Thank you Dr. Bhandarkar for sending the article of SAGES guidelines. However, I am interested on your personal practice and whether you have encountered any cases of DVT or PE after laparoscopic abdominal procedure such as laparoscopic cholecystectomy, Nissen fundoplication, TAPP, etc.

Regards

For non obese non malignant cases we never give prophylaxis. For obese a post op dose of Arixtra is usually our practice. 

This is a difficult question in terms of experience with patients developing thromboembolic complications. In many cases the numbers are low but regarded as sufficient to risk assess and recommend prophylaxis.

E.g a 1% incidence of embolic complications in any personal series will need between 1-5 yr period to find a complication in relation to numbers of cases done and will require active robust monitoring to pick up complications. Then there is the need for an 'alert system' if/when complications do occur. Personally I haven't come across any but that does not mean 'no event' in respect of the above observation.

Chronic postherniorraphy pain is among the most frequent complications after inguinal hernia repair. In some patients it can be disabling. Chronic pain (CP) rates vary between 0% and 63% and may be secondary to a multitude of disorders including the postherniorrhaphy pain complex syndrome. Hernia surgery related nociceptive or neuropathic pain syndromes have to be differentiated from others. Few prospective long-term CP studies are available.Questions remain including what external and patient factors influence CP? How should the nerves be handled intraoperatively and do alloplastic materials play a role in CP?

Dr Alawad: thank you for your contribution, but this comment is meant for the discussion on chronic post hernia repair pain. Awaiting your valuable contribution for this discussion.

Regards

Only in selected patients, in obese and elderly  patients or malignat conditions.

Only in patient who have  risk of  DVT and pulmoner embolism. Not a routine procedure. Low molecular heparine is prefered. 

Actually it is a good question. A few weeks ago we had a disscussion in our Department regarding standard thromboprophylaxis in cancer patients. Most of the patients score high on the risk scores and should be given LMWH. We always give it to patients with colorectal cancer irrespective of the approach - open or lap. We just keep in mind that we would want to give the epidural analgesia in the postoperative period so the LMWH is given at the latest 12 hours prior to surgery. In this group of patients it is mandatory due to the high risk of thrombotic events. And yes over some years, I have seen a few cases of DVT and 2 cases of PE but mainly in cancer patients undergoing major abdominal open procedures. None in the lap group with LMWH prophylaxis.

But why would you give it to a young lady with breast cancer awaiting BCT treatment (60-90 min operative time)?

In my previous place, we had a high case-load of bariatric patients. In these patients we always gave LMWH and apparently it was necessary. When I was preparing a paper on one year outcomes of sleeve gastrectomy I found one case of pulmonary artery embolism causing death - despite given LMWH. 

In other general surgical patients undergoing laparoscopic operations we had no thromboembolic complications but most of the patients recieved LMWH unless contraindicated or emergancy cases.

Considering high incidence of DVT in UK, my practice is no prophylaxis in day cases but I use Flowtron boots while operating.

For in patients undergoing Lap Abdominal surgery, DVT prophylaxis started after 12 to 24 hrs depending on patient's risk factors and type of surgery. If the patient is alreday on LMWH, I omit it on the evening before surgery and start after 12 hrs.

1. LMWH, eg Fragmin 2500 U for 10-12 days, starting the evening before surgery.

2. Very selectively. We believe fast mobilization aided by adequate analgesia is a more physiologic and inexpensive measure to prevent DVT. Close to 100% of TEP/TAPP patients and the majority of lap-choles are day surgery.

3. Risk groups: eg complex surgery, obesity/bariatrics, previous history of DVT

4. Yes, but it is extremely rare (even without LMWH): Way under 1%

Thank you Dr. Novik for your clear reply.

Is giving LMWH for 10 days postoperatively your own personal practice? Or is it the standard practice in Sweden? Actually this is what is promoted by the manufacturers, and is commonly practiced by our orthopaedic colleagues. But I am not sure if this is evidence based.

I am also adopting a selective policy, and administer LMWH the night before surgery and stop it once the patient is fully ambulant for inpatients. The day surgery cases receive nothing. I have encountered one fatal PE in a patient with sickle cell anaemia and gallstones after LC. That was very early in my learning curve. Since then I have encountered none with my selective policy. However, all elderly, obese, cancer patients and laparoscopic colorectal resections receive LMWH routinely. 

Mr Qurashi: thank you. I am adopting more or less the same policy you are adopting. We apply automatic pneumatic compression device routinely in OR for all our patients undergoing surgery. This and early mobilization contribute to reduced thromboembolic events in day case surgery.

Mr Budhoo: thank you for your contribution.

I totally agree with you that "haven't come across any" does not mean "it does not happen". Most of these events are subclinical and therefore go unnoticed. It is also doubtful if subclinical DVT carries any clinical significance. However, it hard to know which subclinical event will give rise to a clinical and perhaps a fatal one. So selective policy is recommended.

Dr. Bhandarkar: thank you for very clear practical answer. This is exactly what we practice in our center. As I mentioned earlier, we have encountered one fatal PE in a sickle cell disease patient after LC early in our experience with these patients.

Thank you Drs. Taha andTurk for your valuable comments.

Thank you Dr. Bobowicz for your valuable comment. It is reassuring to know from that none of the lap group had thrombotic event with LMWH prophylaxis in your center.

Thank you also for bringing to our attention the important issue of giving the spinal anaesthesia during surgery and epidural analgesia in the postoperative period so the LMWH is given at the latest 12 hours prior to surgery. My question: will you restart LMWH on the same day of surgery and when? Thank you