Laparoscopic positioning and nerve injuries

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence

AIMS

To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data.

METHODS

Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value.

RESULTS

The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery.

CONCLUSION

Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

Outpatient Robotic surgery: Considerations for the Anesthesiologist

A shortage of inpatient beds and nurses during the coronavirus disease 2019 pandemic has lent priority to safe same-day discharge after surgery. The minimally invasive nature of robotic surgery has allowed an increasing number of procedures to be done on an outpatient basis. Anesthetic management should be designed to complement the technical advantages of robotic surgery in facilitating early discharge.

SPONGE-assisted versus Trendelenburg position surgery in laparoscopic sigmoid and rectal cancer surgery (SPONGE trial): randomized clinical trial

Background

In minimally invasive surgery of the sigmoid colon and rectum a retractor sponge has been introduced as an alternative to the Trendelenburg position. This randomized clinical trial (RCT) compared postoperative duration of hospital stay and perioperative outcomes in patients with sigmoid or rectal cancer undergoing sponge-assisted versus Trendelenburg position surgery.

Methods

The SPONGE trial is a single-centre RCT nested within the Dutch nationwide prospective observational cohort of patients with colorectal cancer, and follows the Trials within Cohorts (TwiCs) design. Patients with sigmoid or rectal cancer undergoing elective laparoscopic or robotic surgery were randomized to either sponge-assisted or Trendelenburg surgery on a 1:1 basis using block randomization. Duration of postoperative hospital stay was the primary outcome and was compared using the Mann–Whitney U test. Secondary endpoints included the proportion of complications, readmissions, or mortality versus the χ2 test in intention-to-treat and per-protocol analyses. This trial was not blinded for patients in the intervention arm or physicians.

Results

Between November 2015 and June 2021, 82 patients were randomized to sponge-assisted surgery and 81 to Trendelenburg surgery. After post-randomization exclusion, 150 patients remained for analyses (75 patients per arm). There was no statistically significant difference in median duration of hospital stay (5 days versus 4 days, respectively; P = 0.06), 30-day postoperative complications (30 per cent versus 31 per cent; P = 1.00), readmission rate (8 per cent versus 15 per cent; P = 0.30), or mortality (0 per cent versus 1 per cent, P = 1.00). The per-protocol analysis showed similar results. No adverse device events were seen.

Conclusion

Sponge-assisted laparoscopic/robotic surgery does not reduce the duration of hospital stay, or perioperative morbidity or mortality.

Trial registration

NCT02574013 (http://www.clinicaltrials.gov)

Postoperative Lower Extremity Neuropathy With Boot Stirrups Compared With Candy Cane Stirrups

OBJECTIVE

To assess whether candy cane stirrup use is associated with an increased risk of lower extremity peripheral neuropathy compared with boot stirrups in women undergoing surgery requiring dorsal lithotomy positioning.

METHODS

This retrospective cohort study (June 2008-August 2015) included patients who underwent gynecologic surgery for benign indication lasting 60 minutes or longer in the lithotomy position. Patients with preexisting neurologic disease were excluded. Stirrup type, demographics, medical history, surgical factors, and relevant outcomes were collected from the medical record. Postoperative neuropathy was identified in clinical diagnoses or in physician documentation through the 6-week postoperative visit. Patient characteristics and outcomes were compared using Student's t test, χ2 test, or Fisher exact test. Logistic regression analysis was used to adjust for other clinical characteristics associated with the outcome at P≤.1.

