Clinical and Organizational Impact of the AIRSEAL® Insufflation System During Laparoscopic Surgery: A Systematic Review

Incidence, outcomes, and risk factors of postlaparoscopic subcutaneous emphysema: a historical cohort study

PURPOSE

Subcutaneous emphysema is a common complication of laparoscopic surgery. We aimed to determine the incidence, outcomes, and risk factors of postlaparoscopic subcutaneous emphysema.

METHODS

We conducted a single-centre historical cohort study of adult patients who underwent laparoscopic surgery at Kagoshima University Hospital between 1 April 2018 and 31 March 2021. We used multivariable logistic regression analysis to identify independent factors associated with postlaparoscopic subcutaneous emphysema.

RESULTS

We included 1,642 patients with a median [interquartile range] age of 65 [53-72] yr. Postlaparoscopic subcutaneous emphysema was diagnosed in 600 (37%) patients. Female sex (odds ratio [OR], 1.82; 99.5% confidence interval [CI], 1.29 to 2.58), peak end-tidal carbon dioxide ≥ 45 mm Hg (OR, 2.07; 99.5% CI, 1.43 to2.98), and use of the AirSeal® Intelligent Flow System (CONMED Corp., Largo, FL, USA) (OR, 3.37; 99.5% CI, 2.34 to 4.87) were independent factors associated with postlaparoscopic subcutaneous emphysema. In addition, a lower body mass index was significantly associated with increased postlaparoscopic subcutaneous emphysema (P for trend < 0.001). No complications were associated with postlaparoscopic subcutaneous emphysema.

CONCLUSIONS

This historical cohort study showed a relatively high incidence of postlaparoscopic subcutaneous emphysema. In addition to previously reported risk factors, female sex and use of the AirSeal Intelligent Flow System were found to be associated with postlaparoscopic subcutaneous emphysema.

Perioperative outcomes and safety of valveless insufflation system in minimally invasive urological surgery: a systematic review and meta-analysis

BACKGROUND

With the rapid development of laparoscopic and robot-assisted surgery, many technological innovations and improvements have emerged to optimize minimally invasive surgery and ensure minimal patient risk. Although AirSeal has been widely reported in the field of urology, its perioperative outcomes and safety in minimally invasive urological surgery remain unclear because of inconsistent levels of evidence.

OBJECTIVES

The authors performed this meta-analysis to evaluate the perioperative outcomes and safety of the valveless insufflation system (VIS) in minimally invasive urological surgery compared with the conventional insufflation system (CIS).

METHODS

The authors comprehensively searched PubMed, Web of Science, Cochrane Library, and Embase databases to identify eligible studies published up to January 2024. Review Manager software (version 5.3.0) was used for the statistical analysis. Eligible studies were randomized controlled trials (RCTs) or non-RCTs of minimally invasive urological surgery with VIS vs CIS. The study outcomes included perioperative outcomes and safety. The authors excluded publication types, including letters, reviews, case reports, and animal and pediatric studies.

RESULTS

The authors finally identified five RCTs and eight non-RCTs in this meta-analysis. The meta- analysis indicated that the operative time was comparable between the groups ( P =0.57, I2 =91%). However, a VIS may increase blood loss ( P =0.0004, I2 =45%) and shorten hospital stays ( P <0.00001, I2 =90%). Due to the high heterogeneity of the results, the authors carefully evaluated all included studies and discovered that the studies by Bucur and Ferroni may be the sources of heterogeneity. When these two studies were excluded, heterogeneity was significantly reduced, and the operative time for VIS was significantly shorter than that for CIS ( P =0.0002). Adjusted blood loss showed no difference between the VIS and CIS groups ( P =0.10). In terms of safety, the pooled results revealed that the incidence of Clavien-Dindo III-IV complications in the VIS group was significantly lower than that in the CIS group ( P =0.02, I2 =0%). Moreover, VIS significantly reduced general pain ( P =0.02, I2 =15%) and shoulder pain ( P =0.001, I2 =0%) 12-24 h postoperatively. No significant differences were observed in total complications ( P =0.06, I2 =0%), blood transfusion ( P =0.14, I2 =0%), and subcutaneous emphysema ( P =0.96, I2 =63%) between the two groups.

CONCLUSIONS

Our meta-analysis revealed additional perioperative advantages of the VIS in minimally invasive urological surgery. Moreover, VIS is superior to CIS owing to less severe complication rates, general pain, and shoulder pain.

