Laparoscopy has evolved since as early as 1950 to the present state of being the standard approach for most common surgical procedures. It has gained popularity in clinical practice in view of better cosmetics, lesser postoperative pain, shorter hospitalization, and faster recovery. However, the creation of pneumoperitoneum with laparoscopy is associated with various pathophysiological changes, especially involving the cardiovascular and respiratory systems. Electronic databases were searched to obtain the relevant literature with keywords related to laparoscopy from 1985 to 2016. Ninety-three papers were reviewed. Bibliographies were cross-checked and relevant literature was included. The pneumoperitoneum associated with laparoscopy is found to cause a decrease in cardiac output with an increase in pulmonary and systemic vascular resistance. These changes are mainly due to the increase in abdominal pressure which causes elevation of diaphragm with compression of small and big blood vessels. In the lungs, it causes a decrease in functional residual capacity with impaired pulmonary ventilation and perfusion. Increase in intra-abdominal pressure also perils the splanchnic circulation with a decrease in blood flow to the major abdominal organs. Preoperative assessment requires special attention, especially in high-risk patients. General anesthesia with controlled ventilation has proven to the ideal technique. Various pharmacological agents are used with varying success to attenuate the hemodynamic responses to laparoscopy. This article discusses the various consequences of laparoscopy as well as strategies to counteract them. It is essential for the anesthesiologists to have a good understanding of these changes and intervene at appropriate levels in terms of optimization in the preoperative period and management of hemodynamic changes in the perioperative period for a good surgical and patient outcome.

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Context: With advancements in the field of minimally invasive surgery, a variety of general surgical, gynecological, and urological diseases are amenable to treatment by this approach. Combined procedures can be performed for treating coexisting abdominal pathologies. Aims: The study aimed to evaluate our experience of combining multiple minimally invasive procedures in terms of its safety and efficacy. Settings and Design: An observational study was conducted at three hospitals in Kashmir. Materials and Methods: A total of 149 patients underwent combined laparoscopic or combined laparoscopic and endoscopic procedures for the treatment of coexisting abdominal diseases. The outcome was analyzed in terms of mean operative time, postoperative visual analog scale score (0–10), requirement of additional postoperative analgesics, complications, hospital stay, and patient satisfaction. Statistical Analysis: Prospective sample survey analyzing the percentage and mean values. Results: Of 149 patients, 48 (32.2%) were male and 101 (67.7%) were female. Age ranged between 18-58 years in females and 24–70 years in males. The mean operative time ranged between 27 and 115 min. It was the longest in patients who underwent laparoscopic cholecystectomy (LC) with laparoscopically assisted vaginal hysterectomy. The most common organ-specific procedures performed were LC, appendectomy, and ovarian cystectomy in 120, 34, and 15 patients, respectively. Urological procedures were done in 36 patients undergoing either LC or appendectomy. Additional parenteral postoperative analgesics were required in 128 (85.9%) patients. A total of five major and 32 minor complications were noted in 22 (14.7%) patients. Three (2.01%) patients required conversion to open surgery. Orals were started on the 1^st postoperative day in the majority of the patients. The mean hospital stay was 2.4 days (range 1–6 days). Overall, 93.9% of the patients expressed satisfaction to the combined procedure. Conclusions: Simultaneous minimally invasive procedures are feasible for coexisting abdominal pathologies in selected patients with the advantages of single anesthesia and hospital admission, low morbidity, and excellent patient satisfaction.

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Background and Objectives: This is a survey study of adverse events in the postanesthesia care unit (PACU) at the University Malaya Medical Center (UMMC). Patients and Methods: After obtaining the hospital ethics committee approval, 2704 patients who were operated and admitted to the PACU at UMMC were included in the survey. The survey period was from July 1, to September 30, 2005. The modified Aldrete score was used in the PACU. If it was <9 on a 10-point scale that was defined as a patient complication. A patient diagnosed with a complication was immediately notified by the recovery nurse to the attended anesthesiologist who managed the case, and a survey report was completed. Results: Nearly 9.7% reported incidents of adverse events included two accidents of cardiac arrests. The majority of which were due to hypothermia and cardiovascular instability. Most incidents were in American Association of Anesthetists 3 and 4 category. General surgery was associated with the highest incidents. Most of the incidents resulted in prolonged PACU stay. Conclusions: This study provides auditing information on adverse incidence in the PACU with issues of care delivery; besides, it highlights a roadmap for quality improvement for a better patient care.

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As obesity is becoming a global epidemic, many solutions have been proposed to patients from medical to psychological to surgical. Recently, with the advances of laparoscopic surgery and the safety of the anesthesia, bariatric surgeries are expanding, particularly in the countries affected by obesity the most. Saudi Arabia is one of the highest countries with an obesity rate. This study aims to explore the complications of various bariatric surgeries (gastric banding, gastric bypass, and vertical sleeve gastrectomy) by reviewing the literature that has been published in Saudi Arabia. The findings from this study would enlighten the clinicians and patients about the prevalence of these complications in this geographical area and allow a thoughtful comparison between the complication rate among different countries and practice types.

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The prevalence of obesity in Saudi Arabia was 28.7% in 2013, and similar to the west, laparoscopic sleeve gastrectomy (LSG) is nowadays one of the most commonly performed bariatric procedures in Saudi Arabia. Portal vein thrombosis (PVT) was at first thought to be a rare and potentially fatal occurrence postoperatively. Recent data suggest that it is much more prevalent following LSG of all other bariatric procedures, and prognosis is favorable given early diagnosis and treatment. The aim of this article was to describe three cases of PVT post-LSG encountered at our institution and provide a brief review of the literature.

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Foreign body (FB) ingestion is quite frequently seen in clinical practice while intestinal perforation due to it is infrequent. Preoperative diagnosis is quite challenging once the history is inconsistent. We report herein, a young male patient who presented to the emergency department with acute abdomen a day after taking sheep meat with unnoticed ingestion of bone, where a clinical diagnosis of acute appendicitis was made, later came out distal ileal perforation due to “meat bone” that was protruded into the abdominal cavity. The bone was removed and perforation closed through endo stitch. The report of this case highlights the risk of missing the unusual causes of acute abdomen if the history is incomplete or the FB is radiolucent. Surgeons treating acute abdomen should keep the uncommon causes in mind once the common causes are excluded from the study.

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Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi. Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy. Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

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Introduction: The successful maintenance of peritoneal dialysis is the outcome of well functioning of the peritoneal catheter. Catheter outflow obstruction may cripple the usage of the peritoneal catheter. Catheter migration, omental entrapment, and fibrin clots are the usual causes of this failure. Oviduct fimbriae can cause obstruction rarely. Materials and Surgical Technique: We describe a case of a a 65-year-old woman, in whom the obstruction fimbriae was the cause of the obstruction and was managed by cleaning the catheter, and the right  fimbraepexy to the lateral wall of the peritoneal wall in the dependent part with no salpingectomy is required. Discussion: In follow-up of 20 months, the catheter is working; this technique can be used in young patients who need to balance the risk of infertility with the risk of malfunction of peritoneal dialysis catheter. Conclusions: Ovarian fimbria entrapment in the PDC is rarely the cause of dialysis flow obstruction, if occurs, laparoscopic management is ideal way to manage such presentation.

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Background: Laparoscopic cholecystectomy (LC), gaining worldwide popularity for being less invasive, enhances earlier recovery. It can be performed on a short stay basis, reducing health care burden, if postoperative pain is adequately addressed. The aim of the present study is to determine the effect of intraoperative infusion of intravenous (IV) lignocaine primarily in terms of time to achieve fast-track eligibility (White Song score 12 out of 14) and postoperative analgesia in patients undergoing LC. Materials and Methods: A total of 120 ASAPS 1 and 2 patients undergoing elective LC were included in this randomized, prospective, placebo-controlled clinical study. Patients were allocated into two groups to receive intraoperative IV lignocaine (Group L) or normal saline (Group C). Lignocaine bolus dose 1.5 mg/kg was administered over a period of 5 min before induction followed by continuous IV infusion 3 mg/kg/h until extubation. Postoperative fentanyl requirement (during the first 6 postoperative hours) and fast-track eligibility (time to reach White Song score 12 out of 14) were recorded. Results: Time to achieve White Song score 12 out of 14 was found to be earlier in Group L (19.9 ± 3.6 min vs. 22.9 ± 2.9 min, P < 0.001). Postoperative requirement of fentanyl was significantly lower (99.3 ± 29.8 μg in Group L compared to 133 ± 35.9 μg in Group C, P < 0.001) in patients of lignocaine group. Conclusion: IV lignocaine effectively improves recovery and reduces postoperative fentanyl requirement, thereby is an inexpensive and safe method of postoperative analgesia.

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Background: Parturient undergoing elective cesarian delivery (CD) in a busy tertiary care referral hospital often requires blood transfusions. The preoperative ordering for blood crossmatch frequently overshoots the actual need of transfusion. Aims: The primary aim of this study was to audit the local blood ordering practice in obstetric anesthesia and compare with the international guidelines. Materials and Methods: A retrospective analysis of patients who underwent elective CD over a period of 6 months was done. The data collected included patients' age, pretransfusion hemoglobin, timing of transfusion, number of units crossmatched, and number of units transfused. The crossmatch transfusion ratio (CTR), transfusion probability, and transfusion index were calculated from the data. Results: A total of 425 patients underwent CD with mean age 33 (standard deviation 7). Seventy-seven (18%) of them were crossmatched with total 252 units. Thirty-one (7.3%) patients required transfusion and the number of units transfused was 79. CTR in our study was 3.2. Conclusion: CTR for elective CD is higher than the recommended international quality indicator value. There is a need to develop institutional specific blood ordering schedule to bring improvement in transfusion practices.

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