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УДК 616.366-089.87-089.844-089.819:617-031.14 DOI: 10.26565/2313-6693-2021-41-10
EFFECTIVENESS OF THE CONCEPT OF FAST-TRAK SURGERY FOR SIMULTANEOUS LAPAROSCOPIC HERNIOPLASTICS AND CHOLECISTECTOMY
Parkhomenko K. Yu.
The aim of the research was to study the feasibility and effectiveness of simultaneous laparoscopic hernioplasty and cholecystectomy in patients with combined abdominal pathology.
Material and methods. Simultaneous laparoscopic hernioplasty and cholecystectomy during 2015-2019 performed on 70 patients, including 49 (70 %) women, mean age 57.3 ± 6.5 g. In 37 patients the principles of Fast-track surgery were applied (group I), including thorough examination for diagnostics of combined abdominal pathology and clinically significant general somatic pathology; if necessary a course of therapy for full compensation of general somatic pathology was prescribed; during the operation of epidural prolonged anesthesia; choice in favor of laparoscopic technology; at the end of the operation - irrigation of the subdiaphragmatic space with local anesthetic; postoperatively: early drainage removal; withdrawal from opioids by prescribing parenteral paracetomol; activation of the patient 6-8 hours after surgery; on the day of surgery - use of chewing gum and fluid intake. In 33 patients the standard complex of perioperative management (group II) is applied. The immediate results of surgical interventions have been studied.
Results. There were no significant complications during the operation and in the early postoperative period. In the first group, seroma (after open alloplasty) was detected in 2 (5 %) cases, and in the second group, small wound complications were detected in 4 (12 %) cases (p > 0.05 according to the %2 criterion). The duration of inpatient treatment in patients of group I is 4.4 ± 1.2 months, in group II - 7.0 ± 1.3 days (p < 0.001 by Student's test).
Conclusion. Application of the principles of Fast-track surgery and accelerated recovery at all stages of simultaneous laparoscopic hernioplasty and cholecystectomy (preparation for surgery, during the operation and in the postoperative period) does not increase the number of postoperative complications and decreased duration of inpatient treatment from 7,0 ± 1,3 in patients with traditional postoperative management to 4,4 ± 1,2 days.
KEY WORDS: cholecystectomy, hernioplasty, simultaneous operation, Fast-track surgery INFORMATION ABOUT AUTHOR
Parkhomenko Kyrylo, PhD, Associate Professor, Department of General Practice, Family Medicine and Internal Medicine Kharkiv National Medical University, 4. Nauky Avenue, Kharkiv, 61022, Ukraine, e-mail: pku70@ukr.net, ORCID ID: https://orcid.org/0000-0002-0004-2417
INTRODUCTION
The introduction of videoendoscopic technologies into routine practice of abdominal surgery has significantly expanded the possibilities of the operative treatment of various pathologies [1]. Nowadays, volume interventions including those concerning combined pathologies are possible even in severely ill patients. However, there is still no consensus on the feasibility of simultaneous simultaneous surgeries for the correction of combined abdominal diseases. Many researchers report good results of simultaneous surgeries [2, 3, 4], but so far their frequency does not correspond to the prevalence of concomitant pathology [5].
The main argument against simultaneous interventions is the increase in the volume of the surgery, correspondingly increasing the degree of surgical aggression and the risk of adverse events in the postoperative period. This is especially true for elderly and senile patients with concomitant general somatic pathology, in which there is already a high risk of postoperative complications [5]. But this particular contingent is characterized by high comorbidity with the presence of several diseases requiring surgical treatment [6, 7].
Various strategies have been proposed to reduce surgical and anesthetic risk. In recent decades, the strategy of «fast-track surgery» (Fast-track surgery), which aims to reduce the perioperative reaction to stress, the frequency of postoperative complications along with
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reducing the cost and duration of hospital treatment through the use of better surgical techniques, anesthesia and postoperative pain management, has become increasingly popular [8, 9].
A variation of this strategy is the Enhanced recovery after surgery (ERAS) concept, which also consists of comprehensive interventions in the perioperative period to improve surgical outcomes. These strategies are becoming increasingly common in hernia surgery and show good results [10, 11].
We don't found studies on the effectiveness of ERAS protocols in patients with simultaneous laparoscopic hernioplasty and cholecystectomy, which indicates the relevance of this problem.
The aim of the study was to investigate the feasibility and effectiveness of simultaneous laparoscopic hernioplasty and
cholecystectomy in patients with concomitant abdominal pathology.
