First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates,shorter post-operative recovery periods and lower complication rates than open surgery.It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources.However,introducing laparoscopic surgery in low-and-middle-income countries(LMIC)can be expensive and requires resour-ces,equipment,and trainers.AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.METHODS MEDLINE,EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC.Included studies were published between 1996 and 2022 with full text available in English.Exclusion criteria were studies considering only open surgery,ear,nose,and throat,endoscopy,arthro-scopy,hysteroscopy,cystoscopy,transplant,or bariatric surgery.RESULTS Ten studies out of 3409 screened papers,from eight LMIC were eligible for inclusion in the final analysis,totaling 2497 patients.Most reported challenges were related to costs of equipment and training programmes,equipment pro-blems such as faulty equipment,and access to surgical kits.Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff.The benefits of introducing laparoscopic surgery were economic and clinical,including a reduction in hospital stay,complications,and morbidi-ty/mortality.The introduction of laparoscopic surgery also provided training opportunities for junior doctors.CONCLUSION Despite financial and technical challenges,many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients.While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported,more support is critically required,in particular regarding training.

Identification of clinical subphenotypes of sepsis after laparoscopic surgery

Objective:Some patients exhibit septic symptoms following laparoscopic surgery,leading to a poor prognosis.Effective clinical subphenotyping is critical for guiding tailored therapeutic strategies in these cases.By identifying predisposing factors for postoperative sepsis,clinicians can implement targeted interventions,potentially improving outcomes.This study outlines a workflow for the subphenotype methodology in the context of laparoscopic surgery,along with its practical application.Methods:This study utilized data routinely available in clinical case systems,enhancing the applicability of our findings.The data included vital signs,such as respiratory rate,and laboratory measures,such as blood sodium levels.The process of categorizing clinical routine data involved technical complexities.A correlation heatmap was used to visually depict the relationships between variables.Ordering points were used to identify the clustering structure and combined with Consensus K clustering methods to determine the optimal categorization.Results:Our study highlighted the intricacies of identifying clinical subphenotypes following laparoscopic surgery,and could thus serve as a valuable resource for clinicians and researchers seeking to explore disease heterogeneity in clinical settings.By simplifying complex methodologies,we aimed to bridge the gap between technical expertise and clinical application,fostering an environment where professional medical knowledge is effectively utilized in subphenotyping research.Conclusion:This tutorial could primarily serve as a guide for beginners.A variety of clustering approaches were explored,and each step in the process contributed to a comprehensive understanding of clinical subphenotypes.

Application value of machine learning models in predicting intraoperative hypothermia in laparoscopic surgery for polytrauma patients

BACKGROUND Hypothermia during laparoscopic surgery in patients with multiple trauma is a significant concern owing to its potential complications.Machine learning models offer a promising approach to predict the occurrence of intraoperative hypothermia.AIM To investigate the value of machine learning model to predict hypothermia during laparoscopic surgery in patients with multiple trauma.METHODS This retrospective study enrolled 220 patients who were admitted with multiple injuries between June 2018 and December 2023.Of these,154 patients were allocated to a training set and the remaining 66 were allocated to a validation set in a 7:3 ratio.In the training set,53 cases experienced intraoperative hypothermia and 101 did not.Logistic regression analysis was used to construct a predictive model of intraoperative hypothermia in patients with polytrauma undergoing laparoscopic surgery.The area under the curve(AUC),sensitivity,and specificity were calculated.RESULTS Comparison of the hypothermia and non-hypothermia groups found significant differences in sex,age,baseline temperature,intraoperative temperature,duration of anesthesia,duration of surgery,intraoperative fluid infusion,crystalloid infusion,colloid infusion,and pneumoperitoneum volume(P<0.05).Differences between other characteristics were not significant(P>0.05).The results of the logistic regression analysis showed that age,baseline temperature,intraoperative temperature,duration of anesthesia,and duration of surgery were independent influencing factors for intraoperative hypothermia during laparoscopic surgery(P<0.05).Calibration curve analysis showed good consistency between the predicted occurrence of intraoperative hypothermia and the actual occurrence(P>0.05).The predictive model had AUCs of 0.850 and 0.829 for the training and validation sets,respectively.CONCLUSION Machine learning effectively predicted intraoperative hypothermia in polytrauma patients undergoing laparoscopic surgery,which improved surgical safety and patient recovery.

