Elderly patients are considered at high surgical risk because of the increased American Society of Anesthesiologists score generally due to associated comorbidities. In addition, normal physiologic changes of aging such as decreased cardiopul-monary reserve may predispose patients to increased complications from prolonged pneumo-peritoneum.

The minimally invasive nature of laparoscopic surgery in general offers several advantages over open surgery in the elderly patient population.

Dhoste et al. described the cardiovascular and pulmonary changes induced by pneumoperitoneum in 16 patients aged >75 years and American Society of Anesthesiologists III. Cardiovascular monitoring included a radial artery catheter and a pulmonary artery catheter. Peritoneal insufflation resulted in improvement of cardiovascular function with increases in cardiac index, heart rate, mean arterial pressure, and SvO2, which was the result of a sympathetic stimulation. No change in preload, right ventricular end diastolic volume index and systemic vascular resistance was recorded. There was an increase in PaCO2 15 minutes after CO2 insufflation and a further elevation after 60 minutes. There was no change in the intrapulmonary shunt pressure. This study demonstrated that pneu-moperitoneum is well tolerated in older patients (36).

There are several reports documenting safety and efficacy of laparoscopic surgery in the elderly patient especially in the general surgery literature. In a study of 5884 consecutive patients who underwent an attempted laparoscopic cholecystectomy, 395 patients (6.7%) were older than 65 years. The results of laparoscopic cholecystectomy in patients aged 65-69 years were comparable with those reported in younger patients. Patients older than 70 years had a two-fold increase in complicated biliary tract disease and conversion rates because of the nature of the disease, but had a low mortality rate (2%) despite an increase in American Society of Anesthesiologists classification (37). Senagore et al. compared short-term outcomes in age-matched cohorts of patients undergoing laparoscopic versus open segmental colectomy in patients younger versus older than 70 years of age. The length of hospital stay was significantly shorter with laparoscopic surgery in both age cohorts. The direct hospital costs were significantly lower only with laparoscopic colectomy in the older cohorts. Using the physiologic and operative severity score for the enumeration of morbidity and mortality, it was noted that laparoscopy patients in both age groups experienced a rate of morbidity that was significantly lower than expected (38). Another study compared 65 patients (aged 70 and above) who underwent laparoscopic colorectal resection with 89 who had open surgery. Laparoscopic colorectal resection was found to be safe in elderly patients and was associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. Laparoscopy was also associated with less cardiopulmonary morbidity (39).

Hsu et al. retrospectively reviewed the outcome of laparoscopic donor nephrec-tomy in six patients aged 65 years or older. The median donor age was 69.5 years, and the median American Society of Anesthesiologists score was II. The median operative time was 240 minutes, with a median blood loss of 300 mL. No intraoperative complications or open conversions occurred. Postoperatively, the median time to resumption of oral intake was one day, and the median hospital stay was three days, and the median convalescence was two weeks. The one-year renal allograft survival was 100% (40). Fornara et al. reported findings for laparoscopic nephrectomy in 11 patients in comparison with open nephrectomy in 42 patients older than 65 years. Patients in the laparoscopy group demonstrated a significant decrease in blood loss and number of blood transfusions. In addition, benefits were shown for the analgesic consumption, hospital stay, and convalescence parameters for the laparoscopy group. Although the complication rates were comparable in both groups, an increase was observed in both groups for patients aged between 75 and 84 years (41).

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