). “Outcome of 49 repairs of bile duct injuries after laparoscopic cholecystectomy.  World Journal of Surgery 19(5): 753-6; discussion 756-7.
Treatment of bile duct injuries after laparoscopic cholecystectomy is still under discussion. The aim of this study was to evaluate the results of end-to-end or biliodigestive anastomosis for various types of bile duct injury. Patient charts of 49 (0.81%) classified bile duct injuries from a national survey of 6076 laparoscopic cholecystectomies in The Netherlands were analyzed. The median follow-up after repair was 183 days (range 14-570 days). Statistical analysis showed that an end-to-end anastomosis was preferred by the surgeons for less severe bile duct injuries and a biliodigestive repair for more severe injuries. Three patients died owing to a delayed detected bile duct injury. Twelve bile duct strictures occurred after repair, leading to a stricture rate of 25%. The time elapsed between repair and occurrence of a stricture was 134 days (range 13-270 days). The type of repair or the severity of the bile duct injury did not determine the outcome of the repair. Histologically proved cholecystitis predisposed a stricture at the repair site. It was concluded that treatment of bile duct injuries is associated with a high stricture rate at the repair site of the anastomosis. End-to-end anastomosis is mostly successful for the less severe injury detected during laparoscopic cholecystectomy. For all other cases this repair can at least be considered a temporary internal drainage procedure. The biliodigestive anastomosis can best be considered a delayed repair after a drainage procedure has resolved the local inflammatory status.

Schulte Steinberg, H., I. Euchner-Wamser, et al. (1999). “Anasthesie fur laparoskopische Eingriffe.  Anaesthesist 48(10): 755-68.

Schultz, L. S. (1995). “Laparoscopic vs inguinal hernia repairs. Outcomes and costs.  Surgical Endoscopy 9(12): 1307-11.

Schulze, S., K. M. Lyng, et al. (1999). “Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery: comparison between carbon dioxide pneumoperitoneum and gasless laparoscopy.  Archives of Surgery 134(10): 1112-8.
HYPOTHESIS: Gasless laparoscopy produces smaller cardiopulmonary and systemic changes than carbon dioxide (CO2) laparoscopy during colonic surgery. DESIGN: Prospective randomized trial. SETTING: Department of Surgery in a university hospital. PATIENTS: Twenty-two patients scheduled for laparoscopic colonic resection; 5 patients were excluded because of conversion to open surgery (N = 17). INTERVENTIONS: Patients were randomized to either gasless (n = 9) or conventional CO2 (n = 8) surgery. MAIN OUTCOME MEASURES: Intraoperative assessment of hemodynamic factors and pulmonary function, and postoperative assessment of pain, pulmonary function, convalescence, and various injury factors were done several times until 30 days after surgery. Surgical complications were noted. RESULTS: Descending aorta blood flow after 30 minutes (P=.03) and heart rate after 150 minutes were higher in the CO2 group (P=.009). Central venous pressure, PaCO2 inspiration pressure, and end tidal CO2 level were significantly higher in the CO2 group (P = .05, .03, .04, and .01, respectively). Patients in the CO2 group had less pain during mobilization and coughing (P = .008 and .006, respectively), and were significantly more fatigued (P = .04). No other important differences were observed in intraoperative hemodynamic factors, postoperative convalescence, immunocompetence, or pulmonary function. CONCLUSION: No clinically important differences in cardiovascular and systemic response were observed between patients undergoing CO2 or gasless laparoscopy for colonic disease.

Schurz, J. W., M. E. Arregui, et al. (1995). “Open vs laparoscopic hernia repair. Analysis of costs, charges, and outcomes.  Surgical Endoscopy 9(12): 1311-7.

Schwenk, W., B. Bohm, et al. (1998). “Postoperative pain and fatigue after laparoscopic or conventional colorectal resections. A prospective randomized trial.  Surgical Endoscopy 12(9): 1131-6.
BACKGROUND: Conventional colorectal resections are associated with severe postoperative pain and prolonged fatigue. The laparoscopic approach to colorectal tumors may result in less pain as well as less fatigue, and may improve postoperative recovery after colorectal resections. METHODS: Sixty patients were included into a prospective randomized trial to determine the influence of laparoscopic (n = 30) or conventional (n = 30) resection of colorectal tumors on postoperative pain and fatigue. Major endpoints of the study were dose of morphine sulfate during patient-controlled analgesia (PCA), visual analog scale for pain while coughing (VASC), and visual analogue scale for fatigue (VASF). Efficacy of pain medication was assessed by visual analogue score at rest (VASR). RESULTS: Preoperative age, sex, stage, and localization of tumors were comparable in both groups. The PCA dose of morphine given immediately after surgery until postoperative day 4 was higher in the conventional group (median, 1.37 mg/kg; 5-95 percentile 0.71-2. 46 mg/kg) than the laparoscopic group (0.78 mg/kg; 0.24-2.38 mg/kg, p < 0.01). Postoperative VASR was comparable between both groups, but VASC was higher from the first to the seventh postoperative day (p < 0.01). Postoperative fatigue was higher after conventional than after laparoscopic surgery from the second to the seventh day (p < 0. 05). CONCLUSIONS: This study confirms that analgetic requirements are lower and pain is less intense after laparoscopic than after conventional colorectal resection. Patients also experience less fatigue after minimal invasive surgery. Because of these differences, the duration of recovery is shortened, and the postoperative quality of life is improved after laparoscopic colorectal resections.

Seed, R. F., T. F. Shakespeare, et al. (1970). “Carbon dioxide homeostasis during anaesthesia for laparoscopy.  Anaesthesia 25(2): 223-31.

Sfez, M. (1994). “Anesthesie pour coeliochirurgie en pediatrie.  Annales Francaises d Anesthesie et de Reanimation 13(2): 221-32.
The increasing use of laparoscopic surgery in children is associated with the enlargement of the spectrum of indications to appendicectomy, extramucosal pylorotomy and cure of oesophageal reflux. It is also linked with new problems, mainly due to physiologic modifications elicited by pneumoperitoneum and patient's posture. Although sufficient data are not yet available, the respiratory and cardiovascular modifications are probably similar to those occurring in adults, at least in children more than 4-month-old, as long as the intra-abdominal pressure remains under 15 mmHg. The use of higher intra-abdominal pressures has not been reported in children. In this case, the cardiovascular changes consist mainly in an increase in arterial pressure. In some children, non specific decreases in heart rate and in blood pressure can be observed. The latter can be elicited by a surgical complication, hypovolaemia, head-elevated position or deep anaesthesia. In the newborn and infant under 6 months, intra-abdominal pressures of 15 mmHg or more carry a risk of low cardiac output due to a decrease in contractility and compliance of the left ventricle. In this group of age it is therefore recommended to establish a pressure not higher than 6 mmHg. Moreover, in these very young children, the risk for reopening of the right-left shunts can result in heart insufficiency and systemic gas embolism. Peroperative respiratory changes include an increase in PetCO2 and more rarely a decrease in SaO2. The interpretation of the former depends on the site of gas sampling in the anaesthetic system. It is easily controlled by an increased minute ventilation. Various causes, such as bronchial intubation, inhalation of gastric contents or gas embolism, can decrease SaO2. Contra-indications for laparoscopic surgery include hypovolaemia, heart diseases, increased intracranial pressure and alveolar distension. Therefore newborns are patients at high risk in so far as their foramen ovale or their ductus arteriosus is patent, the pulmonary arterial resistances remain increased and a bronchodysplasia is existing. In some cases a special disease is often associated. As an example recurrent bronchitis or asthma is associated with an oesophageal reflux and a sickle-cell disease in patients with cholelithiasis. These patients require special pre-, per- and postoperative care for prevention of complications. Anaesthesia for laparoscopic surgery does not require a major extension of the usual security regulations. Special attention must be paid to arterial pressure. Therefore end-expiratory concentration of the halogenated anaesthetic agent should not be kept higher than 1.5 times the MAC related to the age during maintenance of anaesthesia.(ABSTRACT TRUNCATED AT 400 WORDS)

