Anaesthesia for laparoscopic urological surgery

New techniques of regional anaesthesia for renal laparoscopic surgeries

Renal procedures are performed within the realm of urology, general and transplant surgery. The implementation of new operating techniques imposes on anaesthetists the need to adapt their methods, aiming to improve the patient's perioperative comfort and safety. Laparoscopy is gaining increasing interest as a less invasive procedure; however clinical research shows that pain after the procedure is underestimated and therefore poorly controlled. Multimodal analgesia is very promising, though, as it allows better pain control, expedites discharge and enhances recovery. This is achieved through a combination of general and regional anaesthesia with administration of adjuvant drugs intraoperatively, resulting in reduced opioid requirements in the recovery room with diminished side effects of pain treatment. Good communication between the surgeon and the anaesthetist is the key to effective anaesthesia and analgesia.

Do Small Incisions Need Only Minimal Anesthesia?-Anesthetic Management in Laparoscopic and Robotic Surgery

Laparoscopic techniques have established themselves as a major part of modern surgery. Their implementation in every surgical discipline has played a vital part in the reduction of perioperative morbidity and mortality. Precise robotic surgery, as an evolution of this, is shaping the present and future operating theatre that an anesthetist is facing. While incisions get smaller and the impact on the organism seems to dwindle, challenges for anesthetists do not lessen and could even become more demanding than in open procedures. This review focuses on the pathophysiological effects of contemporary laparoscopic and robotic procedures and summarizes anesthetic challenges and strategies for perioperative management.

Anesthetic management using a combination of anterior quadratus lumborum block and erector spinae plane block for robot-assisted partial nephrectomy: two case reports

BACKGROUND

There has been increasing attention regarding quadratus lumborum block (QLB) and erector spinae plane block (ESPB) as effective truncal blocks. There have been reports of combined QLB and ESPB usage in hip surgery resulting in a symbiotic increase in effectiveness. However, there have been no reports regarding robot-assisted partial nephrectomy (RAPN), which requires multiple port holes ranging from near the xiphoid process to below the umbilicus. We hypothesized that the combined use of QLB and ESPB was an option for anesthesia and analgesia during RAPN.

CASE PRESENTATION

Anterior QLB and ESPB were applied to two patients undergoing scheduled RAPN. With intravenous patient-controlled analgesia, the post-surgery numerical rating scale scores were < 3/10 at rest and < 5/10 upon movement, throughout the perioperative time.

CONCLUSIONS

The combination of QLB and ESPB could be an option for the postoperative analgesia in RAPN.

Robotic Surgery: Anaesthesiologist's Contemplation

Technological advances in the field of surgery and medicine have increased the demand for minimally invasive surgery manifold. Robot assisted surgery is gaining popularity, overcoming the flaws of laparoscopic techniques; with improved surgical precision. The conservative nature of anaesthesia care has to face the challenges with respect to patient positioning, bulkiness of the operating system and being positioned far and away from the patient. Anaesthesiologist’s commitment to be the ‘best man’ for the patient during the perioperative period mandates him to familiarise with these challenges of robot assisted surgical system and provide best possible anaesthetic care and ensure patient safety. In this article, a systematic review of the development of surgical robots and the consideration of unique anaesthetic concerns thereof have been undertaken as any new technology is known to be accompanied by its risks and technical perplexity.

Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring reintubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.

Effect of Esmolol and Diltiazem Infusions on Hemodynamic Response to Pneumoperitoneum on Laparoscopic Simple Nephrectomy: A Randomized Controlled Trial

Background

Several studies have been conducted in search of appropriate drugs to attenuate hemodynamic responses in laparoscopic cholecystectomy, but till date, no such study has been conducted on patients undergoing laparoscopic nephrectomy.

Aim

The study was designed to assess the effect of esmolol and diltiazem infusions on hemodynamic changes during routine laparoscopic transperitoneal simple nephrectomy.

Settings and Design

A prospective double-blinded randomized control trial.

Subjects and Methods

A total of 120 nonhypertensive patients of the American Society of Anesthesiologists physical Status I and II aged 20-60 years about to undergo laparoscopic nephrectomy were enrolled for the study after obtaining Institute Ethical committee approval. The patients were randomly allocated to one of the three groups. Group I (control group) received 10 ml normal saline intravenously (i.v.) before induction of anesthesia, followed by continuous infusion 10-20 ml/h. Group II (esmolol group) received i.v. esmolol 1 mg/kg diluted in 10 ml similarly, followed by continuous infusion of 10-20 ml/h (5-10 μg/kg/min). Group III (diltiazem group) received i.v. diltiazem 0.2 mg/kg diluted in 10 ml before induction of anesthesia, followed by continuous infusion at 10-20 ml/h (0.08-1.25) μg/kg/min. After completion of surgery, all the infusions were stopped. Data recording were done for changes in hemodynamics throughout the surgery.