Subcutaneous emphysema associated with laparoscopic or robotic abdominal surgery: a retrospective single-center study

BACKGROUND

Subcutaneous emphysema (SCE) is a common complication in laparoscopic surgery. However, its precise incidence and impact on the clinical course are partially known. In this study, the incidence and risk factors of SCE were retrospectively analyzed.

METHODS

Patients who underwent laparoscopic/robotic abdominal surgery (e.g., gastrointestinal, hepatobiliary, gynecologic, and urologic surgery) between October 2019 and September 2022 were retrospectively analyzed. The presence of SCE was confirmed by either conclusive findings obtained through chest/abdominal X-ray examination immediately after operation, or intraoperative palpation conducted by nurses. X-ray examination was performed in the operation room before extubation.

RESULTS

A total of 2503 patients treated with laparoscopic/robotic abdominal surgery between October 2019 and September 2022 were identified and all of them were included in the analysis. SCE was confirmed in 23.1% of the patients (i.e., 577/2503). SCE was identified by X-ray examination in 97.6% of the patients. Extubation failure was observed in 10 patients; however, pneumothorax was not observed. Female sex (odds ratio [OR]: 2.09; 95% confidence interval [95%CI]: 1.69-2.57), age ≥ 80 years (OR 1.63; 95%CI 1.19-2.22), body mass index < 20 (OR 1.32; 95%CI 1.06-1.65), operation time > 360 min (OR 1.97; 95%CI 1.53-2.54), robotic surgery (OR 2.54; 95%CI 1.91-3.38), maximum intraabdominal pressure with CO2 > 15 mmHg (OR 1.79; 95%CI 1.02-3.16), and endo-tidal CO2 > 50 mmHg (OR 1.32; 95%CI 1.08-1.62)were identified as independent factors of SCE. Regarding the extubation failure due to SCE, age (OR 5.84; 95%CI 1.27-26.8) and maximum intraabdominal pressure with CO2 (OR 21.7; 95%CI 4.76-99.3) were identified as risk factors.

CONCLUSION

Although the presence of SCE is associated with a low risk of severe complications, monitoring of the perioperative intraabdominal pressure is essential for performing safe laparoscopic/robotic surgery, particularly in elderly patients.

Automatic Smoke Analysis in Minimally Invasive Surgery by Image-Based Machine Learning

INTRODUCTION

Minimally Invasive Surgery uses electrosurgical tools that generate smoke. This smoke reduces the visibility of the surgical site and spreads harmful substances with potential hazards for the surgical staff. Automatic image analysis may provide assistance. However, the existing studies are restricted to simple clear versus smoky image classification.

MATERIALS AND METHODS

We propose a novel approach using surgical image analysis with machine learning, including deep neural networks. We address three tasks: 1) smoke quantification, which estimates the visual level of smoke, 2) smoke evacuation confidence, which estimates the level of confidence to evacuate smoke, and 3) smoke evacuation recommendation, which estimates the evacuation decision. We collected three datasets with expert annotations. We trained end-to-end neural networks for the three tasks. We also created indirect predictors using task 1 followed by linear regression to solve task 2 and using task 2 followed by binary classification to solve task 3.

RESULTS

We observe a reasonable inter-expert variability for tasks 1 and a large one for tasks 2 and 3. For task 1, the expert error is 17.61 percentage points (pp) and the neural network error is 18.45 pp. For tasks 2, the best results are obtained from the indirect predictor based on task 1. For this task, the expert error is 27.35 pp and the predictor error is 23.60 pp. For task 3, the expert accuracy is 76.78% and the predictor accuracy is 81.30%.

CONCLUSIONS

Smoke quantification, evacuation confidence, and evaluation recommendation can be achieved by automatic surgical image analysis with similar or better accuracy as the experts.

Comparison of a Valveless Trocar System and Conventional Insufflation in Pediatric Urologic Surgery

Background: Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods: A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal insufflation system (AIS) or conventional insufflation system (CIS) was utilized were obtained from hospital records. Data were compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal carbon dioxide, oxygen saturation, body temperature, positive inspiratory pressure, systolic blood pressure, and heart rate. Results: There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion: The AirSeal valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study, however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss, operative time, and perioperative complications.

The impact of AirSeal® on complications and pain management during robotic-assisted radical prostatectomy: a single-tertiary center study

PURPOSE

We aimed to compare perioperative outcomes, post-operative complications, and opioid use between AirSeal® and non-AirSeal® robotic-assisted radical prostatectomy (RARP).

METHODS

We retrospectively collected data on 326 patients who underwent elective RARP at our institution either with or without AirSeal®. The first 60 cases were excluded accounting for the institutions' learning curve of RARP. Patient demographics, oncologic, pathologic, and surgical characteristics between AirSeal® and non-AirSeal® cases were compared. Furthermore, outcomes of interest including operative time, length of stay, morbidity, and opioid use for pain management were compared between the two groups. Univariate linear and logistic regression models were developed.