Influence of reduced-port laparoscopic surgery on perioperative indicators, postoperative recovery, and serum inflammation in patients with colorectal carcinoma

BACKGROUND Conventional five-port laparoscopic surgery,the current standard treatment for colorectal carcinoma(CRC),has many disadvantages.AIM To assess the influence of reduced-port laparoscopic surgery(RPLS)on perioperative indicators,postoperative recovery,and serum inflammation indexes in patients with CRC.METHODS The study included 115 patients with CRC admitted between December 2019 and May 2023,52 of whom underwent conventional five-port laparoscopic surgery(control group)and 63 of whom underwent RPLS(research group).Comparative analyses were performed on the following dimensions:Perioperative indicators[operation time(OT),incision length,intraoperative blood loss(IBL),and rate of conversion to laparotomy],postoperative recovery(first postoperative exhaust,bowel movement and oral food intake,and bowel sound recovery time),serum inflammation indexes[high-sensitivity C-reactive protein(hs-CRP),tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)],postoperative complications(anastomotic leakage,incisional infection,bleeding,ileus),and therapeutic efficacy.RESULTS The two groups had comparable OTs and IBL volumes.However,the research group had a smaller incision length;lower rates of conversion to laparotomy and postoperative total complication;and shorter time of first postoperative exhaust,bowel movement,oral food intake,and bowel sound recovery;all of which were significant.Furthermore,hs-CRP,IL-6,and TNF-αlevels in the research group were significantly lower than the baseline and those of the control group,and the total effective rate was higher.CONCLUSION RPLS exhibited significant therapeutic efficacy in CRC,resulting in a shorter incision length and a lower conversion rate to laparotomy,while also promoting postoperative recovery,effectively inhibiting the inflammatory response,and reducing the risk of postoperative complications.

Effect of simulating training of the fundamentals of laparoscopic surgery on the attitude of operating room nurses students:an intervention study

Objective:Clinical education plays a key role in preparing students for patient care.Laparoscopy is one of the most important minimally invasive surgeries(MISs)wherein surgical technologists are responsible for camera navigation and assistant surgeons are responsible for peg transfer.Therefore,it is necessary to improve the attitude of the operating room students toward these skills during their study period.The present study was conducted to determine the effect of simulating training in the fundamentals of laparoscopic surgery(FLS)on the attitude of the operating room students.Methods:This interventional study was conducted on 28 operating room students of Iran University of Medical Sciences in 2019.The census sampling method was used.The data-collection tool included the“Intrinsic motivation inventory(IMI)questionnaire.”The educational intervention was carried out in theoretical(booklet design)and practical(simulation)sections.Data analysis was carried out using descriptive and inferential analyses including the paired t-test,Mann–Whitney U test,and independent t-test.The collected data were analyzed using R and SPSS software.P-value<0.05 was considered as the significant level.Results:The mean±SD of the participants'age was 22.93±2.14 years,and the majority of them were women(67.9%).There was a significant difference in the mean scores of students'attitudes toward the FLS before and after the educational intervention(P<0.001)in all dimensions(interest,perceived competence,perceived choice,and tension).There was also a significant correlation between gender and interest dimension(P=0.005).Conclusions:The results of the present study showed that simulating the training FLS curriculum positively affects students'attitudes.Therefore,the researchers suggest that for creating a positive attitude,increasing students'interest in laparoscopic surgery,and ensuring a more effective presence in the operating room,this training should be considered in the operating room curriculum.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection(SILLR)is the most recent develop-ment in the laparoscopic approach to the liver.SILLR for hepatocellular carci-noma(HCC)has developed much more slowly than multiport LLR.So far,195 patients completed SILLR for HCC.In this paper,we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR,peri and postoperative findings,tricks of patient selection and whether SILLR compromise the oncological principles.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma(GC)is a rare type of cancer of the digestive system,with an incidence that varies by region.Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure.Compared with traditional open surgery,laparoscopic surgery has the advantages of convenient operation and magnified field of view.Laparoscopic surgery has been successful in many fields,including gastrointestinal medicine and gynecology.The gallbladder was one of the first organs to be treated by laparoscopic surgery,and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases.However,the safety and feasibility of laparoscopic surgery for patients with GC remain controversial.Over the past several decades,research has focused on laparoscopic surgery for GC.The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation,possible port site metastasis,and potential tumor seeding.The advantages of laparoscopic surgery include less intraoperative blood loss,shorter postoperative hospital stay,and fewer complications.Nevertheless,studies have provided contrasting conclusions over time.In general,recent research has tended to support laparoscopic surgery.However,the application of laparoscopic surgery in GC is still in the exploratory stage.Here,we provide an overview of previous studies,with the aim of introducing the application of laparoscopy in GC.