MATEPIA.HH TA METOflH
The study was carried out on the basis of the surgical departments of the State Institution «Specialized Medical and Sanitary Unit No. 13» Ministry of Health of Ukraine and the municipal non-profit enterprise of the Kharkiv Regional Council «Regional Clinical Hospital». Simultaneous laparoscopic hernioplasty and cholecystectomy during 2015-2019 was performed in 70 patients, including 49 (70 %) women. The mean age of the patients was 57.3 ± 6.5 (95 % CI 54.7; 59.9) (29 to 83 years).
All patients underwent laparoscopic cholecystectomy (LCE) due to confirmed cholecystolithiasis with a history of chronic cholecystitis.
Hernioplasty was performed
concomitantly with LHE: chiatal hernias (posterior cruorrhaphy with Nissen or Toupee fundoplication) - 12 (17 %); umbilical hernias - 43 (61 %), including - 14 (20 %) -IPOM (intraperitoneal onlay mesh) plasty, 27 (67 %) - open hernioplasty by Meio, 2 (5 %) - open mesh sub-lay hernioplasty ; postoperative hernia 16 (23 %), including 13 (81 %) cases of IPOM plasty and 3 (19 %) cases of open mesh sub-lay alloplasty; white line abdominal hernia - 3 (4 %) IPOM plasty. In four patients along with LHE simultaneous hernioplasty of chiatal and umbilical hernia
was performed. Gynecological surgery was additionally performed in four cases: pangysterectomy type I in 2 women and adnexectomy type I in 2 women.
In addition, 28 (40 %) patients were found to have concomitant hypertension, 10 (14 %) had coronary heart disease, 15 (22 %) were overweight or obese, 8 (11 %) had diabetes, 12 (17 %) were diagnosed with chronic heart failure, and 7 (10 %) had chronic obstructive pulmonary disease.
In 37 patients who were operated on in 2018-2019 in the perioperative period the principles of Fast-track surgery and accelerated recovery after surgery were applied. During preparation for surgery: at the outpatient and polyclinic stage a thorough examination for diagnostics of combined abdominal pathology and clinically significant general somatic pathology; if necessary a course of therapy for full compensation of general somatic pathology was prescribed.
During the operation of epidural prolonged anesthesia; choice in favor of laparoscopic technology; at the end of the operation - irrigation of the subdiaphragmatic space with 0.25 % lidocaine solution (or longocaine).
Postoperatively: early drainage removal (in 10-12 hours). Withdrawal from opioids by prescribing parenteral paracetomol (1000 mg twice a day). Activation of the patient 68 hours after surgery. On the day of surgery -use of chewing gum and fluid intake. From the first day - low-calorie liquid food intake.
Standard complex of preoperative preparation and perioperative management was used in 33 patients.
All patients were operated on routinely after a set of mandatory and additional general clinical, laboratory and instrumental investigations according to the existing guidelines. Immediate results of surgical interventions were studied.
The results are given as the absolute number (%) for qualitative indices and M ± SD (mean and standard deviation of the mean) for quantitative indices. The results were processed using PSRP statistical software package by applying frequency analysis and comparing qualitative data using Fisher exact test and yl criterion, and quantitative data using t-criterion. The
difference between the groups was considered significant at (p < 0.05).
Note. 1 - t-test reliability; 2 - y2 reliability.
In the first group, 28 (66 %) patients underwent all interventions through laparoscopic access, in 9 (34 %) patients -hybrid access with open access hernioplasty of umbilical or postoperative hernias by their own tissues without tension or with the use of a mesh endoprosthesis. Hybrid access was used for small umbilical hernias. In these cases, the main trocar access was subsequently used for open hernioplasty.
In group II patients laparoscopic access was used in 9 (27 %) cases, in most cases hybrid access with open autoplastic hernioplasty - 22 (67 %) cases or alloplastic method - 2 (6 %) (p < 0.01 for %2 criterion).
There were no significant complications during the operation and in the early postoperative period. Seroma was detected in 2 (5 %) cases in the first group (after open aloplasty), small wound complications were detected in 4 (12 %) cases in group II (p > 0.05 by x2 criterion).
More indicative was a significant decrease in the duration of patient treatment: in group I, 4.4 ± 1.2 days, and in group II, 7.0 ± 1.3 days (p < 0.001 by Student's test). The possibility of discharge to outpatient treatment is evidence of complete recovery of motor activity and gastrointestinal function and other functional indicators, more quickly recovered in group I.
First of all, we studied the output data of the patients included in the study (Table 1).
Similar results were obtained by other researchers. In particular, E. Stearns et al. (2018) found a more rapid recovery of bowel function and shorter in patient treatment duration when applying the accelerated recovery protocol after open hernioplasty [12].
W. Ueland et al. (2020) associated a decrease in the duration of hospital treatment with the use of mixed anesthesia and early mobilization [13].