RESULTS

The AirSeal® group consisted of 125 (38.3%) patients while the non-AirSeal® group consisted of 201 (61.7%) patients. No statistically significant difference was seen in terms of patient demographics, oncologic characteristics, surgical characteristics, and pathologic characteristics between the two groups. In addition, univariate linear regression showed that RARP with AirSeal® displayed shorter operative times by 12.3 min and a shorter length of hospital stay by 0.5 days compared to the non-AirSeal® group (p < 0.001). Furthermore, the AirSeal® group witnessed lower odds of Clavien-Dindo (CVD) Class > 2 complications (OR = 0.102) and a lower need for opioid use (OR = 0.49) compared to the non-AirSeal® group (p < 0.022).

CONCLUSION

RARP using AirSeal® is associated with shorter operative times, shorter length of hospital stays, lower odds of CVD > 2 complications, and lower odds of opioid use with respect to non-AirSeal® RARP. The efficacy and cost effectiveness of using the AirSeal® system during RARP should be further studied and evaluated by clinical trials.

The Role of AirSeal in Robotic Urologic Surgery: A Systematic Review

Introduction: The adoption of a valveless trocar system in robotic surgery has allowed for stable pneumoperitoneum and constant smoke evacuation. The reported benefits of this system are improved visualization, lower abdominal pressures resulting in a decrease in cardiopulmonary complications, ileus, and postoperative pain. We endeavored to perform a systematic review of the available literature on the clinical and systems-based outcomes of AirSeal™ during robotic urologic surgery. Materials and Methods: We performed this review according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Our population of interest was any patient undergoing robotic urologic surgery. Our outcomes of interest were (1) clinical effectiveness, (2) safety parameters, and (3) health system outcomes. Results: Of 83 records identified and screened at title/abstract level, 17 were examined for full-text, of which 10 studies enrolling a total of 1765 patients (cohorts ranging in size from 11 to 642 patients) were ultimately used for review. AirSeal resulted in improved respiratory parameters, specifically lower inspiratory plateau pressure, lower minute volume, lower CO2 elimination rate, low end-tidal CO2, and higher static compliance. Two studies described decreased complication rates with low pneumoperitoneum. There were mixed results regarding AirSeal effect on operative time. Conclusion: Valveless trocar technology using the AirSeal system is a valuable adjunct to current robotic urologic surgery. The established benefits include improved cardiopulmonary parameters, particularly within the steep trendelenburg position that is common in pelvic surgery. Further studies are necessary to elucidate the effects on safety and hospital system-wide outcomes.

Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before-after Study

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery

The effect of the AirSeal^® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO₂), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal^®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO₂, peripheral capillary oxygen saturation (SpO₂), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO₂ was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined “positive respiratory and circulatory responses” (positive responses) as a decrease in EtCO₂ ≥ 3 mmHg in addition to decreases in SpO₂ ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO₂) embolism. The median EtCO₂ values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO₂ of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO₂ of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO₂ embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO₂ of hepatectomy was comparable to that of the other surgeries using the AirSeal^®, laparoscopic hepatectomy showed a tendency of CO₂ embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal^® insufflation system.

Features and applications of energy devices for prone robot-assisted minimally invasive esophagectomy: a narrative review

BACKGROUND AND OBJECTIVE

Robot-assisted surgery is particularly useful in esophagectomy for esophageal cancer because robotic systems have high-resolution three-dimensional imaging, tremor filtering, and articulated instruments. This review article focuses on the applications and limitations of surgical devices in robot-assisted minimally invasive esophagectomy (RAMIE).

METHODS

A narrative search of Medline was performed for articles published using the keywords "robot-assisted esophagectomy", "technique", "postoperative complication", and "short-term outcomes".