Anti-infective therapy durations predict psychological stress and laparoscopic surgery quality in pelvic abscess patients

BACKGROUND The degree of psychological stress and the difficulty and efficacy of laparoscopic surgery differ in patients with pelvic abscesses after different durations of antiinfection treatment.AIM To compare and analyse the effects of different durations of anti-infective therapy on patients’preoperative psychological stress level and the clinical efficacy of laparoscopic surgery in patients with pelvic abscesses to offer a reference for the selection of therapy plans.METHODS A total of 100 patients with pelvic abscesses who were admitted to the Department of Gynecology of Suzhou Ninth Hospital affiliated to Soochow University(Suzhou Ninth People's Hospital)from January 2018 to December 2022 were retrospectively enrolled.According to the different durations of antiinfective therapy,they were divided into Group S(50 patients,received antiinfective therapy for 24-48 h)and Group L(50 patients,received anti-infective therapy for 48-96 h).Baseline data,state-trait anxiety score at admission and before surgery,self-rating anxiety scale(SAS)+self-rating depression scale(SDS)score,surgery time,adhesion grading score,intraoperative blood loss,presence or absence of intraoperative intestinal injury,ureteral injury or bladder injury,postoperative body temperature,length of hospital stay,and presence or absence of recurrence within 3 mo after surgery,chronic pelvic pain,incision infection,dysmenorrhea,menstrual disorder or intestinal obstruction were compared between the S group and the L group.RESULTS There was no significant difference in the background data between the S group and the L group(P<0.05).There was no significant difference in the state-trait anxiety score or SAS+SDS score between the S group and the L group on admission(P<0.05).The state-trait anxiety score and SAS+SDS score of the S group were lower than those of Group L after receiving different durations of anti-infective therapy(P<0.05).There was no significant difference in the incidence of intestinal,ureteral or bladder injury between the S group and the L group(P<0.05).The surgery time of Group S was shorter than that of Group L,and the adhesion score and intraoperative blood loss volume were lower than those of Group L(P<0.05).There was no significant difference in the incidence of incision infection,dysmenorrhea,menstrual disorder or intestinal obstruction between the S group and the L group(P<0.05).The postoperative body temperature of Group S was lower than that of Group L(P<0.05),and the hospital stay was shorter than that of Group L(P<0.05).The incidences of recurrence and chronic pelvic pain within 3 mo after surgery were lower than that of Group L(P<0.05).CONCLUSION Twenty-four to forty-eight hours of anti-infective therapy is better than 48-96 h of anti-infective therapy for patients with pelvic abscesses because the degree of psychological stress is lower,which is more conducive to achieving better outcomes after laparoscopic surgery.

Novel combined endoscopic and laparoscopic surgery for advanced T2 gastric cancer:Two case reports

BACKGROUND The standard treatment for advanced T2 gastric cancer(GC)is laparoscopic or surgical gastrectomy(either partial or total)and D2 lymphadenectomy.A novel combined endoscopic and laparoscopic surgery(NCELS)has recently been proposed as a better option for T2 GC.Here we describe two case studies demonstrating the efficacy and safety of NCELS.CASE SUMMARY Two T2 GC cases were both resected by endoscopic submucosal dissection and full-thickness resection and laparoscopic lymph nodes dissection.This method has the advantage of being more precise and minimally invasive compared to current methods.The treatment of these 2 patients was safe and effective with no complications.These cases were followed up for nearly 4 years without recurrence or metastasis.CONCLUSION This novel method provides a minimally invasive treatment option for T2 GC,and its potential indications,effectiveness and safety needs to be further evaluated in controlled studies.

Current applications of artificial intelligence-based computer vision in laparoscopic surgery

Recent advances in artificial intelligence(AI)have sparked a surge in the application of computer vision(CV)in surgical video analysis.Laparoscopic surgery produces a large number of surgical videos,which provides a new opportunity for improving of CV technology in laparoscopic surgery.AI-based CV techniques may leverage these surgical video data to develop real-time automated decision support tools and surgeon training systems,which shows a new direction in dealing with the shortcomings of laparoscopic surgery.The effectiveness of CV applications in surgical procedures is still under early evaluation,so it is necessary to discuss challenges and obstacles.The review introduced the commonly used deep learning algorithms in CV and described their usage in detail in four application scenes,including phase recognition,anatomy detection,instrument detection and action recognition in laparoscopic surgery.The currently described applications of CV in laparoscopic surgery are limited.Most of the current research focuses on the identification of workflow and anatomical structure,while the identification of instruments and surgical actions is still awaiting further breakthroughs.Future research on the use of CV in laparoscopic surgery should focus on applications in more scenarios,such as surgeon skill assessment and the development of more efficient models.

