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Ko Y, Ong H. Elderly man with abdominal pain. J Am Coll Emerg Physicians Open 2020; 1:1110-1111. [PMID: 33145567 PMCID: PMC7593494 DOI: 10.1002/emp2.12162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/10/2022] Open
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Ghoundiwal D, Delaporte A, Bidgoli J, Forget P, Fils JF, Van der Linden P. Effect of pneumoperitoneum on dynamic variables of fluid responsiveness (Delta PP and PVI) during Trendelenburg position. Saudi J Anaesth 2020; 14:323-328. [PMID: 32934624 PMCID: PMC7458000 DOI: 10.4103/sja.sja_737_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/04/2019] [Accepted: 01/26/2020] [Indexed: 11/29/2022] Open
Abstract
Background and Aims: Pulse pressure variation (ΔPP) is considered as one of the best predictors of fluid responsiveness in patients under mechanical ventilation. Pleth Variability Index (PVI) has been proposed as a noninvasive alternative. However, pneumoperitoneum has been recently suggested as a limitation to their interpretation. The aim of this study was to compare changes in ΔPP and PVI related to autotransfusion associated with a Trendelenburg maneuver before and during pneumoperitoneum. Methods: 50 patients undergoing elective abdominal laparoscopic surgery were enrolled in this prospective observational study. All patients were equipped with an invasive radial artery catheter and a PVI probe. After obtaining a stable signal with both ΔPP and PVI, baseline values were recorded, before and after head-down tilts of 10°, with or without abdominal insufflation (10-12 mmHg). All measurements were made before any fluid challenge under standardized anaesthesia, while patients were paralyzed and mechanically ventilated with 8 mL/kg tidal volume. Results: Changes in ΔPP and PVI associated with the Trendelenburg maneuver before and after insufflation of the pneumoperitoneum were significantly different (P < 0.001). In baseline conditions, the Trendelenburg maneuver was associated with a significant decrease in heart rate while mean arterial pressure remained unchanged. Both ΔPP and PVI decreased. After insufflation of the pneumoperitoneum, the Trendelenburg maneuver was associated with a significant decrease in heart rate and ΔPP and an increase in mean arterial pressure while PVI remained unchanged. Conclusion: Pneumoperitoneum did not alter the response of ΔPP to autotransfusion associated with the Trendelenburg maneuver, which was not the case for the PVI. This latter decreased during Trendelenburg maneuver performed alone and remained unchanged during Trendelenburg maneuver performed after insufflation of the pneumoperitoneum.
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Hameed T, Kumar A, Sahni S, Bhatia R, Vidhyarthy AK. Emerging Spectrum of Perforation Peritonitis in Developing World. Front Surg 2020; 7:50. [PMID: 33102512 PMCID: PMC7522547 DOI: 10.3389/fsurg.2020.00050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Gastrointestinal perforations constitute a major cause of patients with acute abdomen pain coming to the surgery emergency room. Incidence, site of perforation, and age is different in the developing world and is showing new trends. The etiological spectrum in the developing world is different from the western world. This study was conducted to find out the latest trends in perforation peritonitis in India. Methods: This study was conducted in a single surgical unit of Darbhanga Medical College and Hospital, India. A total of 350 consecutive patients with perforation peritonitis were studied in terms of age, sex, seasonal variation, biochemical parameters, clinical presentation, radiological and intraoperative findings, surgical intervention, and postoperative outcome. Results: The most common cause of perforation peritonitis in our study was a duodenal ulcer (~50%) followed by typhoid (20%), traumatic (14.5%), appendicular (7.4%), and tubercular (3.1%) cases. Males were three times more commonly affected than females. Peak incidence was noted in the 2nd and 3rd decades of life. Peptic ulcer perforations were common in autumn and winter and typhoid perforations were common during the summer and rainy seasons. Conclusion: Spectrum of perforation peritonitis cases in this part of world is different from developed western countries. It is different in respect of younger age at presentation, site of perforation, and etiological factors. Infective pathology makes up to a quarter of total cases in the developing world. The developing world has more perforation peritonitis cases involving the upper gastrointestinal tract, while the western world has a predominance of lower gastrointestinal tract perforations.
