Physiologic changes during laparoscopy

Renal medullary oxygenation during laparoscopic vs open surgery: the impact of blood pressure management-a pilot randomized controlled trial

The impact of blood pressure targets and surgical approach (laparoscopic or open) on continuous urinary oxygenation (PuO2), a validated surrogate of renal medullary PO2, during general surgery, is unclear. We aimed to assess the effects of different blood pressure targets and surgical procedures on PuO2. We randomized patients receiving either laparoscopic or open surgery into two mean arterial pressure (MAP) target groups: usual MAP or a high MAP. We measured PuO2 in real-time and analyzed it according to the type of surgery and blood pressure target. The study was retrospectively registered on the 5th of July 2023 (ACTRN12623000726651). We included 43 participants who underwent either laparoscopic (n = 20) or open surgery (n = 23). We found that PuO2 significantly decreased during both laparoscopic and open surgery under a usual blood pressure target (- 51% and - 49%, respectively). However, there was a sharper fall with laparoscopic surgery resulting in a higher PuO2 with open surgery (mean difference: 11 ± 1 mmHg higher; p < 0.001). Targeting a higher MAP resulted in a higher PuO2 over time during laparoscopic surgery (mean difference: 7 ± 1 mmHg, p < 0.001). In contrast, targeting a usual MAP resulted in a higher PuO2 during open surgery (mean difference: 7 ± 1 mmHg, p < 0.001). Surgical approach and intraoperative blood pressure targets significantly impact urinary oxygenation. Further studies with larger sample sizes are needed to confirm these findings and understand their potential clinical implications.Registration number: ACTRN12623000726651; Date of registration: 05/07/2023 (retrospectively registered).

Advantages of laparoscopy in gynecologic surgery in elderly patients

OBJECTIVE

Geriatric patients requiring gynecological surgery is increasing worldwide. However, older patients are at higher risk of postoperative morbidity and mortality, particularly cardiopulmonary complications. Laparoscopic surgery is widely used as a minimally invasive method for reducing postoperative morbidities. We compared the outcomes of open and laparoscopic gynecologic surgeries in patients older than 55 years.

METHODS

We included patients aged >55 years who underwent gynecological surgery at a single tertiary center between 2010 and 2020, excluding vaginal or ovarian cancer surgeries were excluded. Surgical outcomes were compared between the open surgery and laparoscopic groups, with age cutoff was set at 65 years for optimal discriminative power. We performed linear or logistic regression analyses to compare the surgical outcomes according to age and operation type.

RESULTS

Among 2,983 patients, 28.6% underwent open surgery and 71.4% underwent laparoscopic surgery. Perioperative outcomes of laparoscopic surgery were better than those of open surgery in all groups. In both the open and laparoscopic surgery groups, the older patients showed worse overall surgical outcomes. However, age-related differences in perioperative outcomes were less severe in the laparoscopic group. In the linear regression analysis, the differences in estimated blood loss, transfusion, and hospital stay between the age groups were smaller in the laparoscopy group. Similar restuls were observed in cancer-only and benign-only cohorts.

CONCLUSION

Although the surgical outcomes were worse in the older patients, the difference between age groups was smaller for laparoscopic surgery. Laparoscopic surgery offers more advantages and safety in patients aged >65 years.

Heart rhythm irregularities during laparoscopy: Description of a novel technique to manage severe intra-operative bradycardia - A case report

INTRODUCTION & IMPORTANCE

Minimally invasive abdominal surgeries need insufflation of a gas (usually carbon dioxide) into the peritoneal cavity for creating a pneumoperitoneum. Laparoscopic techniques have its own set of inherent complications. In order to maintain the operative space, constant gas flow is required to assist various surgeries. Increase in intraabdominal pressure due to high flow rate of gas during peritoneal insufflation is considered to be a probable cause of intraoperative vagal-mediated bradycardia resulting due to stretching of peritoneum. Intraoperative bradycardia during laparoscopic surgery can potentially lead to cardiac arrest and untoward outcomes.

CASE PRESENTATION

We report a case of a middle-aged hypertensive, hypothyroid patient with history of angle closure glaucoma who was undergoing elective laparoscopic cholecystectomy after proper pre-operative anesthesia/ physician and Ophthalmology clearance. Patient underwent general anesthesia (GA) and developed severe sinus bradycardia after insufflation, during stretch over gall bladder. Insufflation was stopped and abdomen deflated immediately. In view of glaucoma, atropine was contraindicated. 10 mL of 1% lignocaine was infiltrated into Calot's triangle and peri-gallbladder area. Surgery was resumed after 5 min and completed laparoscopically.

CLINICAL DISCUSSION

Bradycardia can occur during laparoscopic surgery mostly during rapid inflow of gas leading to peritoneal stretching with the added effect of vagotonic drugs used for general anesthesia. Use of intraperitoneal local anesthesia drugs for postoperative pain has been thoroughly studied and recommended due to statistically significant reduction in early postoperative abdominal pain. The management of intraoperative bradycardia should be prompt as it may be an early warning for cardiac arrest.

CONCLUSION

Vagal response following creation of pneumoperitoneum for minimally invasive abdominal surgeries is thought to be the most common cause for bradycardia. The effect of local anesthetic infiltration into peritoneum to reduce post operative pain is probably be due to blockade of afferent nerve endings in the peritoneum. Local anesthesia infiltration into Calot's triangle can be safely administered to mitigate localised vagal reflex.

Cardiorespiratory effects of different intraabdominal pressures in sheep: An experimental study

