Effects of pneumoperitoneum and reverse Trendelenburg position on cardiopulmonary function in morbidly obese patients receiving laparoscopic gastric banding

[Primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in left colonic and rectal cancer resections - the first Russian experience]

OBJECTIVE

To develop and describe a technique of primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in the left colon and rectal cancer surgery; to evaluate the short-term results of the first series of patients treated with a new minimally invasive method.

MATERIAL AND METHODS

The first 10 patients with adenocarcinoma of the left colon and rectum, who underwent surgical treatment using the retroperitoneal approach with vessel-sparing D3 lymph node dissection, were included in the study. The primary retroperitoneal approach involved mobilization of the left side of the colon, D3 lymph node dissection with skeletonization of inferior mesenteric artery (IMA) and selective ligation of afferent vessels from retroperitoneal space using SILS access system at the first steps of surgery. Intersection of visceral and parietal peritoneum, as well as intersection of mesentery within the bowel resection borders was performed laparoscopically. Surgical specimen was removed through retroperitoneal access incision.

RESULTS

Duration of retroperitoneal stage with lymph node dissection was 100 min (70.0-115.0). There were 28.5 (22-37) regional lymph nodes removed during vessel-sparing D3 lymph node dissection with IMA skeletalization, 3 (1-4) metastatic regional lymph nodes and 3.5 (2-5) apical nodes. In 4 out of 10 patients, we damaged visceral peritoneum during retroperitoneal dissection. Two patients developed Clavien-Dindo grade 1-2 complications. Mean postoperative hospital stay was 8 days (5-12).

CONCLUSION

We developed retroperitoneal vessel-sparing D3 lymph node dissection for the treatment of left colon and rectal cancer. Initial results demonstrated safety and feasibility of this approach.

Comparative Evaluation of the Effects of Three Different Recruitment Maneuvers during Laparoscopic Bariatric Surgeries of Morbid Obese Patients on Cardiopulmonary Indices

Background:

Laparoscopic bariatric surgeries in morbid obese patients may be associated with atelectasis, hypercapnia, and hypoxemia, intra and postoperatively. Several strategies are used for the prevention of these consequences. This study aimed to examine the effects of three different recruitment maneuvers comparatively during surgery and the influence of the maneuvers on some cardiopulmonary indices.

Materials and Methods:

In a clinical trial, ninety participants of laparoscopic surgery with body mass index higher than 40 were randomly divided into three equal groups. The first group was subject to 10 cmH₂O positive end-expiratory pressure (PEEP) during surgery, the second group, after venting the pneumoperitoneum, had 5 deep breaths with a positive pressure of 40 cmH₂O, and the third group was subject to both. Some pulmonary and hemodynamic parameters were measured every 15 min and compared between three groups.

Results:

The average of peak airway pressure, plateau airway pressure, and SpO₂ static and dynamic compliance between the three groups had no meaningful differences (P > 0.05), but PaCO₂in the second group was statistically higher than the other two groups (P < 0.05).

Conclusion:

Multiple deep breaths alone are not as effective as PEEP or PEEP plus MDB in preventing adverse pulmonary effects in laparoscopic bariatric surgeries of morbid obese patients.

Comparison of Arterial Oxygenation Following Head-Down and Head-Up Laparoscopic Surgery

BACKGROUND

Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy.

METHODS

In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations.

RESULTS

Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984).

CONCLUSIONS

In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.

Assessment of Ventilation Distribution during Laparoscopic Bariatric Surgery: An Electrical Impedance Tomography Study