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Jo YY, Lee KC, Chang YJ, Jung WS, Park J, Kwak HJ. Effects of an Alveolar Recruitment Maneuver During Lung Protective Ventilation on Postoperative Pulmonary Complications in Elderly Patients Undergoing Laparoscopy. Clin Interv Aging 2020; 15:1461-1469. [PMID: 32921992 PMCID: PMC7457882 DOI: 10.2147/cia.s264987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 10/26/2022] Open
Abstract
Purpose Controversy remains over whether alveolar recruitment maneuvers (ARMs) can reduce postoperative pulmonary complications. We hypothesized that performing an ARM in addition to lung protective ventilation (LPV) could improve intraoperative arterial oxygenation and postoperative pulmonary complications (PPCs) in elderly patients undergoing laparoscopy in the Trendelenburg position. Patients and Methods Sixty-two patients (aged 65-85) scheduled for laparoscopic low anterior resection were randomized to receive LPV only (LPV group, n = 32) or LPV with an ARM (ARM group, n = 30). LPV was set to a tidal volume of 6 mL/kg with a positive end expiratory pressure (PEEP) of 5 cmH2O. The ARM was performed by serially increasing the PEEP to 10 cmH2O for 3 breaths, 15 cmH2O for 3 breaths, then 20 cmH2O for 10 breaths, both immediately before and after abdominal insufflation. The primary end-point was the frequency of PPCs such as desaturation (SpO2 <90%), atelectasis, and pneumonia. Secondary end-points were changes in intraoperative respiratory and gas exchange parameters and hemodynamic variables. Results One patient in the LPV group experienced desaturation on the first postoperative day. The frequency of chest X-ray abnormalities such as atelectasis or pleural effusion was comparable between groups (6 (19%) and 5 (17%) patients, respectively, P = 0.676). Changes in other respiratory, gas exchange and hemodynamic parameters over time were not significantly different between the groups. However, vasopressor requirements during surgery were higher in the ARM than the LPV group (9 (30%) and 2 (6%) patients, respectively, P = 0.014). Conclusion This study suggests that performing an ARM during LPV may not improve postoperative respiratory outcomes and intraoperative oxygenation compared to LPV alone in geriatric patients undergoing laparoscopy in the Trendelenburg position. In addition, since the ARM could cause a significant deterioration in hemodynamic parameters, applying ARM to elderly patients should be carefully considered.
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Low-pressure pulmonary recruitment maneuver: equal to or worse than moderate-pressure pulmonary recruitment maneuver in preventing postlaparoscopic shoulder pain? A randomized controlled trial of 72 patients. Wideochir Inne Tech Maloinwazyjne 2020; 15:519-525. [PMID: 32904585 PMCID: PMC7457197 DOI: 10.5114/wiitm.2019.89831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/25/2019] [Indexed: 01/07/2023] Open
Abstract
Introduction The pulmonary recruitment maneuver (PRM) has emerged as an effective way of reducing post-laparoscopic shoulder pain (PLSP). However, the optimal lower pressure level for a PRM to reduce PLSP has not yet been investigated. Aim To compare the efficacy of the low-pressure PRM with moderate-pressure PRM in preventing PLSP. Material and methods Seventy-two ASA I-II patients who were scheduled for gynecologic LS for non-malignant conditions were enrolled in this study. Group 1 included patients who received the PRM at a maximum pressure of 30-40 cm H2O in a semi-Fowler position and group 2 included patients who received the PRM at a maximum pressure of 15 cm H2O in a semi-Fowler position. The primary outcome of the study was the difference in PLSP between the two groups. Results There were no significant differences in PLSP and wound pain VAS scores between patients receiving the PRM at 30 cm H2O and 15 cm H2O during postoperative pain monitoring (p < 0.05). The groups were also similar with respect to ambulation time (p = 0.215), length of hospital stay (p = 0.556) and the height of the pneumoperitoneum measured on chest X-ray (p = 0.151). Conclusions The low-pressure PRM (15 cm H2O pressure) provides similar efficacy as the moderate-pressure PRM (30-40 cm H2O) in terms of PLSP, wound pain, height of pneumoperitoneum, time of ambulation and length of hospital stay. We suggest that lower maximal inspiratory pressure of 15 cm H2O might be preferred to avoid the potential complications of the PRM with higher pressures.