Statistical Analysis

was done using Chi-square test for categorical data and one-way ANOVA for continuous data. Tukey ("honestly significant difference") post hoc test was applied for intra- and inter-group comparison in cases where ANOVA was significant. P < 0.05 is considered statistically significant.

Results

All hemodynamic data: Heart rate (HR), systolic, diastolic, and mean arterial pressure were observed to be significantly higher (P < 0.001) from baseline in control group at the time of creation of pneumoperitoneum, till 20 min thereafter. The values were comparable to baseline in both esmolol and diltiazem group. On intergroup comparison, the patients in esmolol group had significantly lower HR and blood pressures than in diltiazem group at the creation of pneumoperitoneum and at extubation (P < 0.05). Mean dose of esmolol and diltiazem used were 7.25 ± 1.33 μg/kg/min and 1.14 ± 0.77 μg/kg/min, respectively.

Conclusion

Both esmolol and diltiazem infusion provide stable intraoperative hemodynamics and protection against stress response triggered by pneumoperitoneum in patients undergoing laparoscopic transperitoneal nephrectomy.

Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery

Background and Objectives:

Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.

Methods:

Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days).

Results:

Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05–3.90; P = .027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501–6.462, P = .002).

Conclusions:

Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.

Advancing frontiers in anaesthesiology with laparoscopy

The introduction of laparoscopy in the surgeon's armamentarium was in fact a "revolution in the history of surgery". Since this technique involves insufflation of carbon dioxide it produces several pathophysiological changes which have to be understood by the anaesthesiologist who can modify the anaesthesia technique accordingly. Advantages of laparoscopy include reduced pain, small scars and early return to work. Certain complications specific to laparoscopic surgery are due to carboperitoneum and increased intra-abdominal pressure. Venous air embolism, although very rare, can be lethal if not managed promptly. Other complications include subcutaneous emphysema, haemodynamic compromise and arrhythmias. Although associated with minimal postoperative morbidity, postoperative pain, nausea and vomiting can be quite problematic. The limitations of laparoscopy have been overcome by the introduction of robotic surgery. There are important implications for the anaesthesiologist during robotic surgeries which have to be practiced accordingly. Robotic surgery has a learning curve for both the surgeon and the anaesthesiologist. The robot is bulky, and cannot be disengaged after docking. Therefore it is important that the anaesthetized patient remains immobile throughout surgery and anaesthesia is reversed only after the robot has been disengaged at the end of surgery. Advances in laparoscopy and robotic surgery have modified anaesthetic techniques too.

Cardiac and hemodynamic consequences during capnoperitoneum and steep Trendelenburg positioning: lessons learned from robot-assisted laparoscopic prostatectomy

STUDY OBJECTIVE

To determine and interpret the changes in preload, afterload, and cardiac function in the different phases of robot-assisted laparoscopic prostatectomy.

DESIGN

Prospective, observational monocenter study.

SETTING

Operating room at a university hospital.

PATIENTS

31 consecutive, ASA physical status 1, 2, and 3 patients.

INTERVENTIONS

Observations were made at 5 distinct time points: baseline after induction of anesthesia, after initiation of capnoperitoneum, immediately after a 45° head-down tilt, 15 minutes after the 45° head-down tilt was established, after the release of the capnoperitoneum, and 5 minutes after the patient was returned to a horizontal position (end).

MEASUREMENTS

Transpulmonary thermodilution and pulse contour analysis were used to record hemodynamic changes in preload, afterload, and cardiac function.

MAIN RESULTS

While central venous pressure increased threefold from baseline, none of the other preload parameters showed excessive fluid overload or demand. There was no significant change in cardiac contractility over time. Afterload increased significantly during the capnoperitoneum and significantly decreased compared with baseline after the release of abdominal pressure at the end of the procedure. Heart rate and cardiac index increased significantly during robot-assisted laparoscopic prostatectomy.

CONCLUSIONS

Selective arterial vasodilation at the time of capnoperitoneum may normalize afterload and myocardial oxygen demand.

Anesthetic challenges of patients with cardiac comorbidities undergoing major urologic surgery

The cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. Number of this group of patients having to go through this procedure is constantly increasing, due to prolonged life, increased agressiveness of surgery and increased anesthesia's safety. The anesthesiologist usually has to deal with several problems of the patient, such as hypertension, chronic heart failure, coronary artery disease, rhythm disturbances, intraoperative hemodymanic changes, intraoperative bleeding, perioperative fluid imbalance, and metabolic disturbances. A cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. The scope of this review article is to present the most frequent issues encountered with this group of patients, and to synthetically discuss the respective strategies and maneuvers during perioperative period, which is the major challenge for the anesthesiologist.