Sha, M., J. Katagiri, et al. (2000). “[A nationwide survey of anesthesia for laparoscopic and thoracoscopic surgeries].  Masui - Japanese Journal of Anesthesiology 49(1): 75-9.
This is the report the first nationwide survey of anesthetic management for laparoscopic and thoracoscopic surgeries. We mailed a questionnaire to anesthetists of 133 hospitals in Japan and 74 completed questionnaires were returned. The number of intra-abdominal and thoracic surgical procedures has been increasing. General anesthesia was used in all cases for endoscopic surgery. The double lumen tube was selected in 79% of patients with pneumothorax for the endobronchial intubation. Patients for the laparoscopic cholecystectomy (LC) were given various types of anesthetics. Thirty-two percent of patients who underwent LC was anesthetized with inhalation anesthetics combined with epidural anesthesia for the early ambulance and postoperative pain control. The maximum length of time for LC surgery was 12.5 hr. Complications related to laparoscopic surgery included bile duct injuries in 72 patients, postoperative bleeding in 32 patients, vascular injuries in 29 patients, pneumothorax in 26 patients, bronchial intubation in 17 patients, gas embolism in 11 patients, bowel injuries in 9 patients and postoperative ileus in 7 patients. Administering anesthesia for endoscopic procedures requires precise knowledge of the surgical procedures, physiologic changes and complications of the pneumoperitoneum, and one lung ventilation.

Shankar, K. B., A. Y. Kumar, et al. (1992). “Ventilatory effects of laparoscopy under general anaesthesia [letter; comment].  British Journal of Anaesthesia 69(5): 542-3.

Shantha, T. R. and J. Harden (1991). “Laparoscopic cholecystectomy: anesthesia-related complications and guidelines.  Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 1(3): 173-8.
Although laparoscopic cholecystectomy is gaining worldwide acceptance, it is associated with some nonsurgical complications. We report the occurrence of massive subcutaneous emphysema, bradycardia, malfunctioning oximeters, pulmonary edema, endobronchial intubation, and the patient falling from the table with change in position during this surgical procedure. Choice of anesthetics, commonly occurring anesthetic complications, and management of these problems during laparoscopic surgery are discussed.

Simpson, R. B. and D. Russell (1999). “Anaesthesia for daycase gynaecological laparoscopy: a survey of clinical practice in the United Kingdom.  Anaesthesia 54(1): 72-6.
Gynaecological laparoscopy is a daycase procedure that can be associated with significant morbidity and patients may require admission to hospital for overnight stay. Following a decision to administer intraperitoneal bupivacaine routinely to such patients in our day surgery unit, we wished to establish whether this was routine practice elsewhere. We therefore carried out a postal survey of consultant anaesthetists in the UK who regularly anaesthetise patients undergoing daycase gynaecological laparoscopy, addressing a number of clinical issues. The results of the survey are presented, discussed and compared with published advice.

Skacel, M., P. Sengupta, et al. (1986). “Morbidity after day case laparoscopy. A comparison of two techniques of tracheal anaesthesia.  Anaesthesia 41(5): 537-41.
A comparison was made of postoperative morbidity following two anaesthetic techniques for day case laparoscopies. One group of patients was allowed to breathe spontaneously after intubation under suxamethonium. The second group received atracurium and their lungs were mechanically ventilated. Patients in the controlled ventilation group experienced significantly less severe sore throats and muscle pain in the first 24 hours postoperatively than the patients who breathed spontaneously. Both techniques proved to be safe and are suitable for day case laparoscopy. The safety of patients is discussed in relation to the choice of anaesthetic technique used.

Snabes, M. C. and A. N. d. Poindexter (1991). “Laparoscopic tubal sterilization under local anesthesia in women with cyanotic heart disease.  Obstetrics & Gynecology 78(3 Pt 1): 437-40.
Laparoscopic tubal sterilization under local anesthesia with intravenous sedation has been shown to be a safe procedure. However, the use of laparoscopy in patients with cyanotic cardiovascular disease is controversial and is generally contraindicated. Five women were referred with uncorrectable cyanotic heart disease and pulmonary hypertension. The mean preoperative arterial oxygen pressure was 56.2 +/- 5 mmHg (N = 5). After cardiology and cardiovascular anesthesia consultation and clearance, the patients underwent laparoscopic sterilization with Silastic rings under local anesthesia using direct trocar entry. Continuous hemodynamic monitoring and pulse oximetry were employed. The patients were kept in the intensive care unit or the hospital for 24 hours for monitoring, and all did well. This hospital for 24 hours for monitoring, and all did well. This small retrospective series demonstrates that laparoscopic sterilization under local anesthesia is a sterilization technique that may be suitable and safe for such patients when appropriate monitoring is performed. Tubal sterilization may be the contraceptive method of choice in women with heart disease when pregnancy is contraindicated.

Song, D., C. W. Whitten, et al. (1998). “Antiemetic activity of propofol after sevoflurane and desflurane anesthesia for outpatient laparoscopic cholecystectomy [see comments].  Anesthesiology 89(4): 838-43.
BACKGROUND: Controversy exists regarding the effectiveness of propofol to prevent postoperative nausea and vomiting. This prospective, randomized, single-blinded study was designed to evaluate the antiemetic effectiveness of 0.5 mg/kg propofol when administered intravenously after sevoflurane- compared with desflurane-based anesthesia. METHODS: Two hundred fifty female outpatients undergoing laparoscopic cholecystectomy were assigned randomly to one of four treatment groups. All patients were induced with intravenous doses of 2 mg midazolam, 2 microg/kg fentanyl, and 2 mg/kg propofol and maintained with either 1-4% sevoflurane (groups 1 and 2) or 2-8% desflurane (groups 3 and 4) in combination with 65% nitrous oxide in oxygen. At skin closure, patients in groups 1 and 3 were administered 5 ml intravenous saline, and patients in groups 2 and 4 were administered 0.5 mg/kg propofol intravenously. Recovery times were recorded from discontinuation of anesthesia to awakening, orientation, and readiness to be released home. Postoperative nausea and vomiting and requests for antiemetic rescue medication were evaluated during the first 24 h after surgery. RESULTS: Propofol, in an intravenous dose of 0.5 mg/kg, administered at the end of a sevoflurane-nitrous oxide or desflurane-nitrous oxide anesthetic prolonged the times to awakening and orientation by 40-80% and 25-30%, respectively. In group 2 (compared with groups 1, 3, and 4), the incidences of emesis (22% compared with 47%, 53%, and 47%) and requests for antiemetic rescue medication (19% compared with 42%, 50%, and 47%) within the first 6 h after surgery were significantly lower, and the time to home-readiness was significantly shorter in duration (216 +/- 50 min vs. 249 +/- 49 min, 260 +/- 88 min, and 254 +/- 72 min, respectively). CONCLUSIONS: A subhypnotic intravenous dose of propofol (0.5 mg/kg) administered at the end of outpatient laparoscopic cholecystectomy procedures was more effective in preventing postoperative nausea and vomiting after a sevoflurane-based (compared with a desflurane-based) anesthetic.

Soper, N. J. (1995). “The outcomes of elective laparoscopic and open cholecystectomies [editorial; comment].  Journal of the American College of Surgeons 180(2): 222-3.

