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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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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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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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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A myoepithelial hamartoma is a very uncommon submucosal tumor of the stomach. The exact pathogenesis and natural history of these lesions are not fully understood, possibly because very few cases have been reported in the literature. Gastrointestinal tract adenomyomas are generally considered to be benign and may present clinically with in part long-standing, but unspecific symptoms, such as pain, nausea, anorexia, and in some patients, they can cause intermittent pyloric obstruction. In an atypical presentation in our case, myoepithelial hamartoma mimicked the clinical presentation of a gastrointestinal stromal tumor.

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Aims: To study the effect of sleeve gastrectomy in patients with type II diabetes mellitus and fatty liver disease. Settings and Design: This is a prospective study that was conducted from September 2016 to 2017 in KSUMC Riyadh, Saudi Arabia. Subjects and Methods: We obtained prospectively collected data from two longitudinal cohort studies at our institution. We included adults who were diagnosed with nonalcoholic fatty liver disease (NAFLD) and diabetes, with a body mass index (BMI) of >30 kg/m², and who underwent sleeve gastrectomy. Statistical Analysis Used: Data were analyzed using JMP® 13.0.0 for data management and reporting. Continuous data were reported as means and standard deviations if normally distributed or as medians and interquartile ranges otherwise. We also used the paired t-test and Chi-square test. Results: Our population included 32 patients (mean age, 39.5 years). The preoperative and postoperative median BMIs were 42.1 and 34.2 kg/m², respectively (P = 0.0003). The percentages of macrovascular steatosis pre- and postoperatively were 37.5 and 10, respectively (P = 0.0328). The patients who had complete diabetes mellitus (DM) remission postoperatively had a higher median BMI of 42.05 kg/m² preoperatively and 35.7 kg/m² postoperatively than that the patients who did not have remission (P = 0.0003). Regarding the age groups, 46.1% of patients aged <40 years at DM onset, and 34.6% of patients aged >40 years who had complete diabetes remission postoperatively, which was not statistically significant. Conclusions: DM remission was statistically significant postoperatively. Remission occurred more in the higher BMI groups. There was no clear relationship between NAFLD and diabetes remission.

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Leak occurring after sleeve gastrectomy is a well-known complication, with an incidence of around 1.9%–2.4%. Varying from very early to very late in onset. One of the different techniques used for the treatment of leaks is esophageal stinting with variable rates of success and reported complications. Here, we report a case of massive bleeding from an aortoesophageal fistula occurring after stent insertion in an attempt of treating postsleeve gastrectomy leak along with a review of the literature.

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Background: Single port surgery and transumbilical surgery are progressing rapidly. The advantages of the cosmetic appearance of this surgery encourages the surgeon to do it which has good acceptance from the patients. Moreover transumbilical laparoscopic cholecystectomy has the miratus of the single port surgery and traditional laparoscopic surgery. Single port surgery seemed to be expensive more than traditional laparoscopic surgery. Transumbilical Laparoscopic surgery is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). Aim: Hereby, we report of the initial clinical experiences in Saudi Arabia with this new technique. Ten cases of gallbladder stone are selected for this new technique. Materials and Methods: Tow curved intra-umbilical incision was made with 5mm port for camera (30 degree angle) and 8mm working port. Two separate incision 2mm each at right upper quadrant. Dissection was performed using an electric cautery hook and an endograsper. Result: Nine out of ten procedures were completed successfully and one case converted to conventional laparoscopic cholecystectomy because acutely inflamed. Average operative time 48 min with minimal blood loss. Postoperative follow-up did not reveal any umbilical wound complication. Conclusion: Therefore, transumbilical laparoscopic cholecystectomy is feasible and a promising alternative method as less scar in abdominal surgery for the treatment of some patients with gallbladder stone. No extra cost or special instruments are used. Moreover, we reduce the risk of the post single port hernia surgery.

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