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Bakshi SG, Paulin SV, Bhawalkar P. A randomised controlled trial to evaluate the peri-operative role of intraoperative dexmedetomidine infusion in robotic-assisted laparoscopic oncosurgeries. Indian J Anaesth 2020; 64:784-789. [PMID: 33162573 PMCID: PMC7641074 DOI: 10.4103/ija.ija_664_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 11/27/2022] Open
Abstract
Background: Robotic and minimal invasive surgeries pose challenges to the anaesthesiologists. Dexmedetomidine (dexmed), with distinct properties of sedation and analgesia has emerged as a promising drug. Our primary aim, in this double-blinded study, was to evaluate reduction in the intraoperative opioid requirement with the use of intravenous dexmed infusion. Secondary objectives included effect on intraoperative anaesthetic and postoperative analgesic requirement. Methodology: After approval from Ethics board and registration of the trial, 46 eligible patients planned for robotic oncosurgeries (abdomen) were included. As per computer generated randomisation chart, patients were randomised into either dexmed or saline group. Five minutes after insufflation of the abdomen, the study drug bolus—saline or dexmed (1 μg/kg) was given over 10 min and was followed by maintenance infusion (0.2 μg/kg/h) until release of pneumoperitoneum. Study drug titration, fentanyl boluses, and changes in minimum alveolar concentration (MAC) of inhalational agent were protocolised. Results: The mean intraoperative fentanyl requirement was significantly lower in the dexmed group 192.6 μg (±66.4) versus the saline group 260.7 μg (±88.6), P = 0.013. The MAC requirement of inhalational agent was significantly lower in the dexmed group. Intraoperative episodes of hypotension and bradycardia were similar in both groups. First analgesic request, 24 h postoperative pain scores and side effects profile were comparable in both groups. Conclusion: Intraoperative dexmed (bolus of 1 μg/kg followed by 0.2 μg/kg/h infusion) has an opioid and inhalational anaesthetic sparing role during robotic oncosurgeries. However, no benefit of the infusion is seen in the postoperative period.
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Jain M, Ramani M, Gandhi S, Jain C, Sarvanan VK. A Randomized Controlled Study to Compare Hemodynamic Effects between Clonidine and Pregabalin in Laparoscopic Cholecystectomy. Anesth Essays Res 2020; 14:4-15. [PMID: 32843784 PMCID: PMC7428121 DOI: 10.4103/aer.aer_15_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/23/2020] [Accepted: 03/20/2020] [Indexed: 11/06/2022] Open
Abstract
Background: Laparoscopic cholecystectomy (LC) is associated with pneumoperitoneum and hemodynamic disturbances. Pregabalin and Clonidine have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated. Aims: The study was done to assess and compare the efficacy of preoperative single oral dose of pregabalin and clonidine in maintaining the hemodynamic parameters in the LC. Settings and Design: The prospective, interventional, randomized, comparative, single-blinded study was conducted in the department of anesthesia and surgery from January 2015 to September 2016 after taking approval from the institutional ethical committee. Materials and Methods: The study included a total of 90 patients, aged between 18 and 56 years of both sexes scheduled for elective LC. Patients were randomized into three groups of 30 each who received oral pregabalin 150 mg, clonidine 200 ug, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse events. Statistical Analysis: Quantitative variables were compared using unpaired t-test (when the data sets were not normally distributed) between the two groups. Qualitative variables were compared using Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: There was a significant increase in the heart rate (HR) and systolic, diastolic, and mean blood pressure during laryngoscopy and pneumoperitoneum in the control group as compared to both pregabalin and clonidine. HR was significantly lower in clonidine group after extubation and in postoperative period than both control group and pregabalin group. There was no major difference in the incidence of side effects. Conclusion: Both pregabalin (150 mg) and clonidine (200 ug) were effective in controlling the hemodynamic parameters during LC, with clonidine providing better hemodynamic stability than Pregabalin.
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Gupta R, Pokharia P, Daspal U, Ammar H. A Case of Pneumatic Rectal Perforation Caused by Compressed Air. Cureus 2020; 12:e9954. [PMID: 32983660 PMCID: PMC7510177 DOI: 10.7759/cureus.9954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Rectal perforation is a rare cause of acute abdomen. The most common cause of rectal perforation is trauma. Barotrauma due to the injection of compressed air in the rectum is an extremely rare cause of rectal perforation. We report a case of extensive pneumoperitoneum with abdominal compartment syndrome caused by rectal perforation secondary to the forceful injection of compressed air through the perineum. The patient was successfully managed by immediate relief of abdominal compartment syndrome by needle decompression followed by surgical repair of rectal perforation.
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Jebin Aaron D, Bhattarai S, Shaikh O, Sistla SC. Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach. Cureus 2020; 12:e9694. [PMID: 32923284 PMCID: PMC7486096 DOI: 10.7759/cureus.9694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.
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Lommen MJ, Zineldine O, Mehta TI, Radtke LE, Serrano O. Pneumatosis Cystoides Intestinalis Identified on Screening Colonoscopy With Associated Pneumoperitoneum. Cureus 2020; 12:e9512. [PMID: 32884868 PMCID: PMC7462655 DOI: 10.7759/cureus.9512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures.