Spivak, H., I. Nudelman, et al. (1999). “Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation.  Surgical Endoscopy 13(10): 1026-9.
BACKGROUND: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. METHODS: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. RESULTS: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 +/- 7 min for unilateral hernia and 65 +/- 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. CONCLUSIONS: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

Stage, J. G., S. Schulze, et al. (1997). “Prospective randomized study of laparoscopic versus open colonic resection for adenocarcinoma [see comments].  British Journal of Surgery 84(3): 391-6.
BACKGROUND: Laparoscopic techniques have been evaluated for many operations, but retrospective and prospective studies have failed to show these techniques to be superior to open operations in all patients with colorectal disease. This study compares laparoscopic and open colonic resection in a randomized fashion with special reference to outcome, complications and immunomodulation. METHODS: The clinical course, assessment of convalescence parameters, immunofunction and pathological evaluation of the operative specimen were compared in 34 patients with colonic adenocarcinoma. The patients were randomized to either laparoscopic surgery (group 1, n = 18) or open surgery (group 2, n = 16). As five patients were excluded the number of patients was 15 in group 1 and 14 in group 2. RESULTS: Patients in group 1 were discharged earlier (P < 0.05) and suffered less pain (P < 0.01 at rest, P < 0.05 during coughing and mobilization). Surgery was equally radical in the two groups. Intraoperative bleeding, postoperative reduction in pulmonary function, and level of fatigue were identical in the two groups. The immunodepression was more pronounced in patients in group 1 (P < 0.01). CONCLUSION: Laparoscopic colonic resection is an acceptable and safe alternative to open procedures; the differences between the two techniques are not marked.

Stanton, J. M. (1991). “Anesthesia for laparoscopic cholecystectomy [letter; comment].  Anaesthesia 46(4): 317.

Sternberg, A., R. Alfici, et al. (1998). “Laparoscopic surgery and splanchnic vessel thrombosis.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 8(2): 65-8.
We report a case of fatal mesenteric artery thrombosis following laparoscopic cholecystectomy in a 60-year-old hypertensive woman, whose preoperative complaints were not typical of calculous biliary disease. Two previous case reports have associated laparoscopic cholecystectomy and acute intestinal ischemia; one of these patients died. Experimental and clinical data indicate that carbon dioxide pneumoperitoneum reduces splanchnic blood flow through several mechanical and physiologic mechanisms. Consequently, we believe that, when laparoscopic surgery is contemplated, physicians and patients should be aware of the risk of splanchnic vessel thrombosis, especially when certain pre-existing conditions are present (e.g., impairment of splanchnic vessel flow, hypercoagulable states, etc.). For such high-risk patients, especially when the planned laparoscopic procedure may be lengthy, gasless or low-pressure laparoscopic surgery, or even reversion to traditional open surgery should be considered.

Stratan, I. and E. Tarcoveanu (1995). “Anestezia in chirurgia laparoscopica.  Revista Medico-Chirurgicala a Societatii de Medici Si Naturalisti Din Iasi 99(3-4): 41-51.
The use of laparoscopic techniques in general surgery is increasing in popularity. The anesthesiologist's goals during laparoscopic surgery are hemodynamic and respiratory stability, appropriate muscle relaxation, control of diaphragmatic excursion, intraoperative and postoperative patient analgesia. The implications are that the anesthesiologist must use a technique that not only allows for optimal surgical conditions but also provides intraoperative patient comfort and safety and a rapid postoperative anesthetic recovery. Laparoscopy is not a benign procedure. It is associated with major and minor surgical and non surgical complications, including death. Therefore, it is imperative that the anesthesiologist and surgeon thoroughly understand the physiopathology and immediate treatment of these potential complications and communicate effectively about their management.

Stuttmann, R., A. Paul, et al. (1995). “Preoperative morbidity and anaesthesia-related negative events in patients undergoing conventional or laparoscopic cholecystectomy [see comments].  Endoscopic Surgery & Allied Technologies 3(4): 156-61.
Laparoscopic cholecystectomy is the standard method for surgical treatment of non-malignant gall bladder disease. Well tolerated in otherwise healthy patients, it remains however, questionable whether the laparoscopic procedure in patients with severe pre-existing morbidity is associated with a higher incidence of negative intraoperative events than open cholecystectomy. Therefore, the incidence of negative intraoperative events was prospectively investigated in a series of 1,367 patients (319 with open cholecystectomy and 1,048 with laparoscopic cholecystectomy) who were analysed for occurrence of events such as hypertension, hypotension, arrhythmia, unusual bleeding and transfusion requirement, regurgitation or aspiration of gastric content and respiratory disorders. For further analysis the patients undergoing each operative procedure were divided into two subgroups with either preoperative ASA physical status I and II or III and IV. The study groups were comparable in sex and age. There were no intraoperative deaths. The frequency of hypertension, hypotension or arrhythmia alone and in combination was similar in both groups. The need for intervention was significantly more frequent in ASA class I/II patients with laparoscopic cholecystectomy. Respiratory disorders were rare. There was a significantly higher incidence of postoperative ventilatory support in patients with conventional cholecystectomy. Transfusion was required significantly less often in patients with laparoscopic cholecystectomy (0.19% versus 15.36%). CO2-pneumoperitoneum led to severe circulatory alterations in 7 healthy patients. The most severe negative event was a cardiac arrest in 1 female patient who was successfully resuscitated without any sequelae. In ASA-class III and IV patients intraoperative negative events were equally frequent and independent of the procedure. Severe preoperative morbidity per se seems to be no contraindication for laparoscopic cholecystectomy.

Stuttmann, R. (1995). “Anaesthesia for laparoscopic cholecystectomy in high-risk patients [editorial; comment].  Endoscopic Surgery & Allied Technologies 3(4): 154-5.

Suarez Gonzalo, L., E. Vilchez Llopis, et al. (1994). “Anestesia y cirugia laparoscopica.  Medicina Clinica 102(12): 476-7.

Subba, B., I. Gupta, et al. (1991). “Studies of cardiovascular and arterial blood gas changes during carbon dioxide pneumoperitoneum for laparoscopic sterilization under general anaesthesia versus local anaesthesia.  Asia-Oceania Journal of Obstetrics & Gynaecology 17(1): 31-5.
This study was conducted to evaluate the different change in arterial blood gases and cardiovascular system in 50 healthy females during laparoscopic sterilization procedure performed under general or local anaesthesia. Women who had laparoscopic sterilization under local anaesthesia, showed an increase in respiratory rate by 17% in response to hypercarbia produced by carbon dioxide insufflation. Subjects undergoing laparoscopic sterilization under general anaesthesia showed significant rise in pulse rate by 6% and systolic and diastolic blood pressure by 8% and 14%, respectively. Also arterial blood gas analysis showed increase in PaO2 by 22.7% which was highly significant. However, PaCO2, pH and base were maintained within normal limits as compared to the other group done under local anaesthesia, where no changes were observed.

Suzuki, K. and K. Fujita (1997). “[Laparoscopic surgery for renal carcinomas].  Gan to Kagaku Ryoho [Japanese Journal of Cancer & Chemotherapy] 24(5): 544-50.
We reviewed the indications and clinical outcome of laparoscopic nephrectomy for renal carcinomas. The most important aspect of laparoscopic nephrectomy for renal carcinomas is complete tumor removal. En bloc dissection of the tumor is easily obtained by laparoscopic surgery. However, tissue morcellation for tumor retrieval is still controversial. The indications for laparoscopic nephrectomy should be limited to early, solitary, small tumors (tumor size less than 5-6 cm in diameter) with no hilar lymph node involvement, or to cytoreduction surgery on solitary tumors (less than 7-8 cm in size). Gasless laparoscopy-assisted nephrectomy with minilaparotomy is preferable for the treatment of renal carcinomas because the renal vessels can be safely prepared under direct vision, the tumor can be removed en bloc, and both hilar and paraaortic lymph node dissection can be performed.

