Pulmonary function changes after laparoscopic surgery: relation to the sites of ports and the duration of pneumoperitoneum

Concurrent robotic renal and prostatic surgery: initial case series and safety data of a new surgical technique

INTRODUCTION

In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience.

PURPOSE

To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme.

PATIENTS AND METHODS

From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively.

RESULTS

Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy.

CONCLUSION

Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.

Physiologic changes during laparoscopy

The short-term benefits of minimal access techniques include less pain, early mobilization, and shorter hospital stay. Nonetheless, significant data have accumulated regarding the complications associated with laparoscopic techniques, including those that are unique to laparoscopic surgery such as bile duct injury and disruption of major blood vessels. Other problems such as myocardial ischemia and respiratory acidosis are associated with the cardiopulmonary effects of pneumoperitoneum and systemic CO2 absorption. These physiologic changes, although tolerated by healthy patients, could have particular adverse consequences for infirm and critically ill patients. It would appear that minimizing IAP during insufflation decreases the risk of potentially marked cardiovascular changes and regional blood flow alterations. In turn, this could arguably decrease the risk of perioperative myocardial events, or organ dysfunction or failure. Laparoscopy in the critically ill patient is questionable because the role is not established. An ICU patient has little to gain from the benefits of early mobilization. Conversely, in the presence of raised ICP or borderline organ function, the physiologic changes associated with pneumoperitoneum and laparoscopy could have profound detrimental effects.

Cardiocirculatory changes during videolaparoscopy in children: an echocardiographic study

We examined cardiovascular changes associated with intra-abdominal insufflation in 20 children (mean age 6.1+/-4.7 years, ASA physical status I or II) undergoing laparoscopic surgery with general anaesthesia using echocardiography with a transthoracic approach. Intra-abdominal pressure never exceeded 10 mmHg. Systolic blood pressure, diastolic blood pressure, endtidal CO2, peak, and mean airway pressure increased during intra-abdominal insufflation (P < 0.001). Pneumoperitoneum was associated with increases (P<0.001) in left ventricular enddiastolic volume, left ventricular end-systolic volume and left ventricular endsystolic meridional wall stress. In addition, before, during and after intra-abdominal insufflation, left ventricular fractional shortening and left ventricular ejection fraction, underwent slight, insignificant changes. Pneumoperitoneum in children has a major impact on cardiac volumes and function, mainly through the effect on ventricular load conditions. The sharp increase in intra-abdominal pressure affects both preload and afterload, while systolic cardiac performance remains unchanged.