The second "time-out": a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second "time-out", aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

Robotic invasion of operation theatre and associated anaesthetic issues: A review

A Robotic device is a powered, computer controlled manipulator with artificial sensing that can be reprogrammed to move and position tools to carry out a wide range of tasks. Robots and Telemanipulators were first developed by the National Aeronautics and Space Administration (NASA) for use in space exploration. Today’s medical robotic systems were the brainchild of the United States Department of Defence’s desire to decrease war casualties with the development of ‘telerobotic surgery’. The ‘master-slave’ telemanipulator concept was developed for medical use in the early 1990s where the surgeon’s (master) manual movements were transmitted to end-effector (slave) instruments at a remote site. Since then, the field of surgical robotics has undergone massive transformation and the future is even brighter. As expected, any new technique brings with it risks and the possibility of technical difficulties. The person who bears the brunt of complications or benefit from a new invention is the ‘Patient’. Anaesthesiologists as always must do their part to be the patient’s ‘best man’ in the perioperative period. We should be prepared for screening and selection of patients in a different perspective keeping in mind the steep learning curves of surgeons, long surgical hours, extreme patient positioning and other previously unknown anaesthetic challenges brought about by the surgical robot. In this article we have tried to track the development of surgical robots and consider the unique anaesthetic issues related to robot assisted surgeries.

A very common case become rare: Anesthetic considerations of lepromatous leprosy

Leprosy or Hansen's disease is very uncommon in developed countries. More than 80% of the world's cases occurs and still reported from developing countries. But nowadays due to increase in international affairs, medical tourism, globalization and immigration, there is increasing possibility to find patients anywhere, which require anesthesia for surgical interventions. Leprosy is a chronic infectious disease caused by Mycobacterium leprae and involves mainly skin, peripheral nervous system, upper respiratory tract, eyes and testes. Anesthetic consideration is focused mainly on complications related to leprosy like cardiac or respiratory dysautonomia, autonomic dysfunctions and side effects which are related to drug therapy and are challenging. There can be drug-related hepatitis and renal insufficiency in these patients. We report the anesthetic management of a patient with lepromatous leprosy who had undergone laparoscopic radical nephrectomy for renal cell carcinoma under general anesthesia.

[Anesthetic considerations in laparoscopy for removal of a kidney from a live donor]

Kidney transplantation is the main therapeutic alternative for patients with end-stage renal failure. However, the main constraint at present is the lack of available organs. Removal of a kidney from a live donor is a better option than conventional transplantation of a cadaver-donated organ. Among the advantages are a shorter waiting time for the organ recipient and greater assurance of graft quality and survival. The postoperative conditions made possible by laparoscopic surgery have encouraged the donation of tissues by live donors. Anesthetic treatment for patients undergoing laparoscopic surgery must be based on an understanding of the pathophysiologic changes that occur in this type of procedure so that complications can be prevented. This review provides an update of progress in laparoscopic surgery and the repercussions of anesthetic management, particularly with respect to anesthesia for kidney donors.

Complications of pure transperitoneal laparoscopic surgery in urology: the Taipei Veterans General Hospital experience

BACKGROUND

We present our experience of complications of pure transperitoneal laparoscopic surgery in urology at Taipei Veterans General Hospital.

METHODS

Between September 2003 and March 2006, 185 laparoscopic urologic operations were performed, consisting of 70 nephrectomies (36 radical, 17 partial, 11 simple, 6 donor), 28 adrenalectomies, 28 nephroureterectomies, 22 radical prostatectomies, 17 ureterolithotomies, 6 radical cystectomies, 5 pyeloplasties, 2 renal cyst unroofings, 2 nephropexies and 5 other operations. We reviewed the database of the patients to evaluate the complications and analyze factors related to laparoscopic surgeries.

RESULTS

A total of 25 patients had 26 complications (14.1%, major in 4, minor in 22). The complications were categorized into intraoperative and postoperative complications in 10 and 16 patients, respectively. The mortality rate was 0%. The conversion rate was 0.54% (1 patient). The re-operation rate was 1.08% (2 patients). The most common intraoperative complication was vascular injury (5 patients). The incidence of complication was related to the difficulty level of operation. No statistically significant differences were found between complication rate and patient age, patient body mass index or the American Society of Anesthesiologist score.

CONCLUSION

The complications of laparoscopic urologic surgeries are strongly correlated with the operative difficulties. In spite of elevated complication rates in difficult surgeries, the major complication rate in this study was very low. As the laparoscopic surgeries in urology involve more and more technique-dependent difficult fields, documentation and analysis of experience of complications is important for the development of this surgical modality.

[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.

Principles of anaesthesia in urological surgery

Anaesthesia for urological surgery poses particular challenges for the anaesthetist related to the patient population and procedure type. The aim of this article is to cover the general principles of anaesthesia, with dedicated sections relevant to practising urological surgeons. This represents vast amounts of knowledge that cannot be covered in one article. We will focus upon preoperative preparation for surgery and anaesthesia, perioperative management including monitoring and analgesia, and postoperative management including fluid balance, critical care and recovery. Significant proportions of urological surgical patients have some degree of renal failure and this may be related to the surgery required. Anaesthetic care of patients with chronic renal impairment and transplant surgery will be covered in a future review.