Increased intraabdominal pressure (IAP) during laparoscopy can reduce venous return, but changes in respiratory system mechanics and their effect in left cardiac function are not well documented. This study evaluated the effects of different IAPs on respiratory mechanics and cardiac function in 10 healthy nonpregnant adult Santa Ines ewes randomly submitted to a crossover study using different IAPs: 0 mm Hg (G1), 10 mm Hg (G2), 12 mmHg (G3), and 15 mmHg (G4). Animals were anesthetized and mechanically ventilated (VT  = 15 ml/kg; positive end-expiratory pressure = 3 cmH2 O; FiO2  = 1.0). Pneumoperitoneum was induced by Hasson's trocar cannula. Variables were measured at INITIAL (IAP, 0 mmHg) and FINAL time points for each IAP after 1 h. At FINAL, driving airway pressure (ΔP,RS ), and percentage fraction of dead space (Vd/Vt) were higher in G3 and G4 than G1 (p = 0.002, difference in means [MD] 4.60, 95% CI: 7.91-1.28, and p < 0.001, MD 5.4, 95% CI: 8.7-2.0; p = 0.016, MD -9.5, 95% CI: -17.9 to -1.2; and p = 0.027, MD -8.7, 95% CI: -17.1 to -0.4). The ejection fraction and fractional shortening were lower in G3 (p = 0.039, MD -11.38, 95% CI: -0.07--22.68; p = 0.015, MD -13.05, 95% CI: -1.74--24.36) and G4 (p = 0.039, MD -9.94, 95% CI: -0.07 to -19.80; p = 0.015, MD -11.43, 95%CI: -1.57 to -21.30, respectively) than G2. In G3, the maximum pulmonary flow velocity correlated negatively with ΔP,RS (r = -0.740; p = 0.018), and Vd/Vt correlated positively with ΔP,RS (r = 0.738, p = 0.046). At IAP of 12 and 15 mm Hg impaired respiratory system mechanics, reduced left cardiac function and no change in maximum pulmonary artery flow velocity were detected. Therefore, respiratory mechanics should be monitored as an interplay to reduce left cardiac function.

Effects of two alveolar recruitment maneuvers in an “open-lung” approach during laparoscopy in dogs

Objectives

The aim of this study was to compare the effects of a sustained inflation alveolar recruiting maneuver (ARM) followed by 5 cmH₂O of PEEP and a stepwise ARM, in dogs undergoing laparoscopic surgery.

Materials and methods

Twenty adult dogs were enrolled in this prospective randomized clinical study. Dogs were premedicated with methadone intramuscularly (IM); anesthesia was induced with propofol intravenously (IV) and maintained with inhaled isoflurane in pure oxygen. The baseline ventilatory setting (BVS) was as follows: tidal volume of 15 mL/kg, inspiratory pause of 25%, inspiratory to expiratory ratio of 1:2, and the respiratory rate to maintain the end-tidal carbon dioxide between 45 and 55 mmHg. 10 min after pneumoperitoneum, randomly, 10 dogs underwent sustained inflation ARM followed by 5 cmH₂O of PEEP (ARMi), while 10 dogs underwent a stepwise recruitment maneuver followed by the setting of the “best PEEP” (ARMc). Gas exchange, respiratory system mechanics, and hemodynamic were evaluated before the pneumoperitoneum induction (BASE), 10 min after the pneumoperitoneum (PP), 10 min after the recruitment (ARM), and 10 min after the pneumoperitoneum resolution (PostPP). Statistical analysis was performed with the ANOVA test (p < 0.05).

Results

Static compliance decreased in both groups at PP (ARMc = 1.35 ± 0.21; ARMi = 1.16 ± 0.26 mL/cmH₂O/kg) compared to BASE (ARMc = 1.78 ± 0.60; ARMi = 1.66 ± 0.66 mL/cmH₂O/kg) and at ARM (ARMc = 1.71 ± 0.41; ARMi = 1.44 ± 0.84 mL/cmH₂O/kg) and PostPP (ARMc = 1.75 ± 0.45; ARMi = 1.89 ± 0.59 mL/cmH₂O/kg), and it was higher compared to PP and similar to BASE. The PaO₂/FiO₂, in both groups, was higher at ARM (ARMc = 455.11 ± 85.90; ARMi = 505.40 ± 31.70) and PostPP (ARMc = 521.30 ± 66.20; ARMi = 450.90 ± 70.60) compared to PP (ARMc = 369.53 ± 49.31; ARMi = 394.32 ± 37.72).

Conclusion and clinical relevance

The two ARMs improve lung function in dogs undergoing laparoscopic surgery similarly. Application of PEEP at the end of the ARMs prolonged the effects of the open-lung strategy.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BACKGROUND

Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

METHODS

A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

RESULTS

A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

CONCLUSION

Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Comparison of LMA supreme, i-gel, and baska mask for airway management during laparoscopic cholecystectomy: A prospective randomized comparative study from North India

Background:

The supraglottic airway device (SAD) has proved to be an appropriate alternative to endotracheal intubation in laparoscopic surgeries owing to various advantages, namely, decreased airway manipulation and stable hemodynamics.

Aims:

We compared the efficacy in terms of oropharyngeal leak pressure (OLP) and safety of laryngeal mask airway (LMA)-Supreme (LMA-S), i-gel, and Baska mask in patients undergoing laparoscopic cholecystectomy.

Settings and Design:

Ninety patients posted for elective laparoscopic cholecystectomy were selected for a prospective randomized comparative study in a tertiary care center.

Materials and Methods:

The study comprised three groups of 30 each based on the different SADs used Group-LS with LMA-Supreme, Group-IG with i-gel, and Group-BM with Baska mask. The secondary objectives were device insertion time, ease of insertion, changes in the peak airway pressure (PAP), heart rate, mean arterial pressure, and airway complications (sore throat, dysphagia. dysphonia, lip/tongue or dental injury, etc.) between three groups.

Statistical Analysis:

The quantitative data were analyzed using the one-way analysis of variance test and Bonferroni post hoc multiple comparison test. Qualitative data were compared using Chi.squared test

Results:

OLP was significantly higher (P = 0.005) in the Baska mask than i-gel and LMA-S groups just after insertion and during carboperitonium. There was no significant difference in time for device insertion, number of attempts, ease of insertion, and use of manipulation (P > 0.05). However, the gastric tube insertion time was significantly lower in Group BM (9.59 ± 2.78) than Group IG with 12.79 ± 3.47 and Group LS with 10.84 ± 3.68 (P < 0.05). There were no significant differences between the groups with regard to changes in the PAP, heart rate, mean arterial pressure at different time intervals, and complications.

Conclusion:

Baska mask provided a significantly higher OLP compared to i-gel and LMA-S without significant airway morbidity in laparoscopic surgeries.