RESULTS

The study included 2,449 patients, 1,838 (75.1%) with boot and 611 (24.9%) with candy cane stirrups. Women positioned in boot stirrups were younger (mean age 45.6 years [SD 13.5] vs 55.9 [SD 15.7] years; P<.001), heavier (mean body mass index [BMI] 31.5 [SD 8.7] vs 29.6 [SD 7.0]; P<.001), more likely to smoke (n=396 [21.5%] vs n=105 [17.2%]; P=.021), and had longer surgical duration (mean 176.5 minutes [SD 90.0] vs 145.3 [SD 63.9] minutes; P<.001), respectively. Diabetes (8.3%) did not differ between the groups (P=.122. Neuropathy occurred less often in the boot cohort (n=29, 1.6%, 95% CI 1.1-2.3%) than in the candy cane cohort (n=21, 3.4%, 95% CI 2.1-5.2%) (P=.008). After adjusting for age, BMI, smoking, anesthesia type and surgical time, only candy cane stirrup type (adjusted odds ratio [aOR] 2.87, 95% CI 1.59-5.19) and surgical time (per hour) (aOR 1.40, 95% CI 1.20-1.63) were independently associated with postoperative neuropathy.

CONCLUSION

Candy cane stirrups are associated with a significantly increased risk of lower extremity postoperative neuropathy compared with boot stirrups for women undergoing gynecologic surgery for benign indication.

Neuropraxia: An Underappreciated Morbidity of Liver Transplantation

BACKGROUND

Peripheral nerve injuries can be devastating complications of surgery, potentially resulting in severe functional disability and decreased quality of life. Long surgeries with considerable tissue manipulation, for example, liver transplantation, may present increased risk; however, neuropraxia in transplantation has not been well investigated.

MATERIALS AND METHODS

This is a retrospective study of all adult patients undergoing liver transplantation at a large academic center between January 2013 and December 2015. Descriptive analyses, logistic regressions, and forward selection procedures were used to determine the odds of developing neuropraxia and associated factors.

RESULTS

Of the 283 liver recipients, the mean age was 55.8 y, 35.1% were female, 65.6% were Caucasian, 8.9% were African American, 16.7% were Hispanic, and mean model for end-stage liver disease sodium score at transplant was 24.2 ± 10.9. The underlying etiology was alcohol (26.2%), hepatitis C (34.8%), nonalcoholic steatohepatitis (13.1%), and other (14.2%). The incidence of neuropraxia after liver transplantation was 8.3% (n = 25), with 60% (n = 16) upper extremities, 82% left sided, and 84% male. There was no difference in age, race, body mass index, hypertension, diabetes, hyperlipidemia, or smoking in those with neuropraxia versus those without. In multivariate analysis, neuropraxia was significantly associated with male gender, lower model for end-stage liver disease score, and longer duration of surgery (P < 0.05). Symptoms lasted median 5 d, with a wide range up to 187 d. Neuropraxia-specific treatment (physical therapy or medications) was required in 32% (n = 9).

CONCLUSIONS

Peripheral nerve injuries are an unexplored complication of liver transplantation. Although transient, a high number (8.2%) of patients developed neuropraxia, negatively affecting their ability for recovery. Exploration of mechanisms for minimizing risk and intraoperative detection and prevention should be considered to mitigate this complication.

Effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures: a randomized clinical trial

BACKGROUND

Laparoscopic surgery has become a standard of care for many gynecological surgeries due to its lower morbidity, pain and cost compared to open techniques. Unfortunately, the use of carbon dioxide (CO2) to insufflate the abdomen is the main contributor to post-operative shoulder pain.

METHODS

We aim to assess the effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures. We hypothesize that maintaining the patient in Trendelenburg for 24 h postoperatively will significantly decrease postoperative shoulder pain and analgesic consumption. After obtaining written informed consent, 108 patients were prospectively randomized into two groups. In the control group, patients underwent standard gynecologic laparoscopic procedures; then after passive deflation of the pneumoperitoneum at the end of the surgery, the patients were placed in supine head up position in the post anesthesia care unit (PACU) and received our institution's common postoperative care. Patients in the intervention group were subjected to the same maneuver but were positioned in a Trendelenburg position (20 °) once fully awake and cooperative in the PACU and retained this position for the first 24 h. Numerical rating scale (NRS) was used to assess shoulder pain and nausea upon patient arrival to the PACU, at 4, 6, 12 (primary outcome) and 24 h postoperatively. Time to first rescue pain medication, total rescue pain medications and overall satisfaction with pain control were recorded. 101 patients were included in the final data analysis.

