Ocular Complications in Laparoscopic Surgery: Review of Existing Literature and Possible Prevention and Treatment

The Effects of Lateral 45° Head-Down Position and Carbon Dioxide Pneumoperitoneum on the Optic Nerve Sheath Diameter in Patients Undergoing Laparoscopic Transperitoneal Nephrectomies: A Prospective Observational Study

Background: The aim of this study is to assess the extent of the increased intracranial pressure resulting from lateral decubitus and 45° downward positioning using sonographic optic nerve sheath diameter (ONSD) in patients undergoing laparoscopic transperitoneal nephrectomy. In addition, we evaluated the effect of the carbon dioxide pneumoperitoneum (CO₂PP) on ONSD. Materials and Methods: Twenty-four adults were enrolled in this prospective observational study. Longitudinal and transverse ONSDs were measured for each eye by ocular ultrasonography. The values were noted in supine position (T0), 20 minutes after induction of anesthesia (T1), after insufflation of the abdomen in lateral 45° head-down position (T2), at 30-minute intervals during surgery (T3-T4-T5), during lateral 45° head-down position after CO₂ exsufflation (T6), before awakening while supine (T7), and at postoperative 24th hour (T8). Hemodynamic and respiratory parameters were investigated at the measurement time points. Results: Average ONSD values for the lower eye was T0 = 4.27 ± 0.4 mm, T1 = 4.56 ± 0.6 mm, T2 = 4.84 ± 0.6 mm, T3 = 4.91 ± 0.4 mm, T4 = 4.99 ± 0.5 mm, T5 = 4.97 ± 0.5 mm T6 = 4.96 ± 0.5 mm, T7 = 4.76 ± 0.4 mm, T8 = 4.36 ± 0.5 mm and for the upper eye was T0 = 4.24 ± 0.4 mm, T1 = 4.39 ± 0.5 mm, T2 = 4.54 ± 0.5 mm, T3 = 4.60 ± 0.4 mm, T4 = 4.66 ± 0.4 mm, T5 = 4.72 ± 0.7 mm, T6 = 4.68 ± 0.4 mm, T7 = 4.52 ± 0.4 mm, T8 = 4.30 ± 0.4 mm (P < .001). Conclusion: In our study, we observed a significant increase in ONSD within minutes after the patient was placed in a head-down position. We also observed that the difference increased more with CO₂PP and was proportional to the length of the surgery. We found that it regressed to initial levels at the postoperative 24th hour. Clinicaltrials.gov: NCT05185908.

Comparison of intraocular pressure during laparoscopic totally extraperitoneal (TEP) versus transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Laparoscopic totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are standard laparoscopic procedures for inguinal hernia repair. Some evidence has shown that pneumoperitoneum can cause an increase in intraocular pressure (IOP) during surgery. This study aimed to compare intraoperative IOP following extraperitoneal CO₂ insufflation with the TEP approach and intraperitoneal CO₂ insufflation with the TAPP approach.

METHODS

This study is a prospective cohort study. Patients who had inguinal hernias suitable for laparoscopic inguinal hernia repair were assigned to undergo the TEP or TAPP approach. We measured preoperative, intraoperative, and postoperative IOP. The IOP of the TEP and TAPP groups was evaluated using a t test. The relations between peak inspiratory pressure (PIP), mean arterial pressure (MAP), and end-tidal CO₂ (EtCO₂) were estimated using ANOVA. Univariate and multivariate analyses were performed to determine the factors associated with IOP.

RESULTS

There were 50 patients in this study (TEP group n = 25, TAPP group n = 25). The change in intraoperative IOP from the preoperative measurement to the measurement after CO₂ insufflation was not statistically significant in either the TEP or TAPP group (p value = 0.357). There was no significant difference in intraoperative IOP change between the TEP and TAPP groups. Intraoperative MAP and PIP were related to IOP, but intraoperative EtCO2 was not.

CONCLUSIONS

There was no significant intraoperative IOP change during laparoscopic inguinal hernia repair. Both the TEP and TAPP techniques can be performed safely without increasing intraoperative IOP.

Systematic Review and Meta-Analysis of Prone Position on Intraocular Pressure in Adults Undergoing Surgery

BACKGROUND

Patients undergoing surgery in the prone position may be at risk for postoperative vision loss associated with increased intraocular pressure. The purpose of this systematic review and meta-analysis is to estimate the magnitude of the increase in intraocular pressure at specific perioperative time points in adult patients. The research question to be addressed is "What is the magnitude of the increase in intraocular pressure at specific perioperative time points in adults undergoing surgery in the prone position?"

METHODS

Comprehensive search strategies were used to identify nine eligible studies (N = 229). Standardized mean difference effect sizes were calculated for two intraoperative time points.Time points for meta-analysis were selected to achieve the greatest number of comparisons for analysis at each time point. Prediction intervals for each time point were also calculated to show the dispersion of true effect sizes around the mean.