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Sag S, Imamoglu M, Sarihan H, Yulug E, Alver A, Geze Saatci S, Cay A. Effects of carbon dioxide pneumoperitoneum on exocrine and endocrine functions, and oxidative state of rat pancreas. Biotech Histochem 2020; 96:257-262. [PMID: 32643433 DOI: 10.1080/10520295.2020.1789224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
We investigated the effects of increased intra-abdominal pressure during laparoscopy on the endocrine and exocrine functions, oxidative stress and histopathology of the pancreas in rats. We established three experimental groups of eight animals. Group 1 was the untreated control. Forth other two groups, pneumoperitoneum with CO2 was established for 60 min at 6 mm Hg for group 2 and 12 mm Hg for group 3; groups 2 and 3 animals were allowed to re-perfuse for 30 min. Amylase, glucagon and insulin levels were analyzed in blood samples and insulin:glucagon ratio was calculated. Histopathology and malondialdehyde assay were performed on pancreatic tissue samples. Histological damage scores for vasocongestion were increased significantly in groups 2 and 3 compared to group 1. Histological damage scores for inflammatory cell infiltration were increased significantly in group 3 compared to group 1. Malondialdehyde levels were increased significantly in group 3 compared to group 1. We found no significant differences among groups for serum amylase levels or histological damage scores for hemorrhage. Insulin and glucagon levels, and the insulin:glucagon ratio was increased significantly in group 3 compared to groups 1 and 2. We found that in rats routine laparoscopy caused increased serum insulin and glucagon levels, and histopathological changes that indicated ischemia-reperfusion injury to the pancreas.
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Kambe K, Nagata T, Taniguchi A, Fukuda KI, Yamaoka N, Iwata G. Is pneumoperitoneum necessary for single-incision laparoscopy-assisted appendectomy for pediatric appendicitis? Asian J Endosc Surg 2020; 13:319-323. [PMID: 31823486 DOI: 10.1111/ases.12765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/28/2019] [Accepted: 10/22/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Several studies have reported the treatment of pediatric appendicitis with single-incision laparoscopy-assisted appendectomy using a muscle hook without pneumoperitoneum to lift the abdominal wall. However, very few studies have investigated the advantages of this procedure. We examined the utility of this procedure in our department. METHODS This study included 33 children with appendicitis who underwent single-incision laparoscopy-assisted appendectomy at our hospital from April 2011 to March 2018. Patients were divided into two groups depending on whether they underwent the procedure with pneumoperitoneum: the no pneumoperitoneum group (n = 12) and the pneumoperitoneum group (n = 21). The clinicopathological factors and surgical costs were compared between the two groups. RESULTS In the pneumoperitoneum group, the procedure was initiated in four patients by lifting the abdominal wall but was changed to include a pneumoperitoneum because of difficulty. There were no significant differences between the two groups with regard to age, sex, or pathological severity. CT revealed a significant difference in the distance from the appendicular root to the umbilicus between the groups. There was a significant difference in the operative duration, but not in estimated blood loss or length of postoperative hospital stay. Complications were observed in one patient in each group. There was a significant difference in cost between the two groups. CONCLUSIONS Single-incision laparoscopy-assisted appendectomy without pneumoperitoneum is less expensive because certain supplies and CO2 are not required. Because there were no differences in the length of postoperative hospital stay or complications, this procedure may be safe in cases that are expected to be mild.
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Ammor A, Nasri S, Rkain M, Benhaddou H. Perforated gastric ulcer: An unusual cause of peritonitis in children. Afr J Paediatr Surg 2020; 17:115-118. [PMID: 33342847 PMCID: PMC8051632 DOI: 10.4103/ajps.ajps_18_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Perforated gastric ulcer is a particularly rare cause of peritonitis in children. Only few cases have been reported in the literature. It is a serious emergency condition which can be overlooked leading to life-threatening consequences. We report a case of a 12-year-old girl who presented with acute abdominal pain and signs of peritonitis. Surgical exploration found a gastric perforation on the anterior side of the antrum. Primary repair of the perforation was performed after thorough decontamination and taking biopsies from its edges. The post-operative period was uneventful. Helicobacter pylori test was negative. Histopathology result was suggestive of ulceration in the gastric wall and did not isolate H. pylori. Gastro-duodenal ulcer perforation should be considered in the differential diagnosis of children presenting with acute abdomen, especially when imaging showing pneumoperitoneum.