RESULTS

Both groups were comparable in terms of baseline characteristics. NRS pain scores were significantly lower in the intervention group at 12 h compared to the control group (0 [0-1] versus 5 [1-4], p < 0.001), furthermore improvement in postoperative shoulder pain between time of arrival to PACU (time zero) and 12 h postoperatively was significantly higher in patients allocated to the experimental group compared to the control group. Pain scores were significantly lower in patients allocated to the experimental group versus the control group (0 [0-1] versus 5 [1-4], p < 0.001).

CONCLUSION

In conclusion, Trendelenburg position is an easy non-pharmacologic intervention that is beneficial in reducing postoperative shoulder pain following gynecologic laparoscopic surgery.

TRIAL REGISTRATION

Retrospectively registered at Clinicaltrials.gov, registration number NCT04129385,  date of registration: June 28, 2019.

Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review

AIMS

To examine the incidence of intraoperative peripheral nerve injury, symptoms, risk factors, functions, and quality of life in patients undergoing robotic-assisted laparoscopic surgery to lithotomy positioning with steep Trendelenburg.

DESIGN

A systematic review.

DATA SOURCES

The Cochrane Library catalogue, PubMed, EMBASE, CINHAL and SveMed + databases were searched from January 2000 - February 2019.

REVIEW METHODS

Titles and abstracts were screened for inclusion. Full-text assessments of each paper were conducted by two reviewers. The quality of the included papers was assessed using the Mixed Methods Appraisal Tool. Descriptive statistics and thematic analysis were used to synthesize the data.

RESULTS

Eleven quantitative studies were included with three themes: (a) incidence of intraoperative peripheral nerve injury; (b) upper extremity intraoperative peripheral nerve injury related to steep Trendelenburg positioning; and (c) lower extremity intraoperative peripheral nerve injury related to lithotomy positioning. The overall incidence of intraoperative peripheral nerve injury in robotic-assisted laparoscopic urologic, gynaecologic and colorectal surgery was 0.16%-10.0% and the symptoms appeared immediately after surgical procedures. Risk factors for intraoperative peripheral injury were prolonged operative time, high American Society of Anesthesiologists scores, comorbidities and high body mass index.

CONCLUSION

Intraoperative peripheral nerve injuries are rare, but occasionally serious when related to lithotomy positioning with steep Trendelenburg. Operating room nurses have a responsibility both for positioning patients and for being familiar with the technological developments that will influence the preoperative handling of patients.

IMPACT

This systematic review emphasizes the need for operating room nurses together with surgical team to have knowledge about mechanisms for injury, positioning, anatomy/physiology, and evaluation of risk factors to ensure that patients are not exposed for intraoperative peripheral nerve injuries. Increased robotic-assisted laparoscopic surgery necessitates further research examining the incidence of intraoperative peripheral nerve injury related to positioning and how these affect patients' function and the quality of life.

Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.

Post-operative extra-spinal etiologies of sciatic nerve impingement

Sciatica is a highly prevalent cause of morbidity, commonly resulting from intra-spinal pathological processes. Many cases can have extra-spinal etiologies and can be clinically challenging. Certain scenarios should suggest an extra-spinal etiology, particularly total and revision hip arthroplasty, surgical hip dislocation, hip arthroscopy, and surgery in the lithotomy position. We review the post-operative clinical scenarios where sciatic neuropathy may occur, along with the pertinent imaging findings.

Differential diagnosis of knee pain following a surgically induced lumbosacral plexus stretch injury. A case report

