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Wise PA, Preukschas AA, Özmen E, Bellemann N, Norajitra T, Sommer CM, Stock C, Mehrabi A, Müller-Stich BP, Kenngott HG, Nickel F. Intraoperative liver deformation and organ motion caused by ventilation, laparotomy, and pneumoperitoneum in a porcine model for image-guided liver surgery. Surg Endosc 2024; 38:1379-1389. [PMID: 38148403 PMCID: PMC10881715 DOI: 10.1007/s00464-023-10612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Image-guidance promises to make complex situations in liver interventions safer. Clinical success is limited by intraoperative organ motion due to ventilation and surgical manipulation. The aim was to assess influence of different ventilatory and operative states on liver motion in an experimental model. METHODS Liver motion due to ventilation (expiration, middle, and full inspiration) and operative state (native, laparotomy, and pneumoperitoneum) was assessed in a live porcine model (n = 10). Computed tomography (CT)-scans were taken for each pig for each possible combination of factors. Liver motion was measured by the vectors between predefined landmarks along the hepatic vein tree between CT scans after image segmentation. RESULTS Liver position changed significantly with ventilation. Peripheral regions of the liver showed significantly higher motion (maximal Euclidean motion 17.9 ± 2.7 mm) than central regions (maximal Euclidean motion 12.6 ± 2.1 mm, p < 0.001) across all operative states. The total average motion measured 11.6 ± 0.7 mm (p < 0.001). Between the operative states, the position of the liver changed the most from native state to pneumoperitoneum (14.6 ± 0.9 mm, p < 0.001). From native state to laparotomy comparatively, the displacement averaged 9.8 ± 1.2 mm (p < 0.001). With pneumoperitoneum, the breath-dependent liver motion was significantly reduced when compared to other modalities. Liver motion due to ventilation was 7.7 ± 0.6 mm during pneumoperitoneum, 13.9 ± 1.1 mm with laparotomy, and 13.5 ± 1.4 mm in the native state (p < 0.001 in all cases). CONCLUSIONS Ventilation and application of pneumoperitoneum caused significant changes in liver position. Liver motion was reduced but clearly measurable during pneumoperitoneum. Intraoperative guidance/navigation systems should therefore account for ventilation and intraoperative changes of liver position and peripheral deformation.
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Affiliation(s)
- Philipp A Wise
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Anas A Preukschas
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Emre Özmen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Nadine Bellemann
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Tobias Norajitra
- Division of Medical and Biological Informatics, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Christof M Sommer
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christian Stock
- Institute for Medical Biometry and Informatics, Heidelberg University, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Division of Abdominal Surgery, Clarunis-Academic Centre of Gastrointestinal Diseases, St. Clara and University Hospital of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Hannes G Kenngott
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Effects of laparoscopy, laparotomy, and respiratory phase on liver volume in a live porcine model for liver resection. Surg Endosc 2021; 35:7049-7057. [PMID: 33398570 PMCID: PMC8599330 DOI: 10.1007/s00464-020-08220-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
Background Hepatectomy, living donor liver transplantations and other major hepatic interventions rely on precise calculation of the total, remnant and graft liver volume. However, liver volume might differ between the pre- and intraoperative situation. To model liver volume changes and develop and validate such pre- and intraoperative assistance systems, exact information about the influence of lung ventilation and intraoperative surgical state on liver volume is essential. Methods This study assessed the effects of respiratory phase, pneumoperitoneum for laparoscopy, and laparotomy on liver volume in a live porcine model. Nine CT scans were conducted per pig (N = 10), each for all possible combinations of the three operative (native, pneumoperitoneum and laparotomy) and respiratory states (expiration, middle inspiration and deep inspiration). Manual segmentations of the liver were generated and converted to a mesh model, and the corresponding liver volumes were calculated. Results With pneumoperitoneum the liver volume decreased on average by 13.2% (112.7 ml ± 63.8 ml, p < 0.0001) and after laparotomy by 7.3% (62.0 ml ± 65.7 ml, p = 0.0001) compared to native state. From expiration to middle inspiration the liver volume increased on average by 4.1% (31.1 ml ± 55.8 ml, p = 0.166) and from expiration to deep inspiration by 7.2% (54.7 ml ± 51.8 ml, p = 0.007). Conclusions Considerable changes in liver volume change were caused by pneumoperitoneum, laparotomy and respiration. These findings provide knowledge for the refinement of available preoperative simulation and operation planning and help to adjust preoperative imaging parameters to best suit the intraoperative situation.