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Kapur A, Kapur V. Robotic Surgery: Anaesthesiologist's Contemplation. Malays J Med Sci 2020; 27:143-149. [PMID: 32684815 PMCID: PMC7337953 DOI: 10.21315/mjms2020.27.3.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 11/02/2019] [Indexed: 11/25/2022] Open
Abstract
Technological advances in the field of surgery and medicine have increased the demand for minimally invasive surgery manifold. Robot assisted surgery is gaining popularity, overcoming the flaws of laparoscopic techniques; with improved surgical precision. The conservative nature of anaesthesia care has to face the challenges with respect to patient positioning, bulkiness of the operating system and being positioned far and away from the patient. Anaesthesiologist’s commitment to be the ‘best man’ for the patient during the perioperative period mandates him to familiarise with these challenges of robot assisted surgical system and provide best possible anaesthetic care and ensure patient safety. In this article, a systematic review of the development of surgical robots and the consideration of unique anaesthetic concerns thereof have been undertaken as any new technology is known to be accompanied by its risks and technical perplexity.
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Kwek JWM, Pang MJ, Heah HHW. Pneumoperitoneum after transoral endoscopic thyroidectomy vestibular approach. Laryngoscope Investig Otolaryngol 2020; 5:580-583. [PMID: 32596503 PMCID: PMC7314460 DOI: 10.1002/lio2.393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 03/12/2020] [Accepted: 04/22/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a relatively safe procedure with comparable safety profile as open thyroidectomy. While gas insufflation complications such as subcutaneous emphysema and pneumomediastinum have been reported postoperatively, there have been no reports of pneumoperitoneum. CASE REPORT Our patient underwent an uneventful TOETVA to remove her left thyroid lobe. Postoperatively, she developed subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum, which were confirmed on CT scan. She was managed conservatively and recovered uneventfully. CONCLUSION The authors report the first case of pneumoperitoneum following TOETVA. Surgeons performing TOETVA should be aware of pneumoperitoneum as a possible complication of this procedure after excluding other possible causes.
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Scott J, Singh A, Valverde A. Pneumoperitoneum in Veterinary Laparoscopy: A Review. Vet Sci 2020; 7:E64. [PMID: 32408554 PMCID: PMC7356543 DOI: 10.3390/vetsci7020064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/27/2020] [Accepted: 05/09/2020] [Indexed: 01/25/2023] Open
Abstract
Objective: To review the effects of carbon dioxide pneumoperitoneum during laparoscopy, evaluate alternative techniques to establishing a working space and compare this to current recommendations in veterinary surgery. Study Design: Literature review. Sample Population: 92 peer-reviewed articles. Methods: An electronic database search identified human and veterinary literature on the effects of pneumoperitoneum (carbon dioxide insufflation for laparoscopy) and alternatives with a focus on adaptation to the veterinary field. Results: Laparoscopy is the preferred surgical approach for many human and several veterinary procedures due to the lower morbidity associated with minimally invasive surgery, compared to laparotomy. The establishment of a pneumoperitoneum with a gas most commonly facilitates a working space. Carbon dioxide is the preferred gas for insufflation as it is inert, inexpensive, noncombustible, colorless, excreted by the lungs and highly soluble in water. Detrimental side effects such as acidosis, hypercapnia, reduction in cardiac output, decreased pulmonary compliance, hypothermia and post-operative pain have been associated with a pneumoperitoneum established with CO2 insufflation. As such alternatives have been suggested such as helium, nitrous oxide, warmed and humidified carbon dioxide and gasless laparoscopy. None of these alternatives have found a consistent benefit over standard carbon dioxide insufflation. Conclusions: The physiologic alterations seen with CO2 insufflation at the current recommended intra-abdominal pressures are mild and of transient duration. Clinical Significance: The current recommendations in veterinary laparoscopy for a pneumoperitoneum using carbon dioxide appear to be safe and effective.
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Barik AK, Kumar A, Dhar M, Ranjan P. A prospective comparative study of arterial blood gas parameters in smoker versus non-smoker patients undergoing laparoscopic cholecystectomy. Indian J Anaesth 2020; 64:397-402. [PMID: 32724248 PMCID: PMC7286393 DOI: 10.4103/ija.ija_953_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/26/2020] [Accepted: 04/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background and Aims: Smoking is a risk factor for postoperative pulmonary complications in patients undergoing general anaesthesia. These may get amplified with effects of pneumo-peritoneum and carbon dioxide (CO2) insufflation during laparoscopic surgeries. Our aim was to compare metabolic and blood gas analysis of smokers versus non-smoker patients during laparoscopic surgeries under general anaesthesia. Methods: After permission from institutional review board, 60 patients undergoing laparoscopic cholecystectomy were divided into two groups, smokers and non-smokers (30 each). Along with baseline haemo-dynamic parameters, arterial blood gas sampling was done to assess and compare PCO2, pH and bicarbonate (HCO3) values at various time intervals with respect to pneumo-peritoneum creation, between smokers and non smokers. Results: Baseline systolic blood pressure was higher and oxygen saturation was significantly lower in smoker group. PCO2 and end-tidal CO2 were significantly higher in smokers at all intervals (P < 0.001). pH was significantly lower and HCO3 higher, in smokers after creation of pneumo-peritoneum. Increase in PCO2 due to pneumo-peritoneum was higher in the smoker group (3.49 ± 8.5) mmHg versus non smoker (0.56 ± 4.86) mmHg, although statistically not significant. Change in pH and HCO3 was similar between smokers and non-smokers. Conclusion: There is a significant difference in baseline arterial blood gas characteristics between smokers and non-smokers. Metabolic effects of CO2 insufflation and increased intraabdominal pressure appears to be more enhanced in smokers.