Prinzmetal’s variant angina during laparoscopy: a case report of vasospasm in the context of cardiac arrest

We report the case of a 43-year-old male patient who experienced cardiac arrest during two elective laparoscopies for cholecystectomy. The first procedure was prematurely interrupted after the return of spontaneous circulation (ROSC) while the other was continued under intravenous (IV) perfusion of nitrates (isosorbide dinitrate). At each time, after a cycle of cardiopulmonary resuscitation (CPR) and injection of atropine 0.5 mg, sinus rhythm was restored. Only 3-lead electrocardiogram (ECG) outlines were recorded, showing ST-elevation in lead II. During the first incident, a coronary angiography was performed showing a vasospasm of the left anterior descending (LAD) coronary artery, reversible upon intracoronary injection of nitrates. ECG during catheterization showed ST-elevation in the anterior coronary territory. Calcium-channel blockers (CCB) were prescribed, and oral nitrates were added after the second episode. Cardiovascular prevention consisted in smoking cessation, aspirin and statins. Reporting this case seems to be relevant due to its unusual presentation: Prinzmetal’s angina is usually described as morning chest pains, and it rarely concerns Caucasian men. Moreover, the vasospasm was associated with cardiac arrest and ECG changes suggestive of ST-elevation myocardial infarction (STEMI). The final diagnosis was myocardial infarction with non-obstructive coronary arteries (MINOCA) due to coronary vasospasm, a few minutes after insufflation of pneumoperitoneum. So far, few cases have been described during non-cardiac surgery, and even fewer during laparoscopy. Sharing our experience seems important to attract attention to cardiovascular events that can occur under general anesthesia, especially when clinical presentation is rare.

Facial Petechiae Following Laparoscopic Surgery: A Case Report of Rumpel-Leede Phenomenon

Petechial development as a result of venous compression has variously been described as acute dermal capillary rupture, mask phenomenon, and Rumpel-Leede Phenomenon. We describe the case of a patient who developed a facial petechial rash following a laparoscopic abdominal hysterectomy in steep Trendelenburg position. We review the physiological effects of laparoscopic surgical techniques and Trendelenburg positioning. These physiological effects lead to cephalad venous compression and are analogous to the venous compression caused by a tourniquet. The circumstances preceding its development and the characteristics of the facial rash lead us to conclude that the patient we present developed facial Rumple-Leede Phenomenon.

Hydromorphone Protects against CO2 Pneumoperitoneum-Induced Lung Injury via Heme Oxygenase-1-Regulated Mitochondrial Dynamics

Various pharmacological agents and protective methods have been shown to reverse pneumoperitoneum-related lung injury, but identifying the best strategy is challenging. Herein, we employed lung tissues and blood samples from C57BL/6 mice with pneumoperitoneum-induced lung injury and blood samples from patients who received laparoscopic gynecological surgery to investigate the therapeutic role of hydromorphone in pneumoperitoneum-induced lung injury along with the underlying mechanism. We found that pretreatment with hydromorphone alleviated lung injury in mice that underwent CO₂ insufflation, decreased the levels of myeloperoxidase (MPO), total oxidant status (TOS), and oxidative stress index (OSI), and increased total antioxidant status (TAS). In addition, after pretreatment with hydromorphone, upregulated HO-1 protein expression, reduced mitochondrial DNA content, and improved mitochondrial morphology and dynamics were observed in mice subjected to pneumoperitoneum. Immunohistochemical staining also verified that hydromorphone could increase the expression of HO-1 in lung tissues in mice subjected to CO₂ pneumoperitoneum. Notably, in mice treated with HO-1-siRNA, the protective effects of hydromorphone against pneumoperitoneum-induced lung injury were abolished, and hydromorphone did not have additional protective effects on mitochondria. Additionally, in clinical patients who received laparoscopic gynecological surgery, pretreatment with hydromorphone resulted in lower serum levels of club cell secretory protein-16 (CC-16) and intercellular adhesion molecule-1 (ICAM-1), a lower prooxidant-antioxidant balance (PAB), and higher heme oxygenase-1 (HO-1) activity than morphine pretreatment. Collectively, our results suggest that hydromorphone protects against CO₂ pneumoperitoneum-induced lung injury via HO-1-regulated mitochondrial dynamics and may be a promising strategy to treat CO₂ pneumoperitoneum-induced lung injury.

Effects of pupillary reflex dilation-guided opioid administration on remifentanil and morphine consumption during laparoscopic surgery: A randomised controlled trial

BACKGROUND

Analysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors.

OBJECTIVE

The present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery.

DESIGN

The study was a single-blind, randomised controlled trial.

SETTING

The study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017.

PATIENTS

A total of 100 patients who underwent scheduled laparoscopic surgery were included.

INTERVENTIONS

Patients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control).

MAIN OUTCOME MEASURES

The primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events.

RESULTS

Data from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] μg kg min, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) μg kg min; P < 0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mg kg (P = 0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4 vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), P = 0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), P < 0.001.

CONCLUSIONS

When PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02116868.

Changes in Hematological Parameters and Liver Enzymes During Laparoscopic Cholecystectomy

Background

Changes in hematological parameters, such as neutrophils, leukocytes, neutrophil-lymphocyte ratio, platelet lymphocyte ratio, and mean platelet volume, have been observed during laparoscopic surgeries.

Objectives

The objectives of this research were to assess the changes in hematological parameters and liver enzymes during laparoscopic cholecystectomy (LC).

Methods

This prospective observational study included patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis. Patients with comorbidities, including hepatitis, diabetes, and where laparoscopic cholecystectomy was converted to open cholecystectomy, were excluded. Preoperative and postoperative baseline hematological parameters and liver function tests (LFTs) were recorded. Characteristics like age, gender, body mass index (BMI), indication for surgery, duration of surgery, the pressure of pneumoperitoneum, and the duration of hospital stay were noted. A paired sample t-test was applied to assess the difference between the mean pre and postoperative values of different hematological parameters.

Results

It was observed that hemoglobin (Hb), hematocrit (Hct), platelets, and alkaline phosphatase (ALP) decreased postoperatively. However, mean corpuscular volume (MCV), mean platelet volume (MPV), leukocytes, and alanine transaminase (ALT) increased postoperatively. The difference in mean Hb, MCV, Hct, leukocytes, MPV, and ALT was statistically significant (p<0.05).

Conclusion

There were significant changes in the levels of hematological parameters and liver enzymes during LC.

