Anesthesia for laparoscopy with emphasis on outpatient laparoscopy

Evaluation of the effect of trendelenburg position duration on intracranial pressure in laparoscopic hysterectomies using ultrasonographic optic nerve sheath diameter measurements

BACKGROUND

During laparoscopic surgery, pneumoperitoneum and Trendelenburg positioning applied to provide better surgical vision can cause many physiological changes as well as an increase in intracranial pressure. However, it has been reported that cerebral autoregulation prevents cerebral edema by regulating this pressure increase. This study aimed to investigate whether the duration of the Trendelenburg position had an effect on the increase in intracranial pressure using ultrasonographic optic nerve sheath diameter (ONSD) measurements.

METHODS

The near infrared spectrometry monitoring of patients undergoing laparoscopic hysterectomy was performed while awake (T0); at the fifth minute after intubation (T1); at the 30th minute (T2), 60th minute (T3), 75th minute (T4), and 90th minute (T5) after placement in the Trendelenburg position; and at the fifth minute after placement in the neutral position (T6).

RESULTS

The study included 25 patients. The measured ONSD values were as follows: T0 right/left, 4.18±0.32/4.18±0.33; T1, 4.75±0.26/4.75±0.25; T2, 5.08±0.19/5.08±0.19; T3, 5.26±0.15/5.26±0.15; T4, 5.36±0.11/5.37±0.12; T5, 5.45±0.09/5.48±0.11; and T6, 4.9±0.24/4.89±0.22 ( p < 0.05 compared with T0). ). No statistical difference was detected in all measurements in terms of MAP, HR and ETCO2 values compared to the T0 value (p > 0.05).

CONCLUSIONS

It was determined that as the Trendelenburg position duration increased, the ONSD values ​​increased. This suggests that as the duration of Trendelenburg positioning and pneumoperitoneum increases, the sustainability of the mechanisms that balance the increase in intracranial pressure becomes insufficient.

TRIAL REGISTRATION

This study was registered at Clinical Trials.gov on 21/09/2023 (registration number NCT06048900).

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.

How can we best prevent or treat postoperative nausea and vomiting?

In pursuit of preventing or rapidly rescuing patients from postoperative nausea and vomiting, new clinical studies provide revised postoperative nausea and vomiting risk prediction tools, risk stratification formulae, comparative trials to identify the most appropriate cost-effective anti-emetics, and several trials recommending the addition of steroids in anti-emetic prophylactic multimodal approaches. Common variables that identify high-risk postoperative nausea and vomiting patients include female sex, a history of postoperative nausea and vomiting or motion sickness, young age, volatile anesthetic agents, nitrous oxide, and the administration of opioids. The most successful approach to the prevention of postoperative nausea and vomiting is multimodal, with combination anti-emetics, dexamethasone, aggressive hydration, the avoidance of opioids, and aggressive pain control.

Minimal impact urethroplasty allows same-day surgery in most patients

OBJECTIVES

To present our evaluation of the safety and feasibility of decreasing the impact of anterior urethroplasty by minimizing the surgery time, maximizing adjuvant pain therapy, and using anesthetic agents that decrease the incidence and severity of side effects, which allows most patients to leave the hospital comfortably within 4 hours of surgery.

METHODS

A retrospective chart review of 54 consecutive anterior urethroplasty patients from August 2000 to August 2004 (34 anterior anastomotic and 20 ventral onlay buccal mucosal graft urethroplasty) was performed.

RESULTS

Historically, 27% of patients had undergone same-day surgery (SDS). After the initiation of minimal impact surgery and early discharge, 85% did so. All but one admission was planned (1 patient [2%] had hypotension in the recovery room and was admitted). No postoperative readmissions or emergency room visits occurred. The admitted patients had comparable stricture length to, but slightly older age (49 years compared with 42 years) than, the SDS patients. The perioperative complications were mild (small wound gap, small scrotal hematoma) and were seen in 5% of SDS patients and 0% of admitted patients. Late complications (chordee, mild erectile dysfunction, and urinary tract infection) were seen in 19% of SDS patients and 18% of admitted patients. The incidence of recurrences after a mean follow-up of 27 months was comparable (3% for the SDS and 6% for the admitted group).

CONCLUSIONS

Decreasing the impact of urethroplasty surgery allows safe early discharge for most patients. Unexpected admissions were uncommon, and we continue to plan for admission only for the extremely elderly, those with severe comorbidities, and those expected to undergo lengthy (longer than 5 hours) surgery.

Microlaparoscopy

Laparoscopic surgeons have made significant efforts to minimize the trauma induced by their procedures. One of the newest methods is the use of mini and micro instruments. This work is reviewed here.

Controversial issues in ambulatory anesthesia

Many controversies surround ambulatory anesthesia, but this article concentrates on two major areas: monitoring devices and airway management. Being able to monitor the depth of anesthesia has been a long-term goal with the aim of avoiding awareness during surgery. As monitoring devices are developed, they are being used to reduce anesthetic delivery and reduce costs, possibly increasing the risk of awareness. Management of the airway has been revolutionized by the laryngeal mask, and this article reviews some controversial uses. Several other airway devices that have been developed and promoted as suitable alternatives also are evaluated.