Background and Purpose: Knee joint biomechanics requires an understanding of lower extremity (LE) segmental interactions. In some cases, knee pain may arise as a result of altered LE biomechanics; while in other cases, knee pain may stem from other causes, such as a peripheral nerve injury. Case Description: A 33-year-old woman presented via direct access for physical therapist (PT) examination with a chief complaint of left knee pain. The day after undergoing a dilation and curettage (D&C) procedure the patient had an acute onset of gait dysfunction. Over the next few days, the patient developed left anterior knee pain (7/10 at worst) in addition to a significant change in physical functioning (Lower Extremity Functional Scale [LEFS] 38/80). Physical examination revealed left LE weakness, altered sensation, and an absent Achilles deep tendon reflex. Outcomes: The patient's presentation was consistent with a lumbosacral plexus stretch injury, with S1 being most affected. A physiatrist was consulted and recommended initiating PT treatment with bi-weekly re-examination. The 6-week (14 visits) re-examination revealed abolished left knee pain and improved physical functioning (LEFS 66/80). Conclusion: Stretch injuries are a known complication of lithotomy positioning. Knowledge of this and the addition of a thorough examination allowed the PT to identify the possible cause of the patient's abrupt onset of left LE dysfunction. Regardless of mode of patient access, screening for referral is crucial and may include referral or, as in this case, consultation with other professionals.

Complications in robotic urological surgeries and how to avoid them: A systematic review

Objectives

To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues.

Methods

A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it.

Results

In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored.

Conclusions

Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.

The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones

OBJECTIVE

To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones.

DESIGN

The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively.

SETTING

Clinical Simulation Center at an academic medical center.

PARTICIPANTS

Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies.

RESULTS

The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out.

CONCLUSIONS

The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.

The impact of retractor SPONGE-assisted laparoscopic surgery on duration of hospital stay and postoperative complications in patients with colorectal cancer (SPONGE trial): study protocol for a randomized controlled trial

BACKGROUND

To achieve an adequate visual working field during laparoscopic colorectal surgery without disturbance of the small intestine, patients are positioned in the Trendelenburg position. This position results in hemodynamic changes that may increase the risk of cardiopulmonary complications and prolonged hospital stay. Recently, an intraoperative retractor sponge was introduced as an alternative to the Trendelenburg position during laparoscopic surgery. The objective of this trial is to study the impact of the use of an intraoperative retractor sponge on the duration of the hospital stay and risk of perioperative complications in patients undergoing laparoscopic surgery for colorectal cancer.

METHODS/DESIGN

The SPONGE trial is a monocenter study and follows the cohort multiple randomized controlled trial (cmRCT) design. It will be conducted within a multicenter prospective observational cohort of colorectal cancer patients of all stages, for whom longitudinal clinical data and patient-reported outcomes are collected. Patients within the cohort, who will undergo laparoscopic surgery for distal colon or rectal cancer, are eligible for inclusion and form a subcohort. From this subcohort, a 1:1 random sample will be offered to undergo surgery with the use of the retractor sponge. Patients from the subcohort who are not selected will undergo standard treatment, that is, surgery in the Trendelenburg position. The primary endpoint is the duration of the postoperative hospital stay. Secondary outcomes are duration of surgery; intraoperative blood loss and fluid balance; and postoperative body temperature, oxygenation and complications. Both arms require 94 patients.

DISCUSSION

This study is the first randomized controlled trial to evaluate the effect of sponge-assisted laparoscopic colorectal surgery in comparison with standard Trendelenburg position on hospital stay and peri- and postoperative complications. Results of this study will also be relevant for other surgical procedures in the pelvic region. The present study is the second randomized controlled trial according to the cmRCT design, which is embedded within our colorectal cancer cohort.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02574013 . Registered 27 September 2015.

Safety and Effectiveness of SAF-R, a Novel Patient Positioning Device for Robot-Assisted Pelvic Surgery in Trendelenburg Position

PURPOSE

We found current robotic positioning devices to be inadequate and cumbersome. Furthermore, we realized there were no premarket well-designed studies to prove their safety and efficacy. In this prospective pilot study, we aimed to investigate the safety and effectiveness of a novel patient-positioning device (SAF-R) to secure the patient in Trendelenburg (T-burg) position for robot-assisted pelvic surgery.

PATIENTS AND METHODS

Sixteen patients undergoing robot-assisted pelvic operation in T-burg position were enrolled. Patients were positioned using SAF-R board. Pressure sensor mats were used for real-time monitoring of the contact pressures and contact area on the shoulders and calves throughout the surgery. Data collection included patients' body mass index (BMI), time needed for positioning, total time in the T-burg position, contact pressure and contact area readings from the sensor mats, and the patient shifting distance on the table. Patients were also followed for 1-month postoperatively for any position-related adverse event.