Effect of Various Modes of Mechanical Ventilation in Laparoscopic Cholecystectomies on Optic Nerve Sheath Diameter and Cognitive Functions

Aim: In this study, we aim at investigating the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) modes on changes in the optic nerve diameter and cognitive functions in laparoscopic cholecystectomy operations. Materials and Methods: Sixty patients who underwent laparoscopic cholecystectomy were randomly divided into two groups based on the mode of mechanical ventilation provided: Group P; PCV, Group V; VCV. Optic nerve sheath diameter was measured when the patient was awake (T0), in the 10th minute after induction (T1), in the 10th minute after the initiation of gas insufflation (T2), when maximum gas pressure was reached in the reverse-Trendelenburg position (T3), and pre-extubation (T4). Partial oxygen saturation (PaO₂), PCO₂, end-tidal carbon dioxide (ETCO₂), and peak airway pressure (pPEAK) were also recorded. A Mini-Mental State Examination (MMSE) was conducted on patients preoperatively and in the postoperative third month. Results: Between the groups, a statistically significant difference was found in Group P compared with Group V in terms of optic nerve diameter at measurement times T1 (P < .05). In the intragroup comparison, a significant difference was found in the initial values in all measurements except for measurement times T0 and T4 in both Group P and Group V (P < .05). pPEAK values were identified to be statistically significantly lower in Group P than Group V at all measurement times (P < .05). No difference was identified in the MMSE scores in the intergroup and intragroup comparisons. Conclusion: Laparoscopic cholecystectomy increases the optic nerve diameter due to the mechanical and systemic effects of the operation, and the PCV mode can be preferred. Clinical Trial Number: NCT04413903.

Pneumomediastinum and ECG changes during laparoscopic Nissen fundoplication in a child; Case report

INTRODUCTION

Laparoscopic surgeries are becoming more popular in many surgical procedures particularly in pediatric age group. The physical responses and hemodynamic changes that occur during laparoscopic surgery differ between adults and pediatrics.

CASE PRESENTATION

We report a sudden hemodynamic instability and abrupt ECG changes associated with pneumomediastinum (PM) during laparoscopic Nissen fundoplication surgery in a 19 months old boy who had gastro-esophageal reflux disease. Procedure was converted to open surgery and all parameters were spontaneously returned back to normal values. The patient was successfully extubated then transferred to intensive care unit (ICU) for close monitoring. He had uneventful post-operative course where PM has been completely resolved in the repeated chest x-ray.

DISCUSSION

Pneumomediastinum (PM) occurs when air escape into the mediastinum. This air might reach the pericardium causing hemodynamic and electrophysiological changes. It is one of the reported complications that might occur during laparoscopic surgery, however isolated PM usually resolve spontaneously without any intervention. Etiology and possible contributing factors were discussed.

CONCLUSION

Pneumoperitonium leads to different hemodynamic changes during laparoscopic surgery in pediatric population compared to adults. Decreasing the insufflation pressure and patient's re-positioning might make continuing laparoscopy safe. However, surgeon must be willing to convert to open surgery to prevent any further complications.

Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population

With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.

Anesthetic Management for Paraesophageal Hernia Repair

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications.

Comparison of clinical performance of i-gelⓇ and Baska MaskⓇ during laparoscopic cholecystectomy

BACKGROUND

The supraglottic airway device is an appropriate alternative to tracheal intubation in laparoscopic surgery. We compared the Baska MaskⓇ with i-gelⓇ by measuring the oropharyngeal leak pressure (OLP) and hemodynamic and respiratory parameters during laparoscopic cholecystectomy.

METHODS

A total of 97 patients were randomly allocated to either i-gel group (n = 49) or Baska Mask group (n = 48). Insertion time, number of insertion attempts, fiber-optic view of the glottis, and OLP were recorded. Heart rate, mean arterial pressure, peak airway pressure (PAP), lung compliance, and perioperative complications were assessed before, during, and after pneumoperitoneum.

RESULTS

There were no significant differences between the two groups regarding demographic data, insertion time, fiber-optic view of the glottis, and the use of airway manipulation. The OLP was higher in the Baska Mask group than in the i-gel group (29.6 ± 6.8 cmH2O and 26.7 ± 4.5 cmH2O, respectively; P = 0.014). Heart rate, mean arterial pressure, PAP, and lung compliance were not significantly different between the groups. The incidence of perioperative complications was small and not statistically significant.

CONCLUSIONS

Both the i-gel and Baska Mask provided a satisfactory airway during laparoscopic cholecystectomy. Compared with the i-gel, the Baska Mask demonstrated a higher OLP.

Laparoscopic Major Gastrointestinal Surgery Is Safe for Properly Selected Patient with COPD: A Meta-Analysis

Background

Laparoscopy has been widely applied in gastrointestinal surgery, with benefits such as less intraoperative blood loss, faster recovery, and shorter length of hospital stay. However, it remains controversial if laparoscopic major gastrointestinal surgery could be conducted for patients with chronic obstructive pulmonary disease (COPD) which was traditionally considered as an important risk factor for postoperative pulmonary complications. The present study was conducted to review and assess the safety and feasibility of laparoscopic major abdominal surgery for patient with COPD.

Materials and Methods

Databases including PubMed, EmBase, Cochrane Library, and Wan-fang were searched for all years up to Jul 1, 2018. Studies comparing perioperative results for COPD patients undergoing major gastrointestinal surgery between laparoscopic and open approaches were enrolled.

Results

Laparoscopic approach was associated with less intraoperative blood loss (MD = −174.03; 95% CI: −232.16 to −115.91, P < 0.00001; P < 0.00001, I²=93% for heterogeneity) and shorter length of hospital stay (MD = −3.30; 95% CI: −3.75 to −2.86, P < 0.00001; P = 0.99, I²=0% for heterogeneity). As for pulmonary complications, laparoscopic approach was associated with lower overall pulmonary complications rate (OR = 0.58; 95% CI: 0.48 to 0.71, P < 0.00001; P = 0.42, I²=0% for heterogeneity) and lower postoperative pneumonia rate (OR = 0.53; 95% CI: 0.41 to 0.67, P < 0.00001; P = 0.57, I²=0% for heterogeneity). Moreover, laparoscopic approach was associated with lower wound infection (OR = 0.51; 95% CI: 0.42 to 0.63, P < 0.00001; P = 0.99, I²=0% for heterogeneity) and abdominal abscess rates (OR = 0.59; 95% CI: 0.44 to 0.79, P < 0.0004; P = 0.24, I²=30% for heterogeneity).

Conclusions

Laparoscopic major gastrointestinal surgery for properly selected COPD patient was safe and feasible, with shorter term benefits.

A Propensity Score-Based Analysis of Laparoscopic Liver Resection for Liver Malignancies in Elderly Patients

PURPOSE

Laparoscopic liver resection is safe, feasible and associated with less blood loss, shorter hospital stays and fewer postoperative complications in the working age patients with malignant liver tumors. However, it is still unclear if the elderly patients with malignant liver tumors would also benefit from that approach as the younger patients. So, the aim of the study was to compare the clinical outcomes of laparoscopic versus open liver resection for malignant liver tumors in elderly patients.