In the first group of patients we used prolonged epidural anesthesia during surgery and in the early postoperative period, the effect of which was enhanced by non-steroidal anti-inflammatory drug administration. The efficacy of anti-inflammatory drugs has been proved in other studies [14, 15]. The positive effect of irrigation of the subdiaphragmatic space with a local anesthetic solution should also be noted, which contributes not only to pain relief, but also has an anti-inflammatory effect [16].
Early mobilization and effective anesthesia without the use of opioids contributed to the rapid recovery of intestinal function. In addition, the prescription of chewing gum in the first day after surgery played an important role. The positive effect
RESULTS AND DISCUSSION
Ta6mnfl 1
Baseline characteristics of the patients included in the study
Index Group I (n = 37) Group II (n = 33) P
Age, years 56,6 ± 11,9 58,1 ± 1,7 > 0,051
Gender, m/w 12/25 9/24 > 0,052
Concomitant pathology:
Overweight and obesity 10 (27 %) 5 (15 %) > 0,052
Diabetes mellitus 5 (14 %) 3 (9 %) > 0,052
Coronary heart disease 5 (14 %) 5 (15%) > 0,052
Heart failure 6 (16 %) 6 (18%) > 0,052
Lung disease 4 (11 %) 3 (9 %) > 0,052
Arterial hypertension 15 (41 %) 13 (39 %) > 0,052
of chewing gum was also noted by other authors [17].
CONCLUSION
Application of the principles of Fast-track surgery and accelerated recovery at all stages of simultaneous laparoscopic hernioplasty and cholecystectomy (preparation for surgery, during the operation and in the postoperative period) does not increase the number of postoperative complications and decreased duration of inpatient treatment from 7,0 ± 1,3 in patients with traditional postoperative management to 4,4 ± 1,2 days.
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11. Slim K, Standaert D. Enhanced recovery after surgical repair of incisional hernias. Hernia. 2020 Feb;24(1):3-8. https://doi.org/10.1007/s10029-019-01992-y
12. Stearns E, Plymale MA, Davenport DL, Totten C, Carmichael SP, Tancula CS, Roth JS. Early outcomes of an enhanced recovery protocol for open repair of ventral hernia. Surg Endosc. 2018;Jun;32(6):2914-2922. https://doi.org/10.1007/s00464-017-6004-0
13. Ueland W, Walsh-Blackmore S, Nisiewicz M, Davenport DL, Plymale MA, Plymale M et al. The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair. Surg Endosc. 2020 Oct; 34 (10): 4638-4644. https://doi. org/10.1007/s00464-019-07233-8
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PROSPECTS FOR FURTHER RESEARCH
It is promising to study different aspects of Fast-track surgery depending on the patient's condition, the presence and severity of comorbidities and the scope of surgery.
CONFLICT OF INTERESTS
The authors declare that there is no conflict of interests regarding the publication of this paper.
16. Kahokehr A, Sammour T, Soop M, Hill AG. Intraperitoneal use of local anesthetic in laparoscopic
cholecystectomy: Systematic review and metaanalysis of randomized controlled trials. 2010; Sep; 17 (5):
637-656
17. Ge W, Chen G, Ding YT. Effect of chewing gum on the postoperative recovery of gastrointestinal
function. Intern J Clin Experim Med. 2015; 8 (8): 11936-11942
ЕФЕКТИВН1СТЬ КОНЦЕПЦП FAST-TRACK SURGERY ПРИ СИМУЛЬТАННШ ЛАПАРОСКОП1ЧН1Й ГЕРШОПЛАСТИЩ ТА ХОЛЕЦИСТЕКТОМП
Пархоменко К. Ю.
Мета до^дження - вивчення доцшьност та ефективност симультанно! лапароскотчно! гертопластики та холецистектомй у пащентш з поеднаною абдомшальною патолопю.
Матерiали та методи дослщження. Симультанну лапароскопiчну гернiопластику та холецистектомж> протягом 2015-2019 рр. здiйснено 70 пащентам, у тому числ^ 49 (70 %) жток, середнiм вжом 57,3 ± 6,5 р. У 37 пащентав застосовано принципи швидко! хiрурги (I група), яю включали ретельне обстеження для дiагностики поеднано! патологи черевно! порожнини та клшчно значущо! загально! соматично! патологи; курс терапп для повно! компенсаци загально! соматично! патологи за необхiднiстю; тд час операцп застосування етдурально! пролонговано! анестези; вибiр на користь лапароскотчно! технологи; в юнщ операци - зрошення пiддiафрагмального простору мiсцевим анестетиком; тсля операци: ранне видалення дренажу; ввдмова вiд опiоlдiв шляхом призначення парентерального парацетомолу; акгивацiя пацiента через 6-8 годин тсля операцп; в день операцп - вживання жувально! гумки та вживання рiдини. Вивчено безпосереднi результати оперативних втручань.