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Bogani G, Uccella S, Cromi A, Serati M, Casarin J, Pinelli C, Ghezzi F. Low vs standard pneumoperitoneum pressure during laparoscopic hysterectomy: prospective randomized trial. J Minim Invasive Gynecol 2013; 21:466-71. [PMID: 24374246 DOI: 10.1016/j.jmig.2013.12.091] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 12/11/2013] [Accepted: 12/13/2013] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To compare the use of low pneumoperitoneum pressure (LPP; 8 mm Hg) vs standard pneumoperitoneum pressure (SPP; 12 mm Hg) during mini-laparoscopic hysterectomy (MLH). DESIGN Randomized controlled trial (Canadian Task Force classification I). SETTING Tertiary care center. PATIENTS Forty-two consecutive women scheduled to undergo MLH to treat benign uterine disease. INTERVENTIONS Women were randomly selected to undergo MLH using LPP (n = 20) or SPP (n = 22). MLH was performed via 3-mm ancillary ports. MEASUREMENTS AND MAIN RESULTS The primary outcome was to evaluate changes in abdominal and shoulder-tip pain via a 100-mm visual analog scale at 1, 3, and 24 hours postoperatively. All procedures were completed via mini-laparoscopy without the need to increase intra-abdominal pressure or convert to conventional laparoscopy or open surgery. Intraoperatively, 1 episode of severe bradycardia occurred in the LPP group, whereas no intraoperative complications were recorded in the SPP group (p = .47). No postoperative complications were recorded (p > .99). Abdominal pain was similar between groups at each time point. Incidence and intensity of shoulder-tip pain at 1 and 3 hours postoperatively was lower in the LPP group than in the SPP group (p < .05), whereas no between-group differences were observed at 24 hours (p > .05). Rescue analgesic requirement did not differ statistically between the LPP and SPP groups (20% vs 41%, respectively; p = .19; odds ratio, 2.7; 95% confidence interval, 0.69-11.08). CONCLUSION In experienced hands, use of LPP is safe and feasible. During performance of MLH, compared with SPP, LPP is a simple method that offers advantages of less shoulder-tip pain.
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Affiliation(s)
- Giorgio Bogani
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy.
| | - Stefano Uccella
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynaecology, University of Insubria, Del Ponte Hospital, Varese, Italy
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Párraga E, López-Albors O, Sánchez-Margallo F, Moyano-Cuevas JL, Latorre R. Effects of pneumoperitoneum and body position on the morphology of the caudal cava vein analyzed by MRI and plastinated sections. Surg Endosc 2012; 27:880-7. [PMID: 23093231 DOI: 10.1007/s00464-012-2528-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 07/24/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pneumoperitoneum and patient positioning are essential factors during laparoscopic surgical procedures. They cause hemodynamic and anatomical changes in several abdominal organs among which the caudal cava vein (CCV) is involved. Hemodynamic changes in this vein (decreased venous return) have been described in the porcine model, but how the vein morphology and size is affected at different abdominal levels is unknown. We sought to assess the morphological and morphometrical changes in the CCV of the pig caused by pneumoperitoneum and the reverse Trendelenburg position by in vivo magnetic resonance imaging (MRI). METHODS Six pigs were scanned via MRI under four situations: S1, control (no pneumoperitoneum); S2, control in the reverse Trendelenburg position; S3, pneumoperitoneum (14 mmHg); and S4, pneumoperitoneum in the reverse Trendelenburg position. MRI and plastinated body sections were used to evaluate the topography, morphology and cross-sectional area of the CCV. RESULTS Two portions of the CCV were differentiated: a prehepatic portion (located between the vertebral levels L1-T15) with flat and irregular morphology, and a hepatic portion (between T14-T11) that was almost rounded. The reverse Trendelenburg position caused an increase in the lumen affecting mainly the prehepatic portion, while pneumoperitoneum caused a decrease in the total vascular lumen, exerting a greater effect on the hepatic portion. The combination of both situations resulted in a further decrease in the vascular area and global morphological changes. CONCLUSIONS The pneumoperitoneum and reverse Trendelenburg position caused morphological and morphometrical changes in the prehepatic and hepatic portions of the CCV, which should assist in gaining a better understanding of the hemodynamic changes described in the literature.
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Affiliation(s)
- E Párraga
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100 Murcia, Spain.
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