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Shanava K, Javor S, Kerkadze V, Abiatari I, Weber G. Protective effects of postconditioning in transvaginally created pneumoperitoneum. Exp Ther Med 2020; 19:3861-3866. [PMID: 32346452 DOI: 10.3892/etm.2020.8616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
There are reports of ischemic complications in clinical practice after laparoscopy using pneumoperitoneum. Conditioning has a beneficial effect for various ischemic diseases. This experimental study was designed to evaluate the effects of postconditioning in transvaginally created pneumoperitoneum. Sixty adult female rats, weighing 300±50 g were divided into four equal groups. Pneumoperitoneum was created by CO2 insufflation under a pressure of 10 mmHg. Rats in the first group (sham) were subjected to only sham-operation or gas insufflation. The second group (TV/PP) was subjected to pneumoperitoneum for 60 min followed by 30 min of desufflation. The third group (post-5) was subjected to pneumoperitoneum for 60 min followed by 5 min of desufflation, 5 min of insufflation and again followed by 30 min of desufflation. The fourth group (post-2.5) was subjected to pneumoperitoneum for 60 min followed by 2.5 min of desufflation and 2.5 min of insufflation-repeated in two cycles- and then followed by 30 min of desufflation. The rats were sacrificed, and blood was collected after 30 min, 2 and 6 h from the last desufflation. Levels of oxidative stress markers, malondialdehyde (MDA), superoxide dismutase (SOD), reduced glutathione (GSH), sulfhydryl groups (SH) and inflammatory cytokine TNF-α, were analyzed. Levels of MDA in the post-5 group were significantly reduced compared to the TV/PP and post-2.5 groups. The level of GSH in TV/PP animals was markedly reduced compared to the Sham, Post-5 and Post-2.5 groups. In addition, levels of SH were increased in the Post-5 group in comparison to the Sham, TV/PP and Post-2.5 groups. No difference in the activity of SOD between the groups was found, and the concentration of TNF-α in TV/PP animals was significantly higher than that in the Sham and postconditioning groups. Overall, the results of the present study indicate that postconditioning can reduce pneumoperitoneum-induced oxidative injury.
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Effects of pneumoperitoneum with carbon dioxide on renal and hepatic functions in rats. Wideochir Inne Tech Maloinwazyjne 2020; 15:574-582. [PMID: 33294072 PMCID: PMC7687661 DOI: 10.5114/wiitm.2020.93990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/23/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Laparoscopic surgery is a preferred method based on its many benefits. However, increasing abdominal pressure by CO2 insufflation during the implementation of this technique poses challenges. Aim To determine the degree of renal and liver injury that occurs in a pneumoperitoneum (PP) model of prolonged CO2 insufflation. Material and methods Twenty-one female Sprague Dawley rats were separated randomly into three groups. Group 1 was the control group and given anesthesia for 3 h. In group 2, PP was administered under anesthesia for 1 h. In the last group, PP was administered under anesthesia to animals for 3 h. We measured renal and liver injury biomarkers and made a histopathological evaluation to estimate the degree of injury and assessed the correlation of biomarkers including kidney injury molecule-1 (KIM-1) with histopathological findings. Results Histopathological analysis according to the kidney ischemia tubular damage score showed a statistically significant difference between the 3 groups (p < 0.001). There was an increase in KIM-1 levels in the groups, although it was not statistically significant (p = 0.062, p = 0.156, p = 0.350 respectively). According to the correlation test in this research, KIM-1 results had a statistically significant association with creatinine, urea, aspartate aminotransferase and alanine aminotransferase levels in all control and study groups. Conclusions According to our results, the increase in KIM-1 was correlated with Cr levels and compatible with histopathological analysis. Moreover, intra-abdominal pressure statistically significantly increased the degree of kidney injury and there was not a significant increase in the levels of KIM-1. There was no difference in liver damage between groups.