RESULTS

The median age of the patients was 56.5 years with median BMI of 27.3. The median positioning time was 6 minutes, duration of T-burg position was 3.5 hours, and patient shift on the table was 1 cm. The contact pressure over the shoulders was in the safe range (< 80 mm Hg) before and at the end of the surgery in all cases (right: 13.12 ± 1.12 vs 20.25 ± 1.56 mm Hg, left: 12.84 ± 1.05 vs 19.60 ± 1.09 mm Hg, p = 0.001). The changes in the mean contact pressure over the calves and the mean contact area for the shoulders and calves during the T-burg position were not significantly different. No significant position-related complication was detected during follow-up.

CONCLUSIONS

SAF-R surgical board is a safe, reliable, and timesaving positioning device for patients undergoing robotic pelvic surgery in the T-burg position.

Intraoperative peripheral nerve injury in colorectal surgery. An update

Intraoperative peripheral nerve injury during colorectal surgery procedures is a potentially serious complication that is often underestimated. The Trendelenburg position, use of inappropriately padded armboards and excessive shoulder abduction may encourage the development of brachial plexopathy during laparoscopic procedures. In open colorectal surgery, nerve injuries are less common. It usually involves the femoral plexus associated with lithotomy position and self-retaining retractor systems. Although in most cases the recovery is mostly complete, treatment consists of physical therapy to prevent muscular atrophy, protection of hypoesthesic skin areas and analgesics for neuropathic pain. The aim of the present study is to review the incidence, prevention and management of intraoperative peripheral nerve injury.

Factors that increase external pressure to the fibular head region, but not medial region, during use of a knee-crutch/leg-holder system in the lithotomy position

Background

Paralysis of the common peroneal nerve is one of the relatively common nerve injuries related to the lithotomy position with the use of a knee-crutch/leg-holder system. Several risk factors have been implicated in lithotomy position-related common peroneal nerve paralysis during operation.

Materials and methods

In the present study, 21 young healthy volunteers participated in the investigation of the causes of the paralysis of the common peroneal nerve in the lithotomy position using a knee-crutch/leg-holder; Knee Crutch. We assessed the external pressure applied to the fibular head and medial regions using the Big-Mat pressure-distribution measurement system. Relationships between the peak contact pressure and physical characteristics, such as sex, height, weight, body mass index (BMI), and fibular head circumference, were analyzed.

Results

The peak contact pressure to the fibular head region was greater for males than for females. For all subjects, significant positive correlations were observed between the peak contact pressure to the fibular head region and weight, BMI, or fibular head circumference. However, there was no significant difference between the peak contact pressure to the fibular head region and height for any subjects. Moreover, there was no sex-related difference in the peak contact pressure to the fibular medial region, and no significant differences between the peak contact pressure to the fibular medial region and height, weight, BMI, or fibular head circumference.

Conclusion

External pressure to the fibular head region is greater for males than for females using a knee-crutch/leg-holder system in the lithotomy position. In addition, the external pressure to the fibular head region, but not the fibular medial region, increases with increasing weight, BMI, and fibular head circumference. Therefore, these patient-related characteristics may contribute to the risk of developing lower-extremity neuropathy, leading to injury or ischemia of the common peroneal nerve.

Post-operative brachial plexus neuropraxia: A less recognised complication of combined plastic and laparoscopic surgeries

This presentation is to increase awareness of the potential for brachial plexus injury during prolonged combined plastic surgery procedures. A case of brachial plexus neuropraxia in a 26-year-old obese patient following a prolonged combined plastic surgery procedure was encountered. Nerve palsy due to faulty positioning on the operating table is commonly seen over the elbow and popliteal fossa. However, injury to the brachial plexus has been a recently reported phenomenon due to the increasing number of laparoscopic and robotic procedures. Brachial plexus injury needs to be recognised as a potential complication of prolonged combined plastic surgery. Preventive measures are discussed.