MATERIALS AND METHODS

Between March 2009 and July 2016, all elderly patients (≥70 years old) who underwent laparoscopic (n = 40) and open (n = 202) liver resection for malignant liver tumors were included. A one to one propensity score matching analysis was performed, based on 6 covariates, to decrease the selection bias.

RESULTS

There was no significant difference between the laparoscopic and open liver resection groups regarding the patient characteristics and tumor features. The operative time was comparable between both groups (Laparoscopic group 259 min vs Open group 308 min, p = .86), while patients who underwent laparoscopic liver resection had lower intraoperative blood loss (30 ml vs 517 ml, p < .0001), shorter hospital stays (10 days vs 23 days, p < .0001), and less overall morbidity (15% vs 38%, p = .04). The one-, three-, and five-year survival for patients with hepatocellular carcinoma was comparable between both groups (Laparoscopic group 96%, 74%, 47%, vs Open group 94%, 71%, 48%, p = .82), whereas The one-, three-, and five-year recurrence-free survival for patients with hepatocellular carcinoma was significantly higher in the laparoscopic group (88%, 60%, 60% vs 54%, 25%, 19%, p = .019).

CONCLUSIONS

Laparoscopic approach for minor liver resection in elderly patients is safe and feasible with less blood loss, a shorter hospital stay, less postoperative complications and a better oncological outcome.

Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery

Although laparoscopic surgery accounts for >2 million surgical procedures every year, the current preoperative risk scores and guidelines do not adequately assess the risks of laparoscopy. In general, laparoscopic procedures have a lower risk of morbidity and mortality compared with operations requiring a midline laparotomy. During laparoscopic surgery, carbon dioxide insufflation may produce significant hemodynamic and ventilatory consequences such as increased intraabdominal pressure and hypercarbia. Hemodynamic insults secondary to increased intraabdominal pressure include increased afterload and preload and decreased cardiac output, whereas ventilatory consequences include increased airway pressures, hypercarbia, and decreased pulmonary compliance. Hemodynamic effects are accentuated in patients with cardiovascular disease such as congestive heart failure, ischemic heart disease, valvular heart disease, pulmonary hypertension, and congenital heart disease. Prevention of cardiovascular complications may be accomplished through a sound understanding of the hemodynamic and physiological consequences of laparoscopic surgery as well as a defined operative plan generated by a multidisciplinary team involving the preoperative consultant, anesthesiologist, and surgeon.

Pneumoperitoneum and hemodynamic stability during pediatric laparoscopic appendectomy

BACKGROUND

Conventional pneumoperitoneum (CP) and automatically maintained pneumoperitoneum using AirSeal Intelligent Flow System (AiFS) were compared during pediatric laparoscopic appendectomy (LA) using intraperitoneal pressure (IPP) and hemodynamic parameters.

METHODS

A prospective review of 39 children aged 3-14years who had standard 3-trocar LA was performed. Pneumoperitoneum was either AiFS (n=18) or CP (n=21) according to the surgeon's preference. IPP during insertion of trocars in all subjects was initially 8-10mmHg, which was reduced to 5mmHg then maintained until LA was completed. Data were collected every 5min during pneumoperitoneum.

RESULTS

Subject demographics were similar for both groups. During pneumoperitoneum, average IPP (AiFS: 7.9; CP: 9.0mmHg), average systolic blood pressure (AiFS: 100.4; CP: 106.9mmHg), and average end-tidal CO₂ (EtCO₂; AiFS: 35.7; CP: 38.5mmHg) were significantly different (p<.05, respectively), while pulse (AiFS: 92.1; CP: 96.4bpm), oxygen saturation (AiFS: 98.8; CP: 98.8%), body temperature (AiFS: 37.2; CP: 37.4), urine output (AiFS: 2.7; CP: 2.4mL/kg per hour), operative time (AiFS: 72.2; CP: 76.2mins), blood loss (AiFS: 3.6; CP: 3.5mL), recommencement of oral intake (AiFS: 1.3; CP: 1.4days), and postoperative hospitalization (AiFS: 4.3; CP: 3.8days) were not.

CONCLUSION

Because IPP was significantly lower during LA with AiFS, EtCO₂ and BP were significantly lower.

LEVEL OF EVIDENCE

Treatment study; prospective comparative study - level II.

Bariatric Surgery Provides a "Bridge to Transplant" for Morbidly Obese Patients with Advanced Heart Failure and May Obviate the Need for Transplantation

BACKGROUND

In patients with advanced heart failure, morbid obesity is a relative contraindication to heart transplantation due to higher morbidity and mortality in these patients.

METHODS

We performed a retrospective analysis of consecutive morbidly obese patients with advanced heart failure who underwent bariatric surgery for durable weight loss in order to meet eligibility criteria for cardiac transplantation.

RESULTS

Seven patients (4 M/3 F, age range 31-56 years) with left ventricular ejection fraction (LVEF) ≤ 25 % underwent laparoscopic bariatric surgery. Median preoperative body mass index (BMI) was 42.8 kg/m(2) (range 37.5-50.8). There were no major perioperative complications in six of seven patients. Median length of hospital stay was 5 days. There was no mortality recorded during complete patient follow-up. At a median follow-up of 406 days, median BMI reduction was 12.9 kg/m(2) (p = 0.017). Postoperative LVEF improved to a median of 30 % (interquartile range (IQR) 25-53 %; p = 0.039). Two patients underwent successful cardiac transplantation. Two patients reported symptomatic improvement with little change in LV function and now successfully meet listing criteria. Three patients showed marked improvement of their LVEF and functional status, thus removing the requirement for transplantation.

CONCLUSIONS

Bariatric surgery can achieve successful weight loss in morbidly obese patients with advanced cardiac failure, enabling successful heart transplantation. In some patients, cardiac transplantation can be avoided through surgical weight loss.

Effect of recruitment maneuver on arterial oxygenation in patients undergoing robot-assisted laparoscopic prostatectomy with intraoperative 15 cmH2O positive end expiratory pressure

BACKGROUND

This randomized, controlled study was designed to compare the effects of recruitment maneuvers (RMs) with a 15 cmH₂O positive end-expiratory pressure (PEEP) on the systemic oxygenation and lung compliance of patients with healthy lungs following robot-assisted laparoscopic prostatectomy (RALP).