Swann, D. G., H. Spens, et al. (1993). “Anaesthesia for gynaecological laparoscopy--a comparison between the laryngeal mask airway and tracheal intubation.  Anaesthesia 48(5): 431-4.
In a single-blind, randomised, controlled study, we compared two anaesthetic techniques in 60 patients undergoing gynaecological laparoscopy. In the first group, ventilation was controlled, after paralysis and tracheal intubation. In the second group, a laryngeal mask airway was inserted and spontaneous or assisted ventilation allowed. There were no clinically significant differences in the intra-operative conditions of the two groups, although the procedure was quicker in the second group. The only significant difference in morbidity was a greater incidence of nausea and vomiting in the second group in the first 4 h after operation. We conclude that use of the laryngeal mask airway is an acceptable technique for elective gynaecological laparoscopy, in patients who are at low risk of regurgitation.

Swanstrom, L. L., B. A. Jobe, et al. (1999). “Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication.  American Journal of Surgery 177(5): 359-63.
BACKGROUND: The addition of an antireflux procedure to all giant paraesophageal hernia (PEH) repairs remains controversial. In addition there are no series evaluating the impact of hernia repair and fundoplication on esophageal physiology. This study examines the outcomes of PEH repair with fundoplication and examines the results of preoperative and postoperative motility and pH testing. METHODS: An analysis of a data base containing all patients undergoing PEH repair between September 1994 and December 1997. Patients underwent laparoscopic sac reduction, hernia repair, and fundoplication. Follow-up was performed under protocol and consisted of a symptoms assessment form, 24 hour pH, and manometry. RESULTS: Fifty-two patients (mean age 63) were treated: 59% complained of heartburn, 50% dysphagia, and 27% chest pain; 26% had a body motility disorder. Complete manometry was not possible in 41%. Mean operative time was 4 hours. There were 48 Nissen, 4 Toupet, and 7 Collis-Nissen procedures. There were 3 (6%) intraoperative and 3 (6%) postoperative complications. There were no operative mortalities. Hospital stay was 3 days (1 to 29). Late follow-up (18 months) was available for 96% of patients and showed dysphagia in 6%, heartburn in 10%, and recurrent herniation in 8%. Objective postoperative testing was available in 61 % of the patients at a mean of 8 months. Twenty-four hour pH tests were abnormal in 4 patients (2 asymptomatic and 2 with a Collis). Lower esophageal sphincter pressures increased 63% and functioned well in 71% of patients; 50% of preoperative motility disorders improved following repair. CONCLUSIONS: Laparoscopic repair of giant PEH is technically difficult but feasible. Routine addition of a fundoplication is advised, as preoperative testing is unreliable for a selective approach and fundoplications are well tolerated in this group of patients.

Szalay, S., P. Kemeter, et al. (1982). “The behaviour of LH, FSH, PRL, T, P, estradiol and cortisol under different kinds of general anesthesias during laparoscopic oocyte recovery for in vitro fertilization.  European Journal of Obstetrics, Gynecology, & Reproductive Biology 14(1): 37-48.

Taddei, F., P. Pedrona, et al. (1992). “L'anestesia per la colecistectomia laparoscopica.  Acta Bio-Medica de l Ateneo Parmense 63(3-4): 207-12.
Alterations in the serological, pulmonary and cardiocirculatory parameters, potentially determined by CO2 pneumo-peritoneum during laparoscopic cholecystectomy, require careful intraoperative evaluation. With the aim of verifying the real entity of these alterations, an experience is reported relating to 76 of the 303 patients undergoing laparoscopic cholecystectomy during 14 months. During surgery, besides an obvious increase in pO2, a slight hypercarbia and a slight decrease in pH were observed, which required pharmacological intervention in only 5 cases. In no case did the respiratory and haemodynamic alterations observed necessitate the conversion into laparotomy. This initial experience gives us reason to conclude that careful monitoring of the respiratory parameters leads to an adequate anaesthesiological conduct, and thus facilitates the completion of laparoscopic procedures.

Tagaya, N., J. Kita, et al. (1995). “Laparoscopic transabdominal preperitoneal herniorrhaphy using abdominal wall-lifting method under regional anesthesia: a preliminary report.  Journal of Laparoendoscopic Surgery 5(4): 215-20.
This report describes a laparoscopic transabdominal preperitoneal herniorrhaphy of groin hernias using an abdominal wall-lifting method under regional anesthesia as compared with pneumoperitoneum under general anesthesia. The series of studies involved the repair of 20 groin hernias; 7 hernias were direct, 11 were indirect, and 2 were femoral. These included 7 recurrent, 1 incarcerated, and 4 bilateral hernias. There were no intraoperative complications, and both procedures required no conversion to open surgery. There are no significant differences between the two groups in operative time and postoperative hospital stay. The only postoperative complication of our procedure was temporary inguinal pain in 2 cases. The follow-up period ranged from 8 to 17 months. To date, no recurrence has developed. We conclude that our procedure is a safe, technically feasible, and useful method to perform laparoscopic herniorrhaphy for groin hernias.

Takagi, S. (1998). “Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatectomy.  Surgical Endoscopy 12(5): 427-31.
BACKGROUND: Laparoscopy under carbon dioxide (CO2) pneumoperitoneum has many advantages. However, the risks of CO2 pneumoperitoneum during laparoscopic hepatectomy (LH) have not been defined. METHODS: The hemodynamics of the hepatic vein were examined during CO2 pneumoperitoneum both pre- and posthepatectomy in eight pigs. Portal blood flow was measured with Doppler ultrasound during laparoscopic cholecystectomy in 10 human patients. RESULTS: Experimentally, elevated intraabdominal pressure (IAP) with CO2 insufflation produced significant increases in CO2 partial pressure and echogenicity of the hepatic vein in the posthepatectomy group. Clinically, elevated IAP caused significant narrowing of the portal vein and significant decreases in portal blood velocity. The mean portal flow was significantly decreased with elevation of IAP >10 mmHg. CONCLUSIONS: LH with CO2 pneumoperitoneum may lead to embolism caused by CO2 bubbling through the hepatic vein. Elevated IAP may cause a decrease in hepatic blood flow and induce severe liver damage, especially in patients with poor liver function. Gasless laparoscopy using abdominal wall lifting should be employed in LH to avoid the risks of CO2 embolism and liver damage.

Takrouri, M. S. (1999). “Anesthesia for laparoscopic general surgery. A special review.  Middle East Journal of Anesthesiology 15(1): 39-62.
Laparoscopy employs highly technical equipment, and the surgeon needs special training in the technique. He should master in-depth knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all, the surgeon must adhere rigidly to guidelines for appropriate technique, and deviation will most assuredly result in complications and even death. General surgery application of laparoscopy followed a wealth of medical experience from gynecological laparoscopies, which declared the technique as safe, reduced hospital stay with little pain and disfigurement. Laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy. Soon many procedures were done using this new technique in adults and children. Anesthesia for laparoscopy has been established with a broad usage of agents and techniques. General anesthesia using balanced anesthesia technique including intravenous induction agents like: thiopentone, propofol, etomidate, and inhalational agents like nitrous oxide, isoflurane, desflurane, has been reported. Variety of muscle relaxants including succinylcholine, mivacurium, atracurium, vecuronium aiming at rapid recovery and cardiovascular stability. Total intravenous anesthesia using agnets like propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy. Epidural anesthesia was considered as safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression. As for pain relief, many methods have been used. The pain mechanism is variable and analgesia requirement is less than those of open surgery. Cited complications include pneumothorax, cardiovascular collapse, surgical emphysema and pneumo-peritoneum complications. Among the implication for anesthesia care, the importance of preoperative monitoring, careful positioning and observation during the insufflation of carbon dioxide. The drive to have short term admission to hospital would make it imperative to use short acting rapidly eliminated anesthetic drugs, avoidance of vomiting and pain by proper use of modern anti-emetics and NSAID to help in avoidance of narcotics or reduction of the requirement.