Position-related injury is uncommon in robotic gynecologic surgery

OBJECTIVE

To assess the rate and risk factors for position-related injury in robotic gynecologic surgery.

METHODS

A prospective database from 12/2006 to 1/2014 of all planned robotic gynecologic procedures was retrospectively reviewed for patients who experienced neurologic injury, musculoskeletal injury, or vascular compromise related to patient positioning in the operating room. Analysis was performed to determine risk-factors and incidence for position-related injury.

RESULTS

Of the 831 patients who underwent robotic surgery during the study time period, only 7 (0.8%) experienced positioning-related injury. The injuries included minor head contusions (n=3), two lower extremity neuropathies (n=2), brachial plexus injury (n=1) and one large subcutaneous ecchymosis on the left flank and thigh (n=1). There were no long term sequelae from the positioning-related injuries. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (P=0.05). There were no significant associations between position-related injuries and operative time (P=0.232), body mass index (P=0.847), age (P=0.152), smoking history (P=0.161), or medical comorbidities (P=0.229-0.999).

CONCLUSIONS

The incidence of position-related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify modifiable risk factors for position-related injury following robotic surgery. A standardized, team-oriented approach may significantly decrease position-related injuries following robotic gynecologic surgery.

Secure patient positioning using Badillo/Trendelenburg restraint strap during robotic surgery

Steep Trendelenburg position is routine during robotic urologic and gynecologic surgery in order to optimize exposure of the pelvis. This position requires that the patient be properly secured as to avoid any movement during the procedure. We analyzed the safety and tolerability of a reusable strap with disposable cushions used during robotic assisted radical prostatectomy. The Badillo/Trendelenburg restraint is a harness which is placed on the table prior to patient transfer. The restraint is a Class I FDA-registered device (Pintler Medical, Seattle, WA). Patients were marked at the beginning and end of the case to determine if any movement had occurred. The Badillo/Trendelenburg restraint was employed in 1,200 consecutive RARP cases. The restraint was used by a single surgeon at two institutions. The operating table was marked from edge of the patients shoulder to the end of the head of table at the beginning and end of the case to determine if any movement had occurred. Maximum movement observed was 1 cm. All patients were questioned and a physical examination were done in the post operative period for any shoulder or nerve injury. No reports of shoulder or brachial injury. For patients undergoing robotic surgery with steep Trendelenburg position the Badillo/Trendelenburg restraint provides a secure, reliable and safe means of maintaining proper position without any patient movement.

The head butler with design modification: a useful mountable shelf for the operating table in robotic surgery

The 'head butler' or 'iron maiden', as it is sometimes referred to, is a mountable shelf that is attached to the main operating room table using stirrup clamps or brackets. It provides an elevated flat surface, which protects the patient's face and chest from inadvertent trauma of robotic arms, instruments and camera while also serving as a platform for placement of instrumentation that minimizes handoffs to improve workflow. Its canted design also prevents slippage of instruments off the operating field during steep Trendelenburg positioning. This operating room equipment was designed to improve efficiency in an operating room set-up while ensuring safety during patient positioning when performing robotic procedures. A modification of the original Head Butler(®) (Tri-Medical Corporation, Portland, OR, USA) is presented here which improves upon the design by avoiding brachial plexus nerve injury to the patient due to pressure from the uprights pressing on the patient's shoulders during use.

A systematic review of peripheral nerve injury following laparoscopic colorectal surgery

AIM

The risk of peripheral nerve injury associated with laparoscopic colorectal surgery has not been well established. We aimed to identify the number and type of peripheral nerve injuries associated with patient positioning in laparoscopic surgery.

METHOD

A systematic review of MEDLINE and Embase was undertaken of English and non-English language articles. Search terms included the key words: laparoscopic, colorectal, nerve injury, nerve damage, brachial plexus, peripheral neuropathy, peripheral nerve injury, nerve and colonic injury. Articles were included where at least one peripheral nerve injury had been documented related to patient positioning at laparoscopic colorectal surgery. Data extraction for articles was conducted by two authors, using predefined data fields.