Laparoscopic Surgery and Modified Xiaoyan Lidan Decoction:An Effective Combination for Treating Cholecystitis with Cholelithiasis

Objective:To assess the clinical effects of combining laparoscopic surgery with Modified Xiaoyan Lidan Decoction in patients diagnosed with cholecystitis and cholelithiasis.Methods:Following the guidelines of the double-blind method,86 cases of cholecystitis with cholelithiasis were randomly divided into two groups,each comprising 43 cases.Both groups underwent laparoscopic surgery,with the observation group additionally receiving Modified Xiaoyan Lidan Decoction.A comparative analysis was conducted on clinical treatment effectiveness,general observation indicators,Traditional Chinese Medicine(TCM)syndrome scores,and the occurrence of adverse reactions between the two groups.Results:The observation group demonstrated a significantly higher overall clinical treatment effectiveness compared to the control group(P<0.05).The clinical symptom improvement time and hospitalization time were shorter in the observation group,and the pain score and TCM syndrome score after treatment were lower than those in the control group(P<0.05).No statistically significant difference was observed in the total reaction values(P>0.05).Conclusion:The combined application of laparoscopic surgery and Modified Xiaoyan Lidan Decoction can enhance clinical treatment efficiency for patients with cholecystitis and cholelithiasis.It facilitates a quicker improvement in clinical symptoms without causing serious adverse reactions,suggesting its potential for widespread adoption.

Postoperative ileus: Impact of pharmacological treatment,laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery.POI represents the single largest factor influencing length of stay (LOS) after bowel resection,and has great implications for patients and resource utilization in health care.New methods to treat and decrease the length of POI are therefore of great importance.During the past decade,a substantial amount of research has been performed evaluating POI,and great progress has been made in our understanding and treatment of POI.Laparoscopic procedures,enhanced recovery pathways and pharmacologic treatment have been introduced.Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection.This editorial outlines resource utilization of POI,normal physiology of gut motility and pathogenesis of POI.Pharmacological treatment,fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI.The optimal integration of these treatment options continues to be assessed in prospective studies.

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer

AIM: To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer. METHODS: A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model. RESULTS: Eight studies matched the selection criteria and reported on 661 subjects, of whom 268 underwent RS and 393 underwent LS for rectal cancer. Compared the perioperative outcomes of RS with LS, reports of RS indicated favorable outcomes considering conversion(WMD: 0.25; 95% CI: 0.11-0.58; P = 0.001). Meanwhile, operative time (WMD: 27.92, 95% CI: -13.43 to 69.27; P = 0.19); blood loss (WMD: -32.35, 95% CI: -86.19 to 21.50; P = 0.24); days to passing flatus (WMD: -0.18, 95% CI: -0.96 to 0.60; P = 0.65); length of stay (WMD: -0.04; 95% CI: -2.28 to 2.20; P = 0.97); complications (WMD: 1.05; 95% CI: 0.71-1.55; P = 0.82) and pathological details, including lymph nodes harvested (WMD: 0.41, 95% CI: -0.67 to 1.50; P = 0.46), distal resection margin (WMD: -0.35, 95% CI: -1.27 to 0.58; P = 0.46), and positive circumferential resection margin (WMD: 0.54, 95% CI: 0.12-2.39; P = 0.42) were similar between RS and LS. CONCLUSION: RS for rectal cancer is superior to LS in terms of conversion. RS may be an alternative treatment for rectal cancer. Further studies are required.

Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery

AIM: To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG).

Overview of single-port laparoscopic surgery for colorectal cancers: Past, present, and the future

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE) - i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery&#x02019;s way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer:A technical review

Single-incision laparoscopic surgery(SILS),or laparoendoscopic single-site surgery,was launched to minimize incisional traumatic effects in the 1990s.Minor SILS,such as cholecystectomies,have been gaining in popularity over the past few decades.Its application in complicated hepatopancreatobiliary(HPB)surgeries,however,has made slow progress due to instrumental and technical limitations,costs,and safety concerns.While minimally invasive abdominal surgery is pushing the boundaries,advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety,including hepatectomies,distal pancreatectomies(DP),and pancreaticoduodenectomies(PD).In contrast,advanced SILS for HPB malignancy has only been reported in a few small case series.Most of the procedures involved minor liver resections and DP;major hepatectomies were rarely described.Singleincision laparoscopic PD has not yet been reported.We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