METHODS

Sixty patients undergoing a RALP with an intraoperative 15 cmH₂O PEEP were randomly allocated to an RM or a Control group. The patients in the RM group received a single RM through the application of a continuous positive airway pressure of 40 cmH₂O for 40 s 15 min after being placed in the Trendelenburg position. The arterial oxygen tension (PaO₂, primary endpoint) and the pulmonary dynamic and static compliances (secondary endpoints) were measured 10 min after the anesthetic induction (T1), 10 min after establishment of the pneumoperitoneum (T2), 10 min after establishment of the Trendelenburg position (T3), 10 min after the RM (T4), 60 min after the RM (T5), and 10 min after deflation of the pneumoperitoneum in the supine position (T6).

RESULTS

The intergroup comparisons of the PaO₂ showed significantly higher values in the RM group than in the Control group at T4 and T5 (193 ± 35 mmHg vs. 219 ± 33 mmHg, P = 0.015, 188 ± 41 mmHg vs. 214 ± 42 mmHg, P = 0.005, respectively). However, the PaO₂ at T6 was similar in the two groups (211 ± 39 mmHg vs. 224 ± 41 mmHg, P = 0.442). Moreover, there were no statistical differences between the groups in the dynamic and static compliances of the lungs at any time point.

CONCLUSIONS

The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH₂O PEEP was improved by a single RM. However, this benefit did not last long, and it did not lead to an amelioration of the lung mechanics.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly

OBJECTIVE

The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients.

MATERIALS AND METHODS

A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients.

RESULTS

Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients.

CONCLUSIONS

Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

Single-port endoscopic mesocolic and mesorectal excision using an extraperitoneal approach

BACKGROUND

The extraperitoneal rectal dissection via a transanal approach facilitates the mesorectal dissection. The retroperitoneal approach for mesocolic excision may also offer some similar advantages. To complete the lymphadenectomy of extraperitoneal mesorectal resection, we developed an innovative approach for upper rectal and mesocolic excision via an exclusive retroperitoneal dissection using a single-port access at the site of the future stomy.

METHODS

This study was a prospective pilot study and was conducted between 2013 and 2015 at two oncologic centers. Five consecutive patients, with ano-rectal cancer requiring permanent stoma, underwent this procedure.

RESULTS

The bowel was never touched or mobilized to perform the lymphadenectomy, and no Trendelenburg was required. The median operative duration was 300 min (range 205-310). The quality of the surgical plane was classified as good (mesorectal) in the five patients. The median circumferential and distal margins were, respectively, 5 mm (range 1-20) and 20 mm (range 5-25). The median number of harvested lymph nodes was 11 (range 5-18). No laparotomy or multiport laparoscopy was required. There was no death. Two patients had perineal wound dehiscence (one minor and one major).

CONCLUSIONS

The mesocolic excision via a retroperitoneal approach is feasible, completes naturally the transanal mesorectal excision and may confer several advantages including no morbidity of small bowel manipulation or Trendelenburg position. Further studies are required to analyze this approach.

Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population

AIM

To evaluate the role of laparoscopy in the treatment of surgical emergency in old population.

PATIENTS AND METHODS

Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test.

RESULTS

159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,250,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1

CONCLUSIONS

The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.

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Key Words

• surgery
• laparoscopy
• elderly
• emergency

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MESH Headings

• Abdomen/surgery
• Aged
• Digestive System Diseases/surgery
• Emergency Treatment
• Hernia, Ventral/surgery
• Humans
• Laparoscopy

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Affiliation(s)

G. COCORULLO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
N. FALCO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
R. TUTINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
T. FONTANA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SCERRINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SALAMONE Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
L. LICARI Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. GULOTTA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy

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Effects of ultrasound-guided stellate ganglion block on autonomic nervous function during CO2-pneumoperitoneum: A randomized double-blind control trial

BACKGROUND

CO2-pneumoperitoneum can cause sympathetic nerve activity increased and is likely to causes severe stress-related homeostatic disorders.

OBJECTIVE

Patients undergoing elective laparoscopic cholecystectomy were administered type-B ultrasound-guided stellate ganglion block (SGB) to observe the effects on autonomic nervous system during CO2- pneumoperitoneum.

DESIGN

A randomized, double-blinded, and placebo-controlled study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Eighty patients (aged 32-75 years; weight, 45-80 kg; American Society of Anesthesiologists (ASA) physical status classification, class I or II) undergoing elective laparoscopic cholecystectomy.

INTERVENTIONS

The RSGB group was administered lidocaine 1% 7 ml under ultrasound guidance.

MAIN OUTCOME MEASURES

The low frequency (LF), high frequency (HF), total power (TP) and LF/HF ratio were recorded before the block (T0), 5 min (T1) and 30 min (T2) following pneumoperitoneum, 5 min after deflation of pneumoperitoneum (T3) and after surgery (T4). The low-frequency normalized unit (LFnu) and high-frequency normalized units (HFnu) were calculated.

RESULTS

Compared with T0, LF, LFnu and LF/HF ratio were significantly elevated at T1-4 (all P< .05 or .01). HFnu was significantly decreased at T2-4 in control group (P< .05) while HF was significantly elevated (P< .01). The LF/HF ratio was significantly decreased (P< .05) at T1-4 in RSGB group. Compared with control group, the LF, LFnu and LF/HF ratio were significantly decreased (P< .05) and HF and HFnu was significantly elevated (P< .05 or .01) at T1-4 in RSGB group.

CONCLUSION

Ultrasound-guided RSGB inhibited CO2-pneumoperitoneum-induced sympathetic neural excitation, upregulated vagal nerve stimulation and maintained stable autonomic nervous function.

Analgesia with interfascial continuous wound infiltration after laparoscopic colon surgery: A randomized clinical trial

OBJECTIVES

For major laparoscopic surgery, as with open surgery, a multimodal analgesia plan can help to control postoperative pain. Placing a wound catheter intraoperatively following colon surgery could optimize the control of acute pain with less consumption of opioids and few adverse effects.

METHODS

We conducted a prospective, randomized, study of patients scheduled to undergo laparoscopic colon surgery for cancer in Galdakao-Usansolo Hospital from January 2012 to January 2013. Patients were recruited and randomly allocated to wound catheter placement plus standard postoperative analgesia or standard postoperative analgesia alone. A physician from the acute pain management unit monitored all patients for pain at multiple points over the first 48 hours after surgery. The primary outcome variables were verbal numeric pain scale scores and amount of intravenous morphine used via patient controlled infusion.