KEY CONTENTS AND FINDINGS

Monopolar scissors: these devices with a sharp tip have an articulating function that allows for fast, sharp dissection without an electrical source. However, scissor-type devices cannot compress the organ, and their hemostatic ability is rather weak. Maryland bipolar forceps: the device has a very thin tip that allows for accurate dissection as well as stronger hemostatic ability by closing the forceps to compress tissues and applying electric current. The disadvantage is longer operation time because the forceps need to be constantly closed and reopened. Long Maryland bipolar grasper: the tip of the long Maryland bipolar grasper is slightly blunt and has the advantage of versatility because it can grip the tissue more delicately. Ultrasonic scalpel: the device can transect tissues speedily without bleeding, shortening operation time, but lacks articulating function. Although thermal spread to the surroundings is relatively narrow, activation time increases with the amount of tissue to be grasped; this raises the temperature above that of the vessel sealer. Vessel sealer: the device is one of the most powerful hemostatic energy devices, based on bipolar electrodes. The articulating jaws on both sides are more suited for sharp transection rather than meticulous dissection because of its powerful hemostatic force and blunt tip. It is also important to note that the vessel sealer produces widespread high-temperature steam. SynchroSeal: the device offers fast activation time, and due to the tip of the device being finely divided, which requires relatively precise manipulation.

CONCLUSIONS

Robot-assisted surgery reduces the limitations of conventional endoscopic surgery by offering stable high-resolution three-dimensional imaging, tremor filtering, and articulated instruments. It is important to understand and exploit the advantages of energy devices suitable for RAMIE.

Standardized Technique of Selective Left Liver Vascular Exclusion During Laparoscopic Liver Resection for Benign and Malignant Tumors

BACKGROUND

Tumors located close to major hepatic veins pose a technical challenge to standard laparoscopic liver resection. Hepatic outflow occlusion may reduce the risks of bleeding from hepatic vein and gas embolism. The aim of this study was to detail our standardized laparoscopic approach for a safe extrahepatic control of the common trunk of middle and left hepatic veins during laparoscopic liver resection and to assess its feasibility in patients with tumors located in both right and left lobes of the liver.

METHODS

Data of 25 consecutive patients who underwent laparoscopic liver resection with extrahepatic control of the common trunk of middle and left hepatic veins were reviewed.

RESULTS

All patients underwent primary hepatectomy. The vast majority (84%) of patients had malignant tumors. The control of the common trunk of middle and left hepatic veins was achieved in 96% of patients. There were 14 (56%) major hepatectomies and 11 (44%) minor hepatectomies. Some form of vascular clamping was performed in 23 (62%) patients: Pringle maneuver in 17 (median time = 45 min; range, 10-109) and selective vascular exclusion of the liver in 6 patients (median time = 30 min; range, 15-94). The median duration of operation was 254 min (range, 70-441). There was one case (4%) of gas embolism but without any complications during the postoperative course. Conversion to open surgery was performed in 2 (7.7%) patients: 1 for oncologic reason and 1 for non-progression during the transection plane. Perioperative blood transfusion rate was nil. The overall morbidity rate was 24%.

CONCLUSIONS

The laparoscopic approach for an extrahepatic control of the common trunk of middle and left hepatic veins is reproducible, safe, and effective, and can be applied during laparoscopic liver resection for tumors close to major hepatic veins.

Intraoperative Measures to Reduce the Risk of COVID-19 Transmission During Minimally Invasive Procedures: A Systematic Review and Critical Appraisal of Societies' Recommendations

BACKGROUND

The coronavirus 2019 pandemic and the hypothetical risk of virus transmission through aerosolized CO2 or surgical smoke produced during minimally invasive surgery (MIS) procedures have prompted societies to issue recommendations on measures to reduce this risk. The aim of this systematic review is to identify, summarize and critically appraise recommendations from surgical societies on intraoperative measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the operative room (OR) staff during MIS.

METHODS

Medline, Embase, and Google Scholar databases were searched using a search strategy or free terms. The search was supplemented with searches of additional relevant records on coronavirus 2019 resource websites from Surgical Associations and Societies. Recommendations published by surgical societies that reported on the intraoperative methods to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the OR staff during MIS were also reviewed for inclusion. Expert opinion articles were excluded. A preliminary synthesis was performed of the extracted data to categorize and itemize the different types of recommendations. The results were then summarized in a narrative synthesis.

RESULTS

Thirty-three recommendation were included in the study. Most recommendations were targeted to general surgery (13) and gynecology (8). Areas covered by the documents were recommendations on performance of laparoscopic/robotic surgery versus open approach (28 documents), selection of surgical staff (13), management of pneumoperitoneum (33), use of energy devices (20), and management of surgical smoke and pneumoperitoneum desufflation (33) with varying degree of consensus on the specific recommendations among the documents.

CONCLUSIONS

While some of the early recommendations advised against the use of MIS, they were not strictly based on the available scientific evidence. After further consideration of the literature and of the well-known benefits of laparoscopy to the patient, later recommendations shifted to encouraging the use of MIS as long as adequate precautions could be taken to protect the safety of the OR staff. The release and implementation of recommendations should be based on evidence-based practices that allows health care systems to provide safe surgical and medical assistance.