RESULTS

Ten cases have been reported in the literature. All injuries involved the brachial plexus. They were associated with a lengthy procedure and abduction of the arm.

CONCLUSION

Although rare, the surgeon and theatre team must be aware of the risk of peripheral nerve injury when positioning patients for laparoscopic colorectal procedures.

Surgically managed stage I endometrial cancer in a low-volume center: outcomes and complications in a military residency program

OBJECTIVE

The purpose of this study was to compare operative outcomes and complications for patients with endometrial cancer who underwent staging by laparoscopy vs laparotomy in a low-volume facility.

STUDY DESIGN

Research was conducted with a retrospective cohort of surgical patients with clinical stage I endometrial cancer from 2004-2009.

RESULTS

Eighty-six demographically similar patients (50 laparotomy and 36 laparoscopy) were identified. Laparoscopy had less estimated blood loss (339 vs 558 mL; P = .013) and lower rates of transfusion (5.6% vs 24%; P = .02). Laparoscopy was longer (281 vs 202 minutes; P < .0005) but required a shorter hospital stay (2.2 vs 5.5 days; P < .0005). Laparoscopy patients had fewer overall complications (16.7% vs 32%; P = .11). No differences in final surgical stage or lymph node yields between the groups were present.

CONCLUSION

Although a longer procedure, laparoscopy had fewer complications and shorter hospital stays. Prolonged operative time, compared with published experience, is potentially the result of unique factors in our center.

Intra-abdominal femoral nerve reconstruction following excision during right hemicolectomy

Iatrogenic femoral nerve injury is an uncommon but recognised complication of abdominal and gynaecological surgery. There have been several reported cases following colorectal surgery which specifically report transient femoral nerve neuropathies with variable but often full recovery. To our knowledge, this is the first documented case of femoral nerve reconstruction after iatrogenic resection during right hemicolectomy. We present a case report of complete femoral nerve transection following abdominal surgery and discuss our management.

Complications associated with two laparoscopic procedures used in the management of rectal endometriosis

BACKGROUND

To evaluate intra- and postoperative complications associated with laparoscopic management of rectal endometriosis by either colorectal segmental resection or nodule excision.

METHODS

During 39 consecutive months, 46 women underwent laparoscopic management of rectal endometriosis and were included in a retrospective comparative study. The distinguishing feature of the study is that the choice of the surgical procedure is not related to the characteristics of the nodule.

RESULTS

Colorectal segmental resection with colorectal anastomosis was carried out in 15 patients (37%), while macroscopically complete rectal nodule excision was performed in 31 women (63%). No intraoperative complications were recorded. In the colorectal resection group, 3 women (18%) had a bladder atony (spontaneously regressive in 2 women), 4 women (24%) experienced chronic constipation, one had an anastomosis leakage (6%), while 2 women (13%) had acute compartment syndrome with peripheral sensory disturbance. In the nodule excision group, 1 woman (4%) developed transitory right obturator nerve motor palsy. Based on both postoperative pain and improvement in quality of life, all 29 women in the excision group (100%) and 14 women in the colorectal resection group (82%) would recommend the surgical procedure to a friend suffering from the same disease.

CONCLUSION

Our study suggests that carrying out colorectal segmental resection in rectal endometriosis is associated with unfavourable postoperative outcomes, such as bladder and rectal dysfunction. These outcomes are less likely to occur when rectal nodules are managed by excision. Information about complications related to both surgical procedures should be provided to patients managed for rectal endometriosis and should be taken into account when a decision is being made about the most appropriate treatment of rectal endometriosis in each case.

Dealing with complications in laparoscopy

With increasing adoption of laparoscopic surgery in gynaecology, there has been a corresponding rise in the types and rates of complications reported. This article sets out to classify complications associated with laparoscopy according to the phases of the surgery; assess the incidence, the mechanisms, the presentations; and recommend methods for preventing and dealing with complications in laparoscopic surgery. Its aim is to promote a culture of risk management based on the development of strategies to improve patient safety and outcome.