RESULTS

92 patients were included in the study, 43 had a wound catheter implanted and 49 did not. Statistically significant differences in morphine consumption were observed between groups throughout the course of the treatment period. The mean total morphine consumption at the end of the study was 5.63±5.02mg among wound catheter patients and 21. 86±17.88mg among control patients (P=.0001). Wound catheter patients had lower pain scale scores than control patients throughout the observation period. No adverse effects associated with the wound catheter technique were observed. The wound catheter group showed lower hospital stays with statistically significant difference (P=.02).

CONCLUSIONS

In patients undergoing laparoscopic colon surgery, continuous infusion of local anaesthetics through interfascial wound catheters during the first 48h aftersurgery reduced the level of perceived pain and also reduced parenteral morphine consumption with no associated adverse effects and lower hospital stays.

Comparison of i-gel® and LMA Supreme® during laparoscopic cholecystectomy

Background

In laparoscopic surgical procedures, many clinicians recommend supraglottic airway devices as good alternatives to intubation. We compared the i-gel® (i-gel) and LMA Supreme® (Supreme Laryngeal Mask Airway, SLMA) airway devices during laparoscopic cholecystectomy regarding sealing pressure and respiratory parameters before, during, and after pneumoperitoneum.

Methods

Following Institutional Review Board approval and written informed consent, 93 patients were randomly allocated into the i-gel (n = 47) or SLMA group (n = 46). Insertion time, number of insertion attempts, and fiberoptic view of glottis were recorded. Oropharyngeal leak pressure (OLP), the use of airway manipulation, peak inspiratory pressure, lung compliance, and hemodynamic parameters were measured before, during, and after pneumoperitoneum.

Results

There were no significant differences between the two groups regarding demographic data, insertion time, fiberoptic view of glottis, and the use of airway manipulation. The gastric tube insertion time was longer in the i-gel group (20.4 ± 3.9 s) than in the SLMA group (16.7 ± 1.6 s) (P < 0.001). All devices were inserted on the first attempt, excluding one case in each group. Peak inspiratory pressure, lung compliance, and OLP changed following carbon dioxide pneumoperitoneum in each group, but there were no significant differences between the groups.

Conclusions

Both the i-gel and SLMA airway devices can be comparably used in patients who undergo laparoscopic cholecystectomy, and they offer similar performance including OLP.

10 cm H2O PEEP application in laparoscopic surgery and cerebral oxygenation: a comparative study with INVOS and FORESIGHT

INTRODUCTION

In the present study, changes in hemodynamic parameters and cerebral oxygen saturation (rSO2) associated with 10 cm H2O PEEP application were investigated, which is assumed beneficial for the respiratory functions and oxygenation during laparoscopic cholecystectomy (LC) applied at 30° head-up left side position. Data gathered via two devices, namely INVOS and FORESIGHT, were compared.

METHODS

After both the ethics committee approval from the hospital and patients' written consents were obtained, patients undergoing elective laparoscopic surgery (only ASA I-II) were randomly divided into two groups (Clinical trials protocol NCT02071550). Sensors of INVOS and FORESIGHT devices were placed on the right side at the forehead region. In total, 11 evaluation periods were formed, namely pre-induction (1st period), post-induction (2nd period), abdominal insufflation outset (3rd period), post-insufflation at 5-min intervals (4th, 5th, 6th, 7th, and 8th period), at the end of insufflation (9th period), at the end of operation (10th period), and at the end of anesthesia (11th period). While one of the groups did not receive PEEP (ZEEP group), the other group received 10 cm H2O along with abdominal insufflation (PEEP group). Demographic data, hemodynamic values, and rSO2 values were recorded for both groups at all 11 periods.

RESULTS

A total of 44 patients in two groups, each group containing 22 individuals, were included in the study. Systolic, diastolic, and mean arterial pressures, etCO2 and SO2 values, and demographic data were found to be similar in both groups. Heart rate was observed to be higher in the PEEP group starting with the PEEP administration. INVOS rSO2 values were found similar in both groups. However, FORESIGHT rSO2 values were found to be higher in the PEEP group compared to the ZEEP group. No patient had cerebral desaturation in both groups throughout the study.

DISCUSSION

Application of PEEP with 10 cm H2O during abdominal insufflation could increase the rSO2 value and heart rate in patients undergoing laparoscopic cholecystectomy. However, all changes observed were within normal limits. FORESIGHT device yielded more compatible results with hemodynamic data compared to INVOS.

Anesthetic Implications of Robotic Gynecologic Surgery

Surgery using robotic techniques is becoming more and more common. One of the specialties at the fore-front of robotic surgery has been gynecology, much like it was at the fore-front a generation ago in bringing laparoscopy into the operating room. New considerations have been noted and new techniques have been learned on both sides of the drape in order to ensure a successful outcome for the patient undergoing robotic gynecologic surgery. The purpose of this article is to bring, to light the concerns facing the anesthesiologist in regards to robotic procedures. We discuss the problems facing anesthesiologists, when a patient is experiencing both intraabdominal insufflation and steep Trendelenburg position, and also the intraoperative management of such a patient.

Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study

BACKGROUND

Laparoscopic surgery causes specific post-operative discomfort and intraoperative cardiovascular, pulmonary, and splanchnic changes. The CO2 pneumoperitoneum-related intra-abdominal pressure (IAP) remains one of the main drivers of these changes. We investigated the influence of deep neuromuscular blockade (NMB) on IAP and surgical conditions.

METHODS

This is an open prospective single-subject design study in 20 patients (14 female/6 male) undergoing laparoscopic cholecystectomy. Inclusion criteria were 18 years or older, and American Society of Anesthesiologists classification 1 to 3. Under a standardised anaesthesia, lowest IAP providing adequate surgical conditions was assessed without NMB and with deep NMB [post-tetanic count (PTC)<2] with rocuronium. The differences between IAP allowing for an adequate surgical field before and after administration of rocuronium were determined, as were effects of patient gender, age, and body mass index.

RESULTS

Mean IAP without NMB was 12.75 (standard deviation 4.49) mmHg. Immediately after achieving a deep NMB, this was 7.20 (2.51). This pressure difference of 5.55 mmHg (5.08, P<0.001) dropped to 3.00 mmHg (4.30, P<0.01) after 15 min. Higher IAP differences were found in women compared with men. A modest inverse relationship was found between pressure difference and age.

