The physiologic effects of pneumoperitoneum in the morbidly obese

Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Preoperative and Intraoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of 30 Studies

This systematic review aims to review articles that evaluate the risk of conversion from laparoscopic to open cholecystectomy and to analyze the identified preoperative and intraoperative risk factors. The bibliographic databases CINAHL, Cochrane, Embase, Medline, and PubMed were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language retrospective studies and systematic reviews with more than 200 patients were included. The time of publication was limited from 2012 to 2022. Our systematic review identified 30 studies with a total of 108,472 patients. Of those, 92,765 cholecystectomies were commenced laparoscopically and 5,477 were converted to open cholecystectomy (5.90%). The rate of conversion ranges from 2.50% to 50%. Older males with acute cholecystitis, previous abdominal surgery, symptom duration of more than 72 hours, previous history of acute cholecystitis, C-reactive protein (CRP) value of more than 76 mg/L, diabetes, and obesity are significant preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Significant intraoperative risk factors for conversion include gallbladder inflammation, adhesions, anatomic difficulty, Nassar scale of Grades 3 to 4, Conversion from Laparoscopic to Open Cholecystectomy (CLOC) score of more than 6 and 10-point gallbladder operative scoring system (G10) score more than 3.

Impact of laparoscopic surgery on short-term and long-term outcomes in elderly obese patients with colon cancer

Background

Laparoscopic surgery is reported to be useful in obese or elderly patients with colon cancer, who are at increased risk of postoperative complications because of comorbidities and physical decline. However, its usefulness is less clear in patients who are both elderly and obese and may be at high risk of complications.

Methods

Data for obese patients (body mass index ≥25) who underwent laparoscopic or open surgery for stage II or III colon cancer between January 2009 and December 2013 were collected by the Japan Society of Laparoscopic Colorectal Surgery. Surgical outcomes, postoperative complications, and relapse-free survival (RFS) were compared between patients who underwent open surgery and those who underwent laparoscopic surgery according to whether they were elderly (≥70 y) or nonelderly (<70 y).

Results

Data of 1549 patients (elderly, n = 598; nonelderly, n = 951) satisfied the selection criteria for analysis. Length of stay was shorter and surgical wound infection was less common in elderly obese patients who underwent laparoscopic surgery than in those underwent open surgery. There were no significant between-group differences in overall complications, anastomotic leakage, ileus/small bowel obstruction, or RFS. There were also no significant differences in RFS after laparoscopic surgery according to patient age.

Conclusion

Laparoscopic surgery is safe in elderly obese patients with colon cancer and does not worsen their prognosis. There was no significant difference in the effectiveness of laparoscopic surgery between obese patients who were elderly and those who were nonelderly.

Visceral obesity and anastomotic leakage rates in colorectal cancer: a systematic review and meta-analysis

Background

Numberous studies have heatedly discussed whether obesity is a risk factor for anastomotic leakage (AL) because of the increasing number of colorectal cancer (CRC) cases and high incidence of CRC in patients with obesity.

Objective

We aimed to explore the relationship between visceral obesity(VO) and AL after CRC surgery. The databases of Pubmed, Embase, and the Cochrane Library were searched for relevant data and articles published until November 1, 2022. We identified the difference in the incidence of AL after CRC surgery between patients with and without VO. The quality of included studies was evaluated using the Newcastle- Ottawa Scale, and odds ratio (OR) and 95% CI were used to assess the association between VO and AL.

Results

This meta-analysis included 7 studies with 2,136 patients. The OR of patients with VO versus those without VO was 2.15 (95%CIs = 1.46-3.15, test for heterogeneity: P = 0.29, I2 = 18%) based on the fixed-effect model in seven studies. Notably, the difference between the two groups was statistically significant (Z = 3.91 P < 0.0001). Patients with VO in the colon cancer group exhibited a higher incidence of AL (OR = 2.88, 95% CIs = 1.38-5.99, test for heterogeneity: P = 0.27, I2 = 20%) than those in the rectal cancer group (OR = 2.74, 95% CIs = 1.13-6.65, test for heterogeneity: P = 0.20, I2 = 38%). In the studies in the relevant literature, heterogeneity was low. Regarding patients with VO, four Asian studies reported increased morbidity due to AL (OR = 2.79, 95% CIs = 1.35-5.78, test for heterogeneity: P = 0.35, I2 = 9%) compared with three non-Asian studies.

Conclusions

Our findings confirmed the significant relationship between VO and AL. Thus, VO could be considered a reliable risk factor of surgery for colon cancer.