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Hanna M, Ng C, Slater K. Small Bowel Diverticulosis As a Cause of Chronic Pneumoperitoneum. Cureus 2020; 12:e7303. [PMID: 32313744 PMCID: PMC7164552 DOI: 10.7759/cureus.7303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pneumoperitoneum, or the accumulation of free air in the peritoneal cavity, is commonly associated with visceral perforation, mandating emergent surgical intervention. Non-surgical pneumoperitoneum, where visceral perforation is not the cause, does not commonly require surgical management. Chronic pneumoperitoneum secondary to small bowel diverticulosis is rare. Of all gastrointestinal diverticular diseases, jejunoileal diverticulosis is the rarest form. We describe a case of chronic pneumoperitoneum in an 83-year-old male presenting with intermittent abdominal distension and constipation over five years resulting in many presentations to his rural hospital. There were never any associated signs of sepsis such as fever or tachycardia. A computed tomography scan revealed large volume pneumoperitoneum without evidence of perforated viscera or free fluid. An elective diagnostic laparoscopy revealed extensive small bowel diverticular disease. One of the diverticuli exhibited pneumotosis intestinalis where bubbles of gas were noted within the diverticulum wall and mesentery in the local vicinity. Given the extent of the small bowel diverticular disease, the patient's advanced age, and relative lack of symptoms, bowel resection was not undertaken and the patient was managed conservatively. This article illustrates a case of chronic pneumoperitoneum due to small bowel diverticulosis. It highlights the differential diagnoses for chronic pneumoperitoneum, increases awareness of this rare and challenging condition, and portrays the utility of conservative management avoiding major surgery and its potential complications.
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Weng E, Valencia DN, Krudy ZA, Ali M. Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic and Therapeutic Colonoscopy with Crohn's-related Stricture Dilation. Cureus 2020; 12:e7162. [PMID: 32257705 PMCID: PMC7112721 DOI: 10.7759/cureus.7162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colonic perforation is an uncommon but known and feared complication of colonoscopy, which carries a high mortality rate. We present an uncommon case of extensive intra- and extraperitoneal air following colonic perforation in a patient undergoing inpatient colonoscopy for evaluation of unintentional weight loss and constipation. During colonoscopy, a splenic flexure stricture was identified and dilated. Postprocedural hemodynamic instability prompted further imaging which revealed pneumoperitoneum, bilateral pneumothorax, pneumomediastinum, pneumopericardium, and severe subcutaneous emphysema. Emergent exploratory laparotomy found perforation of the proximal transverse colon which required resection and transverse colostomy placement. The patient also underwent bilateral chest tube placement and was treated with antibiotics for peritonitis. The patient was eventually diagnosed with Crohn’s disease and discharged to an extended care facility with outpatient follow-up. Extraperitoneal colonic perforations are fairly rare, and to our knowledge, we present the most severe case that has been published in recent years.
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Shuto S, Naka M, Konishi C, Maekawa K. Three cases of intra-abdominal free air onset associated with COPD treated conservatively. Clin Case Rep 2020; 8:428-432. [PMID: 32185030 PMCID: PMC7069865 DOI: 10.1002/ccr3.2687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/11/2019] [Accepted: 01/02/2020] [Indexed: 11/30/2022] Open
Abstract
Pneumoperitoneum is caused by respiratory disease in rare cases and can be treated conservatively. It is important to confirm physical abdominal examinations, laboratory data, and radiological findings to avoid unnecessary surgical procedures. The diagnosis of pneumoperitoneum associated with respiratory disease requires the exclusion of other fatal illnesses, especially gastrointestinal perforation.
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A prospective single-center observational study to assess the efficacy of the second-generation supraglottic airway device I-gel in laparoscopic surgeries in children. J Anaesthesiol Clin Pharmacol 2020. [PMID: 32174652 DOI: 10.11847/zgggws1125160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND AIMS Supraglottic airways used in pediatric surgeries are associated with a lesser number of postanesthesia respiratory complications. However, there is limited literature on the use of i-gel for pediatric laparoscopic surgery. The aim of this study is to assess the adequacy of ventilation of i-gel for pediatric laparoscopic surgery and note any associated adverse event. MATERIAL AND METHODS This is a single-centered prospective observational study including 119 children, aged 6 months to 18 years, scheduled for laparoscopic surgery, during a 9-month period, in a tertiary care center. I-gel was used for positive pressure ventilation, and if the post-insertion oropharyngeal seal pressure was <25 cm H2O, it was replaced with a tracheal tube. Adequacy of ventilation and adverse events were noted. RESULTS Data from 102 cases were analyzed (17 cases excluded: tracheal intubation in 11; missing data in 6 cases). The mean oropharyngeal seal pressure was 34.2 ± 5.2 cm H2O and mean airway pressure was 16.1 ± 2.4 cm H2O. The adverse events included transient cough (10.7%), sore throat (4.9%), and desaturation (3.9%). There was no sign of respiratory distress during the recovery and no intervention was required in any child postoperatively. CONCLUSION I-gel provided adequate ventilation of the lungs in children undergoing laparoscopic surgery with no major adverse event.