LAPAROSCOPIC SURGERY IN PATIENTS WITH HYPOVOLEMIC SHOCK DUE TO ECTOPIC PREGNANCY

Objective To evaluate the feasibility and safety of operative laparoscopy for ectopic pregnancy with hypovolemic shock. Methods Two hundred and fifteen women with ectopic pregnancy underwent operative laparoscopy. These patients were divided into two groups. The study group included 21 patients with shock and intraperitoneal hemorrhage more than 1000 mL, and control group included 194 patients, hemodynamically stable, with blood loss less than 1000 mL. Clinical data of perio-perative periods in two groups were retrospectively analyzed. Results All patients were tubal pregnancies. The occurrence rate of tubal rupture was higher in study group than in control group (80.95% vs. 15.98%, P < 0.001). Intraabdominal blood loss was significantly higher in study group than in control group (1900 mL vs. 300 mL, P < 0.001), and autologous blood transfusions were given to 95.24% and 9.3% of patients in study and control group, respectively (P < 0.001). Laparoscopic salpingectomy was performed on 85.7 % and 50.5% of patients in study and control group (P < 0.001). The operative time was somewhat longer in study group than that in control group (60 minutes vs. 45 minutes), but with no significant difference. All patients had no perioperative complications. Conclusion Operative laparoscopy in patients with hopovolemic shock can be safely and effectively performed by experi-enced laparoscopists with the aid of optimal anesthesia, advanced cardiovascular monitoring, and autologous blood transfusion.

Hand-assisted laparoscopic surgery for complex gallstone disease: A report of five cases

AIM:To describe the use of hand-assisted laparoscopic surg-ery(HALS) as an alternative to open conversion for complex gall-stone diseases, including Mirizzi syndrome (MS) and mimic MS. METHODS: Five patients with MS and mimic MS of 232 consecutive patients undergoing laparoscopic cholecyst-ectomies were analyzed. HALS without a hand-port device was performed as an alternative to open conversion if the anatomy was still unclear after the neck of the gallbladder was reached. RESULTS: HALS was performed on three patients with MS type I and 2 with mimic MS owing to an unclear or abnormal anatomy, or an unusual circumstance in which an impacted stone was squeezed out from the infundibulum or the aberrant cystic duct impossible with laparoscopic approach. The median operative time was 165 min (range, 115-190 min). The median hand-assisted time was 75 min (range, 65-100 min). The median postoperative stay was 4 d (range, 3-5 d). The postoperative course was uneventful, except for 1 patient complicated with a minor incision infection. CONCLUSION: HALS for MS type I and mimic MS is safe and feasible. It simplifies laparoscopic procedure, and can be used as an alternative to open conversion for complex gallstone diseases.

Effect of Preemptive Ketamine Administration on Postoperative Visceral Pain after Gynecological Laparoscopic Surgery

The pain following gynecological laparoscopic surgery is less intense than that following open surgery; however, patients often experience visceral pain after the former surgery. The aim of this study was to determine the effects of preemptive ketamine on visceral pain in patients undergoing gynecological laparoscopic surgery. Ninety patients undergoing gynecological laparoscopic surgery were randomly assigned to one of three groups. Group 1 received placebo. Group 2 was intravenously injected with preincisional saline and local infiltration with 20 m L ropivacaine（4 mg/m L） at the end of surgery. Group 3 was intravenously injected with preincisional ketamine（0.3 mg/kg） and local infiltration with 20 m L ropivacaine（4 mg/m L） at the end of surgery. A standard anesthetic was used for all patients, and meperidine was used for postoperative analgesia. The visual analogue scale（VAS） scores for incisional and visceral pain at 2, 6, 12, and 24 h, cumulative analgesic consumption and time until first analgesic medication request, and adverse effects were recorded postoperatively. The VAS scores of visceral pain in group 3 were significantly lower than those in group 2 and group 1 at 2 h and 6 h postoperatively（P〈0.05 and P〈0.01, respectively）. At 2 h and 6 h, the VAS scores of incisional pain did not differ significantly between groups 2 and 3, but they were significantly lower than those in group 1（P〈0.01）. Groups 1 and 2 did not show any differences in visceral pain scores at 2 h and 6 h postoperatively. Moreover, the three groups showed no statistically significant differences in visceral and incisional pain scores at 12 h and 24 h postoperatively. The consumption of analgesics was significantly greater in group 1 than in groups 2 and 3, and the time to first request for analgesics was significantly longer in groups 2 and 3 than in group 1, with no statistically significant difference between groups 2 and 3. However, the three groups showed no significant difference in the incidence of shoulder pain or adverse effects. Preemptive ketamine may reduce visceral pain in patients undergoing gynecological laparoscopic surgery.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.