Introduction. The aim of the study was to assess changes of regional ventilation distribution at the level of the 3rd intercostal space in the lungs of morbidly obese patients as a result of general anaesthesia and laparoscopic surgery as well as the relation of these changes to lung mechanics. We also wanted to determine if positive end-expiratory pressure of 10 cm H₂O prevents the expected atelectasis in the morbidly obese patients during general anaesthesia. Materials and Methods. 49 patients completed the examination and were randomized to 2 groups: ventilated without positive end-expiratory pressure (PEEP 0) and with PEEP of 10 cm H₂O (PEEP 10) preceded by a recruitment maneuver with peak inspiratory pressure of 40 cm H₂O. Impedance Ratio (IR) was utilized to examine ventilation distribution changes as a result of anaesthesia, pneumoperitoneum, and change of body position. We also analyzed intraoperative respiratory mechanics and pulse oximetry values. Results. In both groups general anaesthesia caused a ventilation shift towards the nondependent lungs which was not further intensified after pneumoperitoneum. Reverse Trendelenburg position promoted homogeneous ventilation distribution. Respiratory system compliance was reduced after insufflation and improved after exsufflation of pneumoperitoneum. There were no statistically significant differences in ventilation distribution between the examined groups. Respiratory system compliance, plateau pressure, and pulse oximetry values were higher in PEEP 10. Conclusions. Changes of ventilation distribution in the obese do occur at cranial lung regions. During pneumoperitoneum alterations of ventilation distribution may not follow the direction of the changes of lung mechanics. In the obese patients PEEP level of 10 cm H₂O preceded by a recruitment maneuver improves respiratory compliance and oxygenation but does not eliminate atelectasis induced by general anaesthesia.

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

Bilateral otorrhagia: a rare complication of laparoscopic abdominopelvic surgery

An 80-year-old woman without any previous otological symptoms underwent laparoscopic abdominoperineal resection for T3N0M0 low rectal carcinoma 4-5 cm from the anal verge. The total operative time was 6 h, of which she spent long hours in the Trendelenburg (35°) position due to difficult pelvic dissection. Midway through the procedure, she developed spontaneous non-traumatic bilateral otorrhagia. This case highlights the potential risk of increased intracranial pressure during prolonged periods of being in a steep Trendelenburg position caused either by the position itself or in combination with carbon dioxide pneumoperitoneum. We also consider the effect of a sudden change from this position to supine as a potential risk.

Hemodynamic changes during robotic radical prostatectomy

BACKGROUND

Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO(2) pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO(2) pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo™1.10.

METHODS

After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl (2 μg/kg) and thiopentone (4-7 mg/kg), and tracheal intubation was facilitated by vecuronium bromide (0.1 mg/kg). The patient's right internal jugular vein was cannulated and the Pre Sep™ central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO(2) pneumoperitoneum, position of the patient was gradually changed to 45° Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure (CVP), stroke volume (SV), stroke volume variation (SVV), cardiac output (CO), cardiac index (CI) and central venous oxygen saturation (ScvO(2)).

RESULTS

After induction of anesthesia, heart rate (HR), SV, CO and CI were decreased significantly from the baseline value (P>0.05). SV, CO and CI further decreased significantly after creating pneumoperitoneum (P>0.05). At the 45° Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45° Trendelenburg position (P=0.001). HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value (P>0.05) during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45° Trendelenburg position (after 5 and 20 min) compared with the baseline postinduction value (P>0.05). All these parameters returned to baseline after deflation of CO(2) pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO(2) throughout the study period.

CONCLUSIONS

The steep Trendelenburg position and CO(2) pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Tissue oxygenation in obese and non-obese patients during laparoscopy

BACKGROUND

Wound infection risk is inversely related to subcutaneous tissue oxygenation, which is reduced in obese patients and may be reduced even more during laparoscopic procedures.

METHODS

We evaluated subcutaneous tissue oxygenation (PsqO(2)) in 20 patients with a body mass index (BMI) > or=40 kg/m(2) (obese group) and 15 patients with BMI <30 kg/m(2) (non-obese group) undergoing laparoscopic surgery with standardized anaesthesia technique and fluid administration. Arterial oxygen tension was maintained near 150 mmHg. PsqO(2) was measured from a surrogate wound on the upper arm.

RESULTS

A mean FIO(2) of 51% (13%) was required in obese patients to reach an arterial oxygen tension of 150 mmHg; however, a mean FIO(2) of only 40% (7%) was required to reach the same oxygen tension in non-obese patients (P=0.007). PsqO(2) was significantly less in obese patients: 41 (10) vs 57 (15) mmHg (P<0.001).

CONCLUSION

Obese patients having laparoscopic surgery require a significantly greater FIO(2) to reach an arterial oxygen tension of about 150 mmHg than non-obese patients; they also have significantly lower subcutaneous oxygen tensions. Both factors probably contribute to an increased infection risk in obese patients.