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Goyal R, Chauhan R, Anand R, Goyal M. A prospective single-center observational study to assess the efficacy of the second-generation supraglottic airway device I-gel in laparoscopic surgeries in children. J Anaesthesiol Clin Pharmacol 2020; 36:20-24. [PMID: 32174652 PMCID: PMC7047697 DOI: 10.4103/joacp.joacp_295_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: Supraglottic airways used in pediatric surgeries are associated with a lesser number of postanesthesia respiratory complications. However, there is limited literature on the use of i-gel for pediatric laparoscopic surgery. The aim of this study is to assess the adequacy of ventilation of i-gel for pediatric laparoscopic surgery and note any associated adverse event. Material and Methods: This is a single-centered prospective observational study including 119 children, aged 6 months to 18 years, scheduled for laparoscopic surgery, during a 9-month period, in a tertiary care center. I-gel was used for positive pressure ventilation, and if the post-insertion oropharyngeal seal pressure was <25 cm H2O, it was replaced with a tracheal tube. Adequacy of ventilation and adverse events were noted. Results: Data from 102 cases were analyzed (17 cases excluded: tracheal intubation in 11; missing data in 6 cases). The mean oropharyngeal seal pressure was 34.2 ± 5.2 cm H2O and mean airway pressure was 16.1 ± 2.4 cm H2O. The adverse events included transient cough (10.7%), sore throat (4.9%), and desaturation (3.9%). There was no sign of respiratory distress during the recovery and no intervention was required in any child postoperatively. Conclusion: I-gel provided adequate ventilation of the lungs in children undergoing laparoscopic surgery with no major adverse event.
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Woolhead VL, Whittemore JC, Stewart SA. Multicenter retrospective evaluation of ileocecocolic perforations associated with diagnostic lower gastrointestinal endoscopy in dogs and cats. J Vet Intern Med 2020; 34:684-690. [PMID: 32067277 PMCID: PMC7096662 DOI: 10.1111/jvim.15731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/03/2020] [Indexed: 12/13/2022] Open
Abstract
Background Ileoscopy is increasingly performed in dogs and cats with gastrointestinal signs, but iatrogenic ileocecocolic (ICC) perforations have not been described. Hypothesis/Objectives To characterize endoscopic ICC perforations in dogs and cats. Animals Thirteen dogs and 2 cats. Methods This is a retrospective case series. Signalment, presentation, endoscopic equipment, colonic preparation, endoscopist's experience level, ileal intubation technique, method of diagnosis, perforation location, histopathology, management, and outcome data were collected and reviewed. Results Six ileal, 5 cecal, and 4 colonic perforations were identified between 2012 and 2019. Dogs weighed 2.4‐26 kg (median, 10.3 kg) and cats 4.6‐5.1 kg (median, 4.9 kg). Endoscopy was performed in dogs presented for vomiting (n = 4), as well as large (n = 5), mixed (n = 4), and small (n = 1) bowel diarrhea. Cats had large bowel diarrhea. Endoscopists included 1 supervised intern, 9 supervised internal medicine residents (2 first year, 6 second year, 1 third year), and 5 internal medicine diplomates. Diagnosis was delayed in 5 dogs, occurring 1‐5 days after endoscopy (median, 3 days); dogs were presented again with inappetence (n = 4), lethargy (n = 4), abdominal pain (n = 3), retching (n = 2), and syncope (n = 1). All animals underwent surgical correction. Histopathology did not identify lesions at the perforation site in any animal. Two dogs required a second surgery; 1 died 12 hours after surgery. Survival to discharge was 93%, with 78% surviving ≥8 months. Conclusions and Clinical Importance Iatrogenic endoscopic ICC perforation is not indicative of underlying disease and is associated with a good prognosis. Delayed diagnosis can occur. Therefore, perforation should be considered in the differential diagnosis for animals with clinical deterioration after endoscopy.
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