Low-Pressure Pneumoperitoneum During Laparoscopic Sleeve Gastrectomy: a Safety and Feasibility Analysis

PURPOSE

Laparoscopy is advised under the lowest possible intra-peritoneal pressure. The aim of this study is to analyze the safety/feasibility of low pneumoperitoneum pressure (LPP) during laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

All primary LSGs who completed a 3-month follow-up were included. Re-do operations and LSGs performed with concomitant procedures were excluded. All LSGs were performed by the senior author. Upon trocar insertions, pressure was set to 10 mmHg, and the procedure was started. The pressure was increased step-wise, according to the senior author's assessment of the quality of exposure. Doing so, three pressure groups were formed: groups 1 (10 mmHg), 2 (11-13 mmHg), and 3 (14 mmHg). All data was retrieved from our database. Statistical analysis was performed using one-way ANOVA/Tukey's HSD test/Chi-square test. P values < 0.05 were regarded as significant.

RESULTS

Between February 2018 and October 2022, 708 consecutive/primary LSGs were studied. No mortality/conversion/thromboembolic event was observed. Groups 1, 2, and 3 comprised 376 (53.1%), 243 (34.3%), and 89 (12.6%) patients, respectively. Demographics, initial weight, duration of surgery, history for abdominoplasty, drain output, length of stay, and %total weight loss were evenly distributed among groups. Among 16 bleeding episodes, 14 occurred in the LPP group (p = 0.019). Including the only leak and stenosis, 8/9 of Clavien-Dindo 3b + 4 complications were observed in the LPP group (p = 0.092).

CONCLUSIONS

LSG with LPP is feasible in about half of the patients. However, almost all potentially life-threatening complications occurred in the LPP group where a significantly higher rate of bleeding was observed. Our findings suggest caution for routinely using LPP during LSG.

Comparison of laparoscopic partial nephrectomy performed with AirSeal® system vs. standard insufflator: results from a referral center

Objective

To compare perioperative and oncologic surgical outcomes during laparoscopic partial nephrectomy (LPN) performed by standard carbon dioxide insufflation, with those from surgeries in which the AirSeal® intelligent insufflation system was used for renal tumors.

Materials and methods

A total of 27 patients with renal tumor were identified, 14 underwent LPN with AirSeal® (group A) and 13 LPN with standard insufflator (group B), respectively. Demographic baseline characteristics were similar in the two groups.

Results

The size of the tumor was largest in group B (29.64 vs. 32.1 mm). The mean operative time was shorter in the AirSeal® group [group A: mean 109.0 min, median 107.5 min, interquartile range (IQR) 85; group B: mean 121.0 min, median 120.0 min, IQR 50.0]. Positive margin rates were absent in the two groups. Estimated blood loss presented a difference in the perioperative period (group A: mean 1.5 g/dL, median 1.45 g/dL; group B: mean 2.15 g/dL, median 2.2 g/dL). Time to ischemia was found to be shorter in group A with a median of 18 min compared to a median of 20 min in group B. No subcutaneous emphysema, pneumothorax, and pneumomediastinum cases occurred in either group. A postoperative complication developed in one patient requiring superselective embolization.

Conclusion

In selected patients, our preliminary surgical experience has shown that the LPN procedure performed with the aid of the AirSeal® intelligent insufflation system can be used to treat even medium-/high-complexity kidney lesions, with a reduction in operating times, lower rates of complications, and perioperative blood loss.

Clinical trial registration

AirSealV1.

Severe Pulmonary Hypertension Meets Intraperitoneal Surgery: No Place to Inflate?

Severe pulmonary hypertension (PH) is associated with poor operative outcomes; however, guidance for perioperative management of this population is lacking. Mechanical ventilation has known deleterious effects on right ventricular preload and cardiac output. Meanwhile, pneumoperitoneum results in further cardiopulmonary insults. We report the successful case management of a patient with severe PH scheduled for elective cholecystectomy. While patients undergoing this surgery typically benefit from the less invasive, laparoscopic approach, the risk-benefit ratio may tilt towards risk in the setting of severe PH. A multidisciplinary approach to optimize outcome included the decision to perform an open rather than laparoscopic procedure, which resulted in a favorable outcome.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Effects of pneumoperitoneum and patient position on intracranial pressure in obese patients undergoing laparoscopic cholecystectomy

Background/Aim: Optic nerve sheath diameter (ONSD) measurement is one of the non-invasive techniques used for intracranial pressure (ICP) measurement. ICP changes have been evaluated based on ONSD measurements during many laparoscopic surgeries. However, such analyses in the obese patient populations are limited. This study aimed at investigating the effects of pneumoperitoneum and reverse Trendelenburg and head-up position on ICP based on ONSD measurements in obese patients undergoing laparoscopic cholecystectomy. Methods: This observational study included 60 female patients who were scheduled for laparoscopic cholecystectomy. Obese patients with a body mass index (BMI) of 30 and above were assigned to Group 1, while BMI < 30 patients were assigned to Group 2. The first ONSD measurement was performed just before insufflation (T1). The second measurement was taken 5 min after insufflation (T2), the third measurement 5 min after placing patients in the reverse Trendelenburg and head-up position (T3), and the last measurement 5 min after the deflation while the reverse Trendelenburg and head-up position was maintained (T4). Results: ONSD measurements at the T2 and T3 time points in Group 1 patients were higher than in Group 2 patients (P = 0.012 versus P = 0.020). Both measurement values were higher in obese patients. In Group 1 patients, T2 and T3 measurements were significantly higher than T1 and T4 measurements (T2 > T1; P < 0.001, T2 > T4; P < 0.001, T3 > T1; P < 0.001, and T3 > T4; P < 0.001). No significant difference between T2 and T3 and between T1 and T4 measurements were found. In Group 2 patients, T2 measurements were significantly higher than the T1, T3, and T4 measurements, while T3 measurements were significantly higher than T1 and T4 measurements (T2 > T1; P < 0.001, T2 > T3; P = 0.022, T2 > T4; P < 0.001, T3 > T1; P < 0.001, and T3 > T4; P = 0.048). No significant difference between T1 and T4 measurements was noted. Conclusion: Laparoscopic cholecystectomy does not cause an increase in ICP of obese patients with limited pneumoperitoneum pressure, reverse Trendelenburg and head-up position, and controlled anesthesia.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery

The effect of the AirSeal^® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO₂), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal^®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO₂, peripheral capillary oxygen saturation (SpO₂), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO₂ was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined “positive respiratory and circulatory responses” (positive responses) as a decrease in EtCO₂ ≥ 3 mmHg in addition to decreases in SpO₂ ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO₂) embolism. The median EtCO₂ values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO₂ of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO₂ of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO₂ embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO₂ of hepatectomy was comparable to that of the other surgeries using the AirSeal^®, laparoscopic hepatectomy showed a tendency of CO₂ embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal^® insufflation system.

Effects of two alveolar recruitment maneuvers in an “open-lung” approach during laparoscopy in dogs

Objectives

The aim of this study was to compare the effects of a sustained inflation alveolar recruiting maneuver (ARM) followed by 5 cmH₂O of PEEP and a stepwise ARM, in dogs undergoing laparoscopic surgery.

Materials and methods

Twenty adult dogs were enrolled in this prospective randomized clinical study. Dogs were premedicated with methadone intramuscularly (IM); anesthesia was induced with propofol intravenously (IV) and maintained with inhaled isoflurane in pure oxygen. The baseline ventilatory setting (BVS) was as follows: tidal volume of 15 mL/kg, inspiratory pause of 25%, inspiratory to expiratory ratio of 1:2, and the respiratory rate to maintain the end-tidal carbon dioxide between 45 and 55 mmHg. 10 min after pneumoperitoneum, randomly, 10 dogs underwent sustained inflation ARM followed by 5 cmH₂O of PEEP (ARMi), while 10 dogs underwent a stepwise recruitment maneuver followed by the setting of the “best PEEP” (ARMc). Gas exchange, respiratory system mechanics, and hemodynamic were evaluated before the pneumoperitoneum induction (BASE), 10 min after the pneumoperitoneum (PP), 10 min after the recruitment (ARM), and 10 min after the pneumoperitoneum resolution (PostPP). Statistical analysis was performed with the ANOVA test (p < 0.05).

Results

Static compliance decreased in both groups at PP (ARMc = 1.35 ± 0.21; ARMi = 1.16 ± 0.26 mL/cmH₂O/kg) compared to BASE (ARMc = 1.78 ± 0.60; ARMi = 1.66 ± 0.66 mL/cmH₂O/kg) and at ARM (ARMc = 1.71 ± 0.41; ARMi = 1.44 ± 0.84 mL/cmH₂O/kg) and PostPP (ARMc = 1.75 ± 0.45; ARMi = 1.89 ± 0.59 mL/cmH₂O/kg), and it was higher compared to PP and similar to BASE. The PaO₂/FiO₂, in both groups, was higher at ARM (ARMc = 455.11 ± 85.90; ARMi = 505.40 ± 31.70) and PostPP (ARMc = 521.30 ± 66.20; ARMi = 450.90 ± 70.60) compared to PP (ARMc = 369.53 ± 49.31; ARMi = 394.32 ± 37.72).

Conclusion and clinical relevance

The two ARMs improve lung function in dogs undergoing laparoscopic surgery similarly. Application of PEEP at the end of the ARMs prolonged the effects of the open-lung strategy.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Effect of obesity on post-operative outcomes following colorectal cancer surgery

BACKGROUND

Colorectal cancer (CRC) resection is currently being undertaken in an increasing number of obese patients. Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery.

AIM

To evaluate the post-operative outcomes of obese patients following CRC resection, as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery.

METHODS

Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index (BMI): Obese [BMI ≥ 30, n = 182 (29.6%)] and non-obese [BMI < 30, n = 433 (70.4%)]. Demographics, comorbidities, surgical features, and post-operative outcomes were compared between both groups. Post-operative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery [n = 472: BMI ≥ 30, n = 136 (28.8%); BMI < 30, n = 336 (71.2%)].

RESULTS

Obese patients had a higher burden of cardiac (73.1% vs 56.8%; P < 0.001) and respiratory comorbidities (37.4