Targarona, E. M., J. J. Espert, et al. (1999). “Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery.  Surgical Endoscopy 13(6): 559-62.
BACKGROUND: Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach. METHODS: Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400-1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups. RESULTS: Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 +/- 2.4 days vs. 4 +/- 2.3 days; p < 0. 05). CONCLUSIONS: In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.

Taylor, E., R. Feinstein, et al. (1992). “Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide contraindicated?  Anesthesiology 76(4): 541-3.
Since it has been suggested that the use of nitrous oxide (N2O) may contribute to bowel distention, we evaluated the effects of N2O on operating conditions during laparoscopic cholecystectomy in 50 healthy patients using a double-blind protocol design. All patients received the same preanesthetic medication (midazolam, 2 mg intravenously) and induction of anesthesia consisted of intravenously administered fentanyl 1.5 micrograms.kg-1, thiopental 4-6 mg.kg-1, and a nondepolarizing muscle relaxant. For maintenance of anesthesia, patients were randomly assigned to one of two treatment groups: group 1 (n = 26) received isoflurane with 70% N2O in oxygen (O2), whereas group 2 (n = 24) received isoflurane in an air/O2 mixture. The surgeon (blinded to the anesthetic technique) estimated the degree of technical difficulty before beginning the operation using a five-point scale. At 15-min intervals throughout the operation, the surgeon was asked to evaluate both "overall operating conditions" and degree of "bowel distension" using independent five-point scales. At the end of the operation, the surgeon was asked whether or not N2O had been used as part of the anesthetic technique. There were no significant intraoperative differences between the two groups with respect to operating conditions or bowel distension. More importantly, there was no time-related change in either variable during the course of the operation. Finally, the incidence of postoperative nausea and vomiting was similar in both treatment groups. The surgeon was able to correctly determine that N2O had been administered only 44% of the time. Thus, N2O had no clinically apparent deleterious effects during laparoscopic cholecystectomy.

Terrosu, G., A. Donini, et al. (1996). “Laparoscopic splenectomy in the management of hematological diseases. Surgical technique and outcome of 17 patients [see comments].  Surgical Endoscopy 10(4): 441-4.
After being successfully applied to other intraabdominal organs, the laparoscopic approach has been applied to the spleen since 1991. The experience with 17 cases of laparoscopic splenectomy performed due to immune thrombocytopenia purpura (10 instances), hereditary spherocytosis (2 cases), and Hodgkin's disease where the staging was done according to Standford (5 cases), have been reported. With the patient in anti-Trendelenburg position, and the surgeon between the patient's legs, four or five trocars are introduced into the upper abdominal quadrants and the spleen hilum is isolated. Hilar vessels are dissected and ligated with a surgical stapler. A plastic bag is introduced into the abdomen cavity and the spleen is slipped inside; it is then extracted through an umbilical incision after morcellation. Advantages of the open operation include a decrease in postoperative pain, a decrease in pulmonary sequelae, a reduced incidence of subphnic abscesses, and cosmetic advantages. The decrease of postoperative sequelae reduces hospitalization and costs, which are higher for the operation itself (materials and staff's training).

Tobias, J. D., G. W. Holcomb, 3rd, et al. (1994). “General anesthesia by mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children.  Journal of Laparoendoscopic Surgery 4(6): 379-84.
We prospectively examined the cardiorespiratory changes seen with general anesthesia by mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. Anesthesia consisted of isoflurane in 50% oxygen/air and a caudal epidural block. The patient was allowed to ventilate spontaneously without assistance. Baseline measurements of heart rate, systolic/diastolic blood pressure (BP), end-tidal CO2 (PETCO2), tidal volume, respiratory rate, and oxygen saturation were recorded every 1 min for 5 min before the start of laparoscopy and every minute during the laparoscopic procedure. A total of 20 patients were enrolled in the study, ranging in age from 15 to 80 months (mean 40.8 months) and in weight from 10.5 to 27 kg (mean 15.9 kg). The length of the laparoscopy varied from 3 to 18 min (mean 6.9 min). No significant changes (increase or decrease of 20% from baseline) of heart rate or BP occurred. Oxygen saturation remained at 98%-100% throughout the procedure in all patients. The baseline tidal volume before the start of laparoscopy was 6.27 +/- 1.9 mL/kg and increased to 7.3 +/- 2.2 mL/kg during laparoscopy (p = 0.01). The baseline respiratory rate was 27.7 +/- 7.0 breaths/min and increased to 33.5 +/- 7.2 breaths/min during laparoscopy (p = 0.0001). PETCO2 increased from a baseline value of 37.5 +/- 6.5 to 44.6 +/- 6.8 mm Hg (p = 0.0001). The increase in PETCO2 was 10 or greater in 3 patients and exceeded 50 mm Hg in 3 patients, with a maximum value of 66 torr.(ABSTRACT TRUNCATED AT 250 WORDS)

Tobias, J. D., G. W. Holcomb, 3rd, et al. (1996). “General anesthesia using the laryngeal mask airway during brief, laparoscopic inspection of the peritoneum in children.  Journal of Laparoendoscopic Surgery 6(3): 175-80.
The authors prospectively examined the cardiorespiratory changes seen with general anesthesia using the laryngeal mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. Anesthesia consisted of halothane in 50% oxygen/air and a caudal epidural block. The patient was allowed to ventilate spontaneously without assistance. Baseline measurements of heart rate, systolic blood pressure (SBP), end-tidal CO2 (ETCO2), tidal volume, respiratory rate, and oxygen saturation were recorded every 1 min for 5 min prior to the start of laparoscopy and every minute during the laparoscopic procedure. A total of 15 patients were enrolled in the study ranging in age from 15 to 90 months (35.5 +/- 23.8 months) and in weight from 10 to 26.4 kg (14.9 +/- 4.9 kg). The length of the laparoscopy varied from 3 to 9 min (6.1 +/- 2.1 min). Although clinically insignificant, there was an increase in the heart rate from a baseline value of 141 +/- 9 to 148 +/- 9 beats/min (p = 0.0016) and in the SBP from a baseline value of 97 +/- 6 mm Hg to 101 +/- 7 mm Hg (p = 0.0087). The baseline tidal volume prior to the start of laparoscopy was 5.2 +/- 1.1 mL/kg and increased to 6.4 +/- 1.4 mL/kg during laparoscopy (p < 0.0001) while the respiratory rate increased from 32 +/- 4 to 40 +/- 6 breaths/min (p < 0.0001). ETCO2 increased from a baseline value of 47 +/- 6 to 53 +/- 6 torr (p = 0.0059). The maximum value of the ETCO2 was 55 torr or greater in 6 patients, exceeded 60 torr in 3 patients, with a maximum value of 63 torr. The increased ETCO2 returned to baseline within 2 to 7 min (4.7 +/- 1.5 min) following completion of the laparoscopy. There was no significant change in oxygen saturation. Our initial experience suggests that general anesthesia may be provided using the laryngeal mask during brief laparoscopic inspection of the peritoneum.

Todesco, S., M. Muraca, et al. (1977). “Electrocardiogram, arterial and central venous pressure during laparoscopy under local anaesthesia.  Endoscopy 9(2): 82-6.
Cardiovascular hazards of laparoscopy performed under local anaesthesia and with room air pneumoperitoneum are not well known. Therefore we have recorded electrocardiogram, arterial blood pressure and central venous pressure in 63 consecutive liver patients undergoing this procedure. Electrocardiographic changes were found in 34 cases, and consisted in transistory tachycardia and bradycardia, ectopic supraventricular and ventricular beats, ST segment depression and flattening of T wave. Blood pressure did not change significantly, but five patients had transitory hypotension during the procedure. Central venous pressure did not vary immediately after inflation, but a significant increase was found during the performance of laparoscopy and it was still observed after deflation. Our findings show that cardiovascular changes during laparoscopy under local anaesthesia are minimal, and that they are probably due to neurogenic factors.