CONCLUSIONS

We found an almost 25% lower IAP after a deep NMB compared with no block in laparoscopic cholecystectomy. Younger and female patients appear to benefit more from deep neuromuscular blockade to reduce IAP.

Laparoscopic surgery in the elderly: a review of the literature

Laparoscopic techniques are gradually replacing many common surgical procedures that are performed in an increasingly aging population. Laparoscopy places different physiologic demands on the body than in open surgery. PubMed was searched for evidence related to the use of laparoscopy in the elderly population to treat common surgical pathologies. Randomized trials, systematic reviews, and meta-analyses were preferred. Currently, over 40% of all surgeries performed in the U.S. are on patients older than 65 years. By the end of the 21st century, Americans are expected to live 20 years longer than the current average. However, elderly patients clearly show higher rates of surgical morbidity and mortality overall. Laparoscopic techniques show decreased wound complications, post-operative ileus, intraoperative blood loss, and reduced need for post-operative rehabilitation. In conclusion, laparoscopic surgery is safe in the elderly population and affords multiple advantages including decreased pain and convalescence. However, the physiology of laparoscopy places demands on elderly patients that typically present with more medical comorbidities.

Delayed recovery from anaesthesia in a patient with optimised hypothyroidism and incidental hypokalemia

Delayed recovery/awakening/ emergence can occur under anaesthesia and is multifactorial, could be drug or non drug related. Similarly, we report a case of delayed recovery in a 68-year-old patient, for laparoscopic cholecystectomy, a known case of hypertension, bronchial asthma and hypothyroidism. Preoperatively, she was optimised for her medical disorders; however, she had delayed recovery from general anaesthesia. The delayed recovery, often, would be expected in a case of hypothyroidism, however in our patient it was found to be associated with inadvertent hypokalemia.

Technique of last resort: characteristics of patients undergoing open surgery in the laparoscopic era

BACKGROUND

The utilization rates for minimally invasive colorectal resection techniques (MICR) continue to increase. In some centers MICR methods are the preferred approach, however, open methods continue to be utilized for select patients. In this study, the profile and short-term outcomes of open colorectal resection (CR) and MICR patients are determined and compared.

METHODS

A retrospective review of patients who underwent elective CR over 11 years at two institutions was performed. The MICR group contained both laparoscopic-assisted and hand-assisted cases. The past medical and surgical histories, indications, operations performed, and short-term outcomes were assessed. The Charlson co-morbidity index (CMI) was used to assess risk.

RESULTS

During the study period 1080 patients underwent CR (Open, 141; MICR, 939). As judged by the CMI, there were more high-risk patients (score ≥2) in the Open group (34.38%) versus MICR (22.11%) p = 0.0029. Significantly more open patients had prior abdominal surgery and specifically CRs (Open, 15.60% vs. MICR, 2.13%, p < 0.001). Intraoperative transfusion (Open 25.7%; MICR 6.8%, p < 0.001) and diversion (25.53 vs. 11.50%, p < 0.001) were more common in the Open group. Not surprisingly, recovery of bowel function and length of stay were longer for the Open group. The overall complication rate was also higher for the Open patients (p < 0.001).

CONCLUSION

When MICR is the procedure of choice, patients selected for Open CR are higher risk and more complex as judged by the CMI and past operative history. Not surprisingly, this translates into a longer length of stay, higher rates of transfusion, diversion, and complications. This disparity in patients undergoing CRs makes direct comparison of MICR and Open resection outcomes not reasonable.

Temporary postoperative visual loss associated with intracerebral hemorrhage after laparoscopic appendectomy: a case report

Postoperative visual loss (POVL) after non-ophthalmic surgery is rare, with a reported incidence ranging from 0.013 to 0.2%. Most perioperative visual loss is associated with spine operations and cardiac bypass procedures. The most common cause of POVL is ischemic optic neuropathy. However, there are no previous reports of postoperative visual loss after laparoscopic appendectomy. A 43-year-old female with no underlying disease underwent laparoscopic appendectomy; the operation was completed in one hour and her blood pressure was stable during the perioperative period. In the post-anesthetic care unit, the patient complained of nausea and headache, but she did not complain of any unusual visual symptoms. Approximately one hour after arriving at the ward, the patient complained of visual disturbance. Neurologic examination revealed left homonymous hemianopsia, and subarachnoid hemorrhage and intracerebral hemorrhage were found in the occipital area on brain MRI.

Anaesthesia for laparoscopic kidney transplantation: Influence of Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, respiratory and renal function

Background:

Laparoscopic donor nephrectomy is a routine practice since 1995. Until now, the recipient has always undergone open surgery for transplantation. In our institute, laparoscopic kidney transplantation (LKT) started in 2010. To facilitate this surgery, the patient must be in steep Trendelenburg position for a long duration. Hence, we decided to study the effect of CO2 pnuemoperitoneum and Trendelenburg position in chronic renal failure (CRF) patients undergoing LKT.

Methods:

A total of 20 adult CRF patients having mean age of 31.7±10.36 years and body mass index 19.65±3.41 kg/m² without significant coronary artery disease were selected for the procedure. Cardiovascular parameters heart rate (HR), mean arterial pressure (MAP), Central venous pressure (CVP) and respiratory parameters (ETCO₂, peak airway pressure) were noted at the time of induction, after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position, 15 min after decompression of pnuemoperitonuem and after extubation. Arterial blood gas analysis was carried out after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position and 15 min after clamp release. Total duration of surgery, anastomosis time, time for the establishment of urine output and total urine output were noted. Serum creatinine on the 1^st and 7^th post-operative day were recorded.

Results:

Significant increase in HR was observed after creation of CO₂ pneumoperitoneum and just before extubation. Significant increase in the MAP and CVP was noted after creation of pneumoperitoneum and after giving Trendelenburg position. No significant rise in the ETCO₂ and PaCO₂ was observed. Significant increase in the base deficit was observed after the clamp release, but none of the patients required correction.

Conclusion:

LKT performed in steep Trendelenburg position with CO₂ pneumoperitoneum significantly influenced cardiovascular and respiratory homeostasis; however, measured parameters remained within clinically acceptable range without affecting early function of the transplanted kidney.

Current and future practices in surgical retraction

Retraction of tissues and anatomical structures is an essential component of all forms of surgery. The means by which operative access is gained through retraction are many and diverse. In this article, the various forms of retraction methods currently available are reviewed, with special reference to hand held, self-retaining and compliant techniques. The special challenges posed by laparoscopic surgery are considered and future developments in new retraction techniques are anticipated.