Результати та обговорення. Суттевих ускладнень пiд час операцп та у ранньому пiсляоперацiйному перiодi не було. В I грут у 2 (5%) випадках виявлено серому (пiсля вiдкритоl алопластики), в II грут - малi рановi ускладнення виявлено в 4 (12%) випадках (р > 0,05 за критерiем X2). Тривалють стацiонарного лжування у пацiентiв I групи - 4,4 ± 1,2 дн., в II грут - 7,0 ± 1,3 дн (р < 0,001 за крше^ем Стьюдента).
Висновок. Застосування принцитв швидко! операцil та прискореного вщновлення на всiх етапах одночасно! лапароскотчно! гертопластики та холецистекгомil (тдготовка до операцil, пiд час операцп та в тсляоперащйному перiодi) не збшьшуе кiлькiсть пiсляоперацiйних ускладнень та скорочуе тривалiсть стацiонарного лiкування з 7,0 ± 1,3 днiв у пащентав з традицiйним пiсляоперацiйним лжуванням до 4,4 ± 1,2 днш.
КЛЮЧОВ1 СЛОВА: холецистектомiя, гернiопластика, симультанна операцiя, Fast-track surgery 1НФОРМАЦ1Я ПРО АВТОРА
Пархоменко Кирило Юршович, к.мед.н., доцент, кафедри загально! практики-с1мейно! медицини та внутршшх хвороб, Харкiвський нацюнальний медичний ун1верситет, пр. Науки, 4, Харгав, Укра1на, 61022, e-mail: pku70@ukr.net ORCID ID: https://orcid.org/0000-0002-0004-2417
ЭФФЕКТИВНОСТЬ КОНЦЕПЦИИ FAST-TRACK SURGERY ПРИ СИМУЛЬТАННОЙ ЛАПАРОСКОПИЧЕСКОЙ ГЕРНИОПЛАСТИКЕ И ХОЛЕЦИСТЭКТОМИИ
Пархоменко К. Ю.
Цель исследования - изучение целесообразности и эффективности симультанной лапароскопической герниопластики и холецистэктомии у пациентов с сочетанной абдоминальной патологией.
Материал и методы исследования. Симультанная лапароскопическая герниопластика и холецистэктомия на протяжении 2015-2019 гг. выполнена 70 пациентам, в том числе, 49 (70 %) женщин, средний возраст 57,3 ± 6,5 лет. У 37 пациентов применены принципы быстрой хирургии (I группа), которые включали тщательное обследование для диагностики сочетанной патологии брюшной полости и клинически значимой общей соматической патологии; курс терапии для полной компенсации общей соматической патологии при необходимости; во время операции применение эпидуральной пролонгированной анестезии; выбор в пользу лапароскопической технологии; в конце операции - орошение поддиафрагмального пространства местным анестетиком; после операции: раннее удаление дренажа; отказ от опиоидов путем назначения парентерального парацетомола;
активация пациента через 6-8 часов после операции; в день операции - употребление жевательной резинки и употребление жидкости. Изучены непосредственные результаты оперативных вмешательств.
Результаты и обсуждение. Существенных осложнений во время операции и в раннем послеоперационном периоде не было. В первой группе у 2 (5 %) случаях выявлена серома (после открытой алопластики), во II группе - малые раневые осложнения выявлены в 4 (12 %) случаях (р > 0,05 по критерию х2). Продолжительность стационарного лечения у пациентов I группы -4,4 ± 1,2 мес., во II группе - 7,0 ± 1,3 дней (р < 0,001 по критерию Стьюдента).
Вывод. Применение принципов быстрой хирургии и ускоренного восстановления на всех этапах симультанной лапароскопической герниопластики и холецистэктомии (подготовка к операции, во время операции и в послеоперационном периоде) не увеличивает частоту послеоперационных осложнений и сокращает продолжительность стационарного лечения с 7,0 ± 1,3 дней у пациентов с традиционным послеоперационным лечением до 4,4 ± 1,2 дней.
КЛЮЧЕВЫЕ СЛОВА: холецистэктомия, герниопластика, симультанная операция, Fast-track surgery
ИНФОРМАЦИЯ ОБ АВТОРЕ
Пархоменко Кирилл Юрьевич, к.мед.н., доцент, кафедри общей практики-семейной медицини и внутренних болезней, Харьковський национальний медицинский университет, пр. Науки, 4, Харьков, Украина, 61022, e-mail: pku70@ukr.net, ORCID ID: https://orcid.org/0000-0002-0004-2417
Отримано: 15.12.2020 р.
Прийнято до друку: 15.01.2021 р.