Topal, B., R. Aerts, et al. (1999). “The outcome of major biliary tract injury with leakage in laparoscopic cholecystectomy.  Surgical Endoscopy 13(1): 53-6.
BACKGROUND: Concern has been expressed regarding the increased rates of biliary tract injury (BTI) at laparoscopic cholecystectomy. The aim of the present investigation was to analyze the outcome of laparoscopic biliary tract injury with leakage. METHODS: Sixteen patients having major laparoscopic BTI with leakage were treated. Thirteen of them were referred to our institution for further treatment. The follow-up was complete and focused on clinical outcome and biochemical analysis. RESULTS: Eight BTI were identified at the time of laparoscopic cholecystectomy, and the procedure was converted to a laparotomy. In eight additional patients, BTI was recognized postoperatively. In this group one patient died because of lately diagnosed biliary peritonitis, whereas in the seven surviving patients nine attempts to repair the BTI and eight other interventions were performed. In the conversion group 14 attempts to repair the BTI and 11 other interventions were needed to completely solve the problems. Final restoration of the BTI was done by Roux-en-Y hepaticojejunostomy in 11 patients and suture repair with T-tube drainage of the bile duct in 4. During a median follow-up time of 63 months, three patients suffered from recurrent segmental cholangitis. In the other patients, neither clinical nor biochemical evidence of biliary disease has been found up to this writing. CONCLUSIONS: Laparoscopic BTI has a high morbidity and mortality rate that seems comparable to BTI at open cholecystectomy. The number of attempts to repair the BTI as well as additional interventions is too high, but in this patient series the final outcome seemed to be similar after BTI recognized during and after laparoscopic cholecystectomy.

Tortosa, J. A. and J. Hernandez-Palazon (1997). “Anaesthesia for laparoscopic cholecystectomy in myasthenia gravis: a non-muscle relaxant technique [letter].  Anaesthesia 52(8): 807-8.

Uhrbrand, B. and H. S. Hansen (1994). “Anaestesiologiske aspekter ved laparoskopi til gynaekologiske indgreb.  Ugeskrift for Laeger 156(33): 4700-4.
A review of anaesthesia for gynaecologic laparoscopic surgery is given. Special criteria are needed for selection of patients, choice of anaesthesia and intraoperative monitoring. The cardiovascular and respiratory system are affected by tension from the pneumoperitoneum, absorption of CO2 and Trendelenburg position. Gas insufflation can provoke venous gas embolism, pneumothorax, pneumomediastinum, pneumopericardium and subcutaneous emphysema. The introduction of laparoscopic instruments may result in unintentional injuries to intra-abdominal organs. The possibility that the procedure may have to be converted to open laparotomy needs to be considered. Bowel burns may result in perforation, peritonitis and sepsis. Laparoscopy is contraindicated in patients with serious cardiac disease, extensive bowel adhesions or intestinal obstruction. General anaesthesia with muscle paralysis, tracheal intubation and controlled ventilation is the preferred technique in these cases. Short acting anaesthetics are preferred in day case laparoscopy. Central neural blockade or infiltration anaesthesia supplemented with sedation and analgetics can be used for short laparoscopic procedures. The electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, intra-abdominal pressure monitor, pulse oximeter and CO2 monitor are used routinely. Antiemetics and analgetics may be needed postoperatively.

Ure, B. M., H. Troidl, et al. (1993). “Preincisional local anesthesia with bupivacaine and pain after laparoscopic cholecystectomy. A double-blind randomized clinical trial.  Surgical Endoscopy 7(6): 482-8.
The aim of this study was to investigate whether local anesthesia of abdominal wall wounds prior to laparoscopic cholecystectomy leads to decreased pain beyond the immediate postoperative period and thus improves the comfort of the patient. In a randomized, double-blind study 50 patients scheduled for laparoscopic cholecystectomy were divided into two groups. In one group (n = 25) the skin, subcutis, fascia, muscle, and preperitoneal space were infiltrated with 8 ml of bupivacaine 0.5% 5 min before each abdominal wall incision. The control group (n = 25) received normal saline. The intensity of pain was assessed by a 100-point visual analogue scale (VAS) at rest and during movement and by the consumption of analgesics. Analgesic therapy was provided by on-demand analgesia with piritramide intravenously for 24 h and continued by ibuprofen orally on request. The mean intensity of pain at rest and during movement was lower but not statistically significant in patients who received bupivacaine compared to the control group up to the second postoperative day. The difference was between 4 and 9 VAS points and therefore of doubtful clinical relevance. Similar statistically nonsignificant results were found for the mean consumption of piritramide up to 16 h after the operation. Three patients (12%) in the bupivacaine group localized the most severe pain up to the second postoperative day to the right lower abdominal wall wound where the gallbladder had been extracted compared to 11 patients (44%) of the control group (P = 0.012). These results indicate that bupivacaine was effective at the site where it was administered.(ABSTRACT TRUNCATED AT 250 WORDS)

Ushiyama, T., Y. Kurita, et al. (1993). “[Experience of laparoscopic pelvic lymphadenectomy in 10 patients].  Nippon Hinyokika Gakkai Zasshi - Japanese Journal of Urology 84(10): 1776-82.
From November 1991 through January 1993, we performed laparoscopic lymphadenectomy on 10 patients. These patients were aged 54 to 77 years. All laparoscopic procedures were performed under general anesthesia. We dissected obturator lymph nodes on bilateral side. Total operation time ranged from 127 to 325 minutes. We could excise 3 to 9 lymph nodes on right side and 0 to 10 lymph nodes on left side. Blood loss was 180 ml in one patient, but minimal in the remaining 9 patients. Ureteral injury occurred during laparoscopic procedure in one patient. This injury could be managed with laparoscopic and cystoscopic procedure. Postoperatively complications were observed in 5 procedures, which consisted of subcutaneous emphysema in 2 procedures, fever (over 38 degrees C) in 2, shoulder and arm pain in 1, ileus in 1. The patient with ileus complained of abdominal fullness but he was able to ingest. All patients resumed their preoperative activity by postoperative day 3 to 5. We believe that this procedure was safe and useful for decision making in the management of our patients. We need further study on indications and techniques for this procedure.

Valdivia Uria, J. G. and E. Lanchares Santamaria (1993). “Anestesia en cirugia urologica laparoscopica.  Archivos Espanoles de Urologia 46(7): 559-65.
Although minimally invasive, urological laparoscopic surgery is still a major surgery and has special characteristics which should not be ignored. Our protocol includes: premedication with diazepam and atropine, preinduction with fentanyl, induction with propofol, followed by atracurium or succinylcholine for tracheal intubation. Anesthesia is sustained with continuous pump infusion of propofol at gradually lower doses and is discontinued on removing the abdominal trocars. Muscle relaxation throughout the operation is maintained with atracurium in continuous infusion and is discontinued at the same time as propofol. Intraoperative analgesia is achieved with bolus administration of fentanyl. We routinely use vesical and nasogastric catheters; the latter is removed at the end of the operation. Similarly, compressive bandaging is done for the lower limbs in all patients. Intraoperative monitoring includes ECG, heart rate, arterial blood pressure (noninvasive method), end expiratory CO2, O2 saturation, minute/volume, tidal volume and respiratory rate, airway pressures, temperature and diuresis. Pulmonary ventilation is by IPPV with a mixture of oxygen and air, maintaining FiO2 at 0.4. Nitrous oxide is not utilized, therefore the airways were only used for lung ventilation and not for the administration of inhalatory anesthetic agents. The higher increments of end expiratory CO2 of up to 48 mm Hg were observed at the end of the procedure following peritoneal desufflation. In summary, the technique of choice is total i.v. anesthesia with propofol and monitoring as complete as possible (noninvasive). Furthermore, capnographic and capnometric control of end expiratory CO2 is warranted.