RESULTS

Meta-analysis showed that intraocular pressure increased significantly between induction of anesthesia and up to 10 minutes of prone position (T1: standardized mean difference [d] = 2.55; P < .001) and continued to increase significantly until the end of the prone position (T2: d = 3.44; P = .002).

CONCLUSIONS

Intraocular pressure increases of this magnitude demonstrate the need for implementing interventions to reduce the risk for postoperative vision loss in patients undergoing surgery in the prone position.

CLINICAL RELEVANCE

Implementing preoperative ophthalmologic examinations for patients undergoing surgery in the prone position may help to reduce the risk for ocular injury. Intraoperative interventions that can be implemented to reduce or mitigate the increase in intraocular pressure include implementing a 5- to 10-degree reverse Trendelenburg prone position, reducing the amount of time the patient is in the prone position, considering staged procedures, monitoring intraocular pressure, providing periodic position changes or rest periods, preventing pressure on the eye, and administering specific medications or anesthetics.

Are you seeing this: the impact of steep Trendelenburg position during robot-assisted laparoscopic radical prostatectomy on intraocular pressure: a brief review of the literature

With the increasing popularity, frequency, and acceptance of the robotic-assisted laparoscopic radical prostatectomy procedure, an awareness of unique intra- and postoperative complications is heightened, including that of increases in intraocular pressure. The steep Trendelenburg positioning required for operative exposure has been shown to increase this value. While the literature is infrequent and undeveloped, certain anesthetic parameters including deep neuromuscular blockade, modified positioning, and the use of dexmedetomidine have been shown to have mild-to-modest decreases in intraocular pressure for baseline. In the four randomized control trials and four observational studies that were found via PubMed/Medline search, the aforementioned techniques demonstrate some preliminary evidence of operative considerations in this unique patient population. These modifications may prove to have even greater significance in patients with pre-existing ophthalmologic pathologies, such as glaucoma, which were excluded from the studies' analyses. This review summarizes the early literature obtained in this subject, with the intent of emphasizing the initial hypotheses and identifying areas for future study.

Patient positioning during minimally invasive surgery: what is current best practice?

Introduction

Positioning injuries are a known surgical complication and can result in significant patient morbidity. Studies have shown a small but significant number of neurovascular injuries associated with minimally invasive surgery, due to both patient and case-specific factors. We sought to review the available literature in regards to pathophysiological and practical recommendations.

Methods

A literature search was conducted and categorized by level of evidence, with emphasis on prospective studies. The result comprised 14 studies, which were summarized and analyzed with respect to our study objectives.

Results

While incidence of positioning injury has been identified in up to one-third of prospective populations, its true prevalence after surgery is likely 2%-5%. The mechanism is thought to be intraneural disruption from stretching or pressure, which results in decreased perfusion. On a larger scale, this vascular compromise can lead to ischemia and rhabdomyolysis. Prevention hinges on addressing patient modifiable factors such as body mass index, judicious positioning with appropriate devices, and intraoperative team awareness consisting of recurrent extremity checks and time management.

Conclusion

The risk for positioning injuries is underappreciated. Surgeons who perform minimally invasive surgery should discuss the potential for these complications with their patients, and operative teams should take steps to minimize risk factors.

Intraocular Pressure Changes With Positioning During Laparoscopy

Background and Objectives:

Pneumoperitoneum during laparoscopy can produce changes in intraocular pressure (IOP) that may be influenced by several factors. In this study, we investigated changes in IOP during laparoscopy with different positioning.

Methods:

We recruited adult patients without eye disease scheduled to undergo laparoscopic operation requiring a reverse Trendelenburg tilt (rTr; group A; n = 20) or Trendelenburg tilt (Tr; Group B; n = 20). IOP was measured at 7 time points (T1–T7). All procedures were performed with standardized anaesthetic protocol. Mean arterial pressure (MAP), heart rate (HR), peak and plateau airway pressure, and end-tidal carbon dioxide (ETCO₂) measurements were taken at each time point.

Results:

Both groups were similar in age, sex, mean body mass index (BMI), duration of surgery, and preoperative IOP. A decrease in IOP was observed in both groups after induction of anaesthesia (T2), whereas induction of pneumoperitoneum produced a mild increase in IOP (T3) in both groups. The Trendelenburg tilt produced IOP elevations in 80% of patients compared to 45% after the reverse Trendelenburg tilt (P = .012). A significant IOP increase of 5 mm Hg or more was recorded in 3 (15%) patients in the Trendelenburg tilt group and in none in the reverse Trendelenburg group. At T7, IOP had returned to preoperative levels in all but 3 (15%) in the Trendelenburg and 1 (5%) in the reverse Trendelenburg group. Reversible changes were observed in the MAP, HR, ETCO₂, and airway pressures in both groups.

Conclusions:

IOP changes induced by laparoscopy are realigned after evacuation of pneumoperitoneum. A Trendelenburg tilt however produced significant changes that may require careful patient monitoring during laparoscopic procedures.