The edition · General Surgery
TAP block cut rescue analgesia after cholecystectomy by two-thirds
A three-arm trial favours a laparoscopic-guided TAP block over port-site infiltration; alongside, when laparoscopic adhesiolysis stops paying off, why watchful waiting for hernias leaks patients, ICG targeting by CRP, and a year of symptoms after pancreatectomy.
The edition in brief
A three-arm randomised trial of 180 elective laparoscopic cholecystectomies found that a laparoscopic-guided transversus abdominis plane (TAP) block lowered early pain and reduced rescue tramadol to 8.3% with low-pressure pneumoperitoneum and 13.3% with standard pressure, against 41.7% with port-site infiltration. Shoulder-tip pain fell from 20.0% to 3.3% with the low-pressure combination. A single-centre series of 373 adhesive small bowel obstruction operations found laparoscopic adhesiolysis beat open surgery when completed, but conversion (15.8%) and every extra 15 minutes of operating (OR 1.40 for complications) eroded that advantage; higher BMI and prior cancer surgery predicted dense adhesions. In 400 patients on watchful waiting for inguinal hernia, 60% dropped out of follow-up, rising to 92.9% under age 30, with no emergency repairs detected. A cohort of 221 emergency cholecystectomies saw no conversions with ICG cholangiography against 8.8% without, the gap widening with CRP. In 1,009 patients after pancreatectomy for cancer, severe gastrointestinal symptoms affected 52% at a year. The pearl restates the critical view of safety.
Laparoscopic adhesiolysis: the advantage fades with time on the clock
Start laparoscopically in selected adhesive obstruction, but convert early when dissection is slow rather than prolonging it.
Watchful waiting for inguinal hernia: most patients stop coming back
When choosing watchful waiting for an inguinal hernia, rely on clear written safety-net advice rather than on follow-up visits.
ICG cholangiography in acute cholecystitis: most useful when CRP is high
Where ICG supply is limited, consider prioritising it for acute cholecystitis with high CRP.
After pancreatectomy for cancer, half still have severe gut symptoms at a year
Ask about gastrointestinal symptoms at every visit after pancreatectomy and treat exocrine insufficiency when present.
The critical view of safety: three criteria before you clip
Do not clip or divide anything until all three criteria of the critical view of safety are met.
TAP block beats port-site infiltration after laparoscopic cholecystectomy
Consider a laparoscopic-guided TAP block instead of port-site infiltration for routine cholecystectomy; it needs no ultrasound and cut rescue analgesia.
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