Velanovich, V. (1999). “Comparison of symptomatic and quality of life outcomes of laparoscopic versus open antireflux surgery.  Surgery 126(4): 782-8; discussion 788-9.
BACKGROUND: Even though laparoscopic antireflux procedures have become the surgical treatment of choice for gastroesophageal reflux disease (GERD), little quantitative data exist comparing symptomatic and quality of life outcomes between laparoscopic and standard open procedures. This study was done to compare short-term outcomes. METHODS: All patients referred for surgical treatment of GERD are prospectively followed with a disease-specific reflux symptom score (the GERD-HRQL, best score 0, worst score 50) and a generic quality of life questionnaire (the SF-36, best score 100, worst score 0). Patients are evaluated preoperatively and at least 6 weeks postoperatively. Patients were treated with either laparoscopic or open Nissen (360-degree wrap) or Toupet (270-degree wrap) fundoplications. RESULTS: Sixty patients underwent laparoscopic surgery (LS) and 20 open surgery (OS). LS and OS had significant improvement in the median GERD-HRQL scores, 27 to 3 and 27 to 1, respectively, both P < .000001. LS had statistically significant improvements in the SF-36 domains of mental health (62 to 71.5, P = .05) and general health (57 to 67, P = .004). There was no worsening in any of the other 6 domains. OS produced a worsening score in the domain of physical functioning (75 to 67.5, P = .02). LS had better postoperative scores compared with OS in the domains of physical functioning (80 vs 67.5, P = .05) and trended to better scores in bodily pain (64 vs 51.5, P = .09). CONCLUSIONS: LS produces equivalent improvement in reflux symptoms compared with OS, with improved general quality of life outcomes.

Vezakis, A., D. Davides, et al. (1999). “Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy.  Surgical Endoscopy 13(9): 890-3.
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.

Viani, M. P., R. V. Poggi, et al. (1995). “Gasless laparoscopic removal of retroperitoneal leiomyosarcoma.  Journal of Laparoendoscopic Surgery 5(1): 47-54.
Leiomyosarcoma is a rare malignant tumor originating from the smooth muscular tissue in any part of the organism. The only therapy is its complete removal. We describe herein the operative treatment of a retroperitoneal leiomyosarcoma with gasless laparoscopic complete removal. The procedure was successfully performed in a consenting woman with an abdominal mass. Gasless laparoscopic removal was performed with a mechanical retractor (Laparolift, Origin Medsystem Inc.), obviating the creation of the pneumoperitoneum and of the sealed environment. The technique is a simple, safe, and effective surgical method. Gasless technique guarantees a clear vision, makes possible continuous suction of smoke and fluids, and allows the use of conventional instruments and easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless miniinvasive surgery.

Viani, M. P., R. V. Poggi, et al. (1995). “Gasless laparoscopic gastrostomy.  Journal of Laparoendoscopic Surgery 5(4): 245-9.
Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. Laparoscopic gastrostomy is usually performed when PEG is contraindicated, for example, in patients with esophageal strictures, large gastric tumors, or a history of multiple abdominal surgery. We report herein a case of gasless laparoscopic gastrostomy performed for carcinoma associated with a severe respiratory distress syndrome in a malnourished patient with a tight esophageal stricture. The gasless technique uses the Laparolift System (Laparolift, Origin Medsystem, Inc.), a device composed of a fan-shaped retractor and a mechanical lifting arm that produces an abdominal wall distention resembling a truncated pyramid. Gasless laparoscopy was a safe alternative approach to CO2 pneumoperitoneum in this patient.

Viani, M. P., M. Intra, et al. (1997). “Gasless laparoscopic treatment of perforated duodenal ulcer: a case report.  Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 7(4): 249-56.
Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases. Its emergency treatment is based on surgery, namely, simple closure or more definitive ulcer surgery. Laparoscopic repair of perforated duodenal ulcer with classic insufflation of CO2 is quick, simple, and technically feasible in most patients. We describe herein the operative treatment of a perforated duodenal ulcer in a 33-year-old man who presented to our Hospital with acute onset of severe abdominal pain. Wide peritoneal lavage and suture of the perforation was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. This new approach enables the use of conventional instruments and provides a clear field of vision in the abdomen equal to that created by the traditional CO2 technique. Because there is not a pneumoperitoneum to maintain, the gasless technique permits a constant irrigation and suction of the abdominal cavity, a wide peritoneal lavage, and the continuous suction of fluid, blood, smoke, and humidity without losing the camera set. If indicated, it permits the laparoscopic repair of the perforation combined with the laparoscopic vagotomy in the same emergency setting. The present case proved it to be another abdominal procedure that can be carried out with all the technical and anesthesiological advantages of gasless minimally invasive surgery.

Victorzon, M., M. Lundin, et al. (1999). “Short and long term outcome after laparoscopic cholecystectomy.  Annales Chirurgiae et Gynaecologiae 88(4): 259-63.
BACKGROUND: As an audit of patients undergoing laparoscopic cholecystectomy this study not only reports the short term results, but attempted to assess the long term effect of the operation on the symptom profiles of the patients. METHODS: Three hundred unselected consecutive patients underwent elective laparoscopic cholecystectomy from January 1991 to July 1994. Short term outcome was analysed by reviewing patient files for operation details, postoperative morbidity, complications, and gallbladder histology. Long term (median 2 years) outcome was evaluated by a detailed postal questionnaire. Symptomatic benefit ratios (BR) accruing from the laparoscopic removal of the gallbladder were calculated. RESULTS: Twelve operations (4.0%) were converted to open surgery and were excluded from long term outcome analyses. Median operation time was 93 (range 40-245) minutes. There were no deaths. Overall morbidity was 13 %. Median postoperative hospital stay was 2 days (range 1-18 days) and median time-off work 15 days (range 2-49 days). The overall response rate to the questionnaire was 87%. Only one of the 261 patients (0.4%) suffered from recurrent common bile duct stones so far. As shown by the benefit ratios the symptoms most effectively relieved by laparoscopic cholecystectomy were biliary pain (0.97), nausea (0.95), vomiting (0.96) and jaundice (0.94). Most patients with diarrhoea (0.70) and heartburn (0.66) felt relief. Constipation (0.39) and food intolerance (0.57) were unaffected. Most patients (90%) felt that the operation-initiating symptom had disappeared and 98 percent of the patients considered that they had obtained overall symptomatic improvement by the operation. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe and effective way of treating the most common symptoms related to gallstone disease.

Voigt, E. (1978). “Notwendigkeit der endexspiratorischen CO2-Kontrolle wahrend laparoskopischer Sterilisation in Allgemeinnarkose mit kontrollierter Beatmung.  Anaesthesist 27(5): 219-22.
During laparoscopy and intraabdominal insufflation of CO2 cardio-respiratory accidents following increased PaCO2 are possible. The continuous measurement of endexpiratory CO2-concentration by infrared absorption spectrometry is a simple method for controlling the level of ventilation. Respiratory acidosis under controlled artificial ventilation during laparoscopy can thus be avoided.

Wagner, B. K. and D. A. O'Hara (1995). “Cost analysis of propofol versus thiopental induction anesthesia in outpatient laparoscopic gynecologic surgery.  Clinical Therapeutics 17(4): 770-6.
This study investigated the cost of propofol versus thiopental anesthesia in 243 patients who underwent outpatient laparoscopic gynecologic surgery. Patients records were analyzed for medication use, duration of surgery, anesthesia, recovery room stay, and associated costs. Despite the higher drug cost for propofol, the total mean cost was $273.00 less per patient for patients receiving propofol induction anesthesia. Extension of these data translates into cost savings of approximately $7900.00 if propofol had been used for all patients. Although the duration of surgery for the propofol group was shorter by nearly 12 minutes, the anesthesia duration and recovery room stay were both longer for the thiopental group, reflecting the longer duration of action of thiopental. Although the realized cost savings of drugs, surgery, anesthesia, and recovery time when propofol versus thiopental is used for outpatient laparoscopic gynecologic surgery are relatively small on an individual patient basis, cost savings may become more significant if larger patient populations are studied.

Walsh, M. T. and T. R. Vetter (1992). “Anesthesia for pediatric laparoscopic cholecystectomy.  Journal of Clinical Anesthesia 4(5): 406-8.
We report the general anesthetic events and clinical concerns encountered with a laparoscopic cholecystectomy in a 19-month-old toddler. Carbon dioxide was insufflated to create a pneumoperitoneum, with resulting intra-abdominal pressures ranging from 5 to 11 mmHg. The end-tidal partial pressure of carbon dioxide (PETCO2) rose as high as 48 mmHg (a 10 mmHg increase from baseline), requiring a 68% increase in minute ventilation to achieve preinsufflation values. Careful monitoring of ventilation, PETCO2, and intra-abdominal pressure are recommended for optimal anesthetic management of the pediatric laparoscopic cholecystectomy patient.

Wang, Q., S. Deng, et al. (1995). “[Application of gasless laparoscopic device in laparoscopic surgery].  Chung-Hua Wai Ko Tsa Chih [Chinese Journal of Surgery] 33(1): 15-8.
The aim of this study was to evaluate the gasless laparoscopic device (GLD) in laparoscopic surgery. GLD, independently designed and manufactured by ourselves in 1993, incorporates a manipulator and laparoscopic abdominal retractor. From August to October 1993, we conducted an experimental study on gasless laparoscopic cholecysto-duodenostomy in 5 dogs. Four of them were completely successful and one was converted to open surgery due to gallbladder rupture. The result showed that GLD could maintain good exposure in laparoscopic surgery, laparoscopic suturing and knotting could become easier and operative cost could be reduced with conventional instruments. We also developed an intracorporeal "Chinese Knotting" and a self-designed push tube for extracorporeal knot tying. During April and August 1994, we successfully applied our modified GLD in gasless laparoscopic cholecystectomy, inguinal herniorrhaphy laparoscopic-assisted sigmoidectomy, abdomino-perineal resection of rectal carcinoma.

Waterstone, J. J., V. N. Bolton, et al. (1992). “Laparoscopic zygote intrafallopian transfer using augmented local anesthesia.  Fertility & Sterility 57(2): 442-4.
In this study, 29 laparoscopic ZIFTs were performed in 21 patients using local anesthesia augmented with intravenous analgesia. The technique was well tolerated; significant discomfort arose only when the fallopian tubes were manipulated and was minimized by transferring zygotes to one tube only. Seven pregnancies resulted, of which three have delivered and one is ongoing.

Watson, D. I., G. Mathew, et al. (1995). “Impact of laparoscopic cholecystectomy in a major teaching hospital: clinical and hospital outcomes.  Medical Journal of Australia 163(10): 527-30.
OBJECTIVE: To compare the clinical, training and cost implications of laparoscopic cholecystectomy with open cholecystectomy. SETTING: A university teaching hospital. DESIGN: A retrospective review of all patients who underwent cholecystectomy in 1989, before the introduction of the laparoscopic technique, and in 1993, after the learning curve for laparoscopic cholecystectomy had been overcome. MAIN OUTCOME MEASURES: Surgical indications, feasibility of laparoscopic approach, type of surgeon, operating time, hospital stay, postoperative complications, and cost analysis. RESULTS: 240 cholecystectomies were performed in 1989 and 293 in 1993. This is a 22% increase in overall workload and includes a significant increase (85%; P < 0.0001) in elective caseload. In 1993, 89% of patients underwent laparoscopic surgery, with conversion to open cholecystectomy in 6.8% of elective patients and 33% of emergency patients. Surgical indications remained the same, as did the time from diagnosis to cholecystectomy. There were significant changes in median length of hospital stay (from 10 days in 1989 to 4 days in 1993; P < 0.0001), successful intraoperative cholangiography (93% versus 73%; P < 0.0001), and exploration of the common bile duct (15% versus 5% of patients; P = 0.0005). The number of cholecystectomies performed by surgeons-in-training decreased from 65% to 40%, individual treatment costs were reduced by 62% and overall hospital costs were reduced by 53%. Complications fell from 12% to 7% (P = 0.07), with the only major bile duct injury occurring in 1989. There were three deaths in 1989 and two deaths in 1993. All deaths followed open surgery. CONCLUSIONS: Laparoscopic cholecystectomy is associated with improved patient outcomes and, despite the increased workload, significant savings for hospitals.

Way, L. W. (1990). “Changing therapy for gallstone disease [editorial; comment].  New England Journal of Medicine 323(18): 1273-4.

Wellwood, J., M. J. Sculpher, et al. (1998). “Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost [published erratum appears in BMJ 1998 Sep 5;317(7159):631].  BMJ 317(7151): 103-10.
OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Westerband, A., J. Van De Water, et al. (1992). “Cardiovascular changes during laparoscopic cholecystectomy.  Surgery, Gynecology & Obstetrics 175(6): 535-8.
Although the technique of laparoscopic cholecystectomy has increasing appeal, physiologic data to support the safety of this procedure are lacking. We studied the cardiovascular changes in 16 patients undergoing laparoscopic cholecystectomy, using impedance cardiography as a noninvasive means of continuous monitoring of cardiac output. Serial measurements of mean arterial pressure (MAP), heart rate (HR), intraperitoneal pressure and expired carbon dioxide tension (PECO2) were also recorded. Results revealed a decrease of 30 percent (p < 0.001) in cardiac index and 5 percent (p = 0.089) in HR, along with increases of 15 percent (p < 0.001) in MAP and of 79 percent (p < 0.001) in the calculated total peripheral resistance index. This elevation in afterload could lead to both an increase in myocardial oxygen consumption and to the potential risk of myocardial ischemia and possibly infarction or congestive heart failure, or both, in patients who are susceptible. The data suggest that patients with a history of cardiac disease should have preoperative cardiac evaluation and be closely monitored during laparoscopic cholecystectomy, as in any other extensive operation.

Whitford, J. H. and A. J. Gunstone (1972). “Gastric perforation: a hazard of laparoscopy under general anaesthesia.  British Journal of Anaesthesia 44(1): 97-9.

Wolf, J. S., Jr., M. B. Tchetgen, et al. (1998). “Hand-assisted laparoscopic live donor nephrectomy.  Urology 52(5): 885-7.
Minimally invasive live donor nephrectomy has been described using both standard laparoscopic dissection and "gasless" endoscopically assisted techniques. We report another method, hand-assisted laparoscopic live donor nephrectomy, which uses an occlusive sleeve to maintain pneumoperitoneum. The procedure is performed under excellent laparoscopic visualization in a generous operative field, and is facilitated substantially by manual assistance, which takes advantage throughout the procedure of the incision that is necessary for intact organ removal. The results of our first procedure are encouraging.

Yacoub, O. F., I. Cardona, Jr., et al. (1982). “Carbon dioxide embolism during laparoscopy.  Anesthesiology 57(6): 533-5.

Yokomori, K., K. Terawaki, et al. (1998). “A new technique applicable to pediatric laparoscopic surgery: abdominal wall 'area lifting' with subcutaneous wiring.  Journal of Pediatric Surgery 33(11): 1589-92.
BACKGROUND: Recently, the authors developed a unique method of laparoscopic surgery without pneumoperitoneum: "area lifting of the abdominal wall with subcutaneous wiring." METHODS: In this gasless procedure, the anterior abdominal wall is pulled upward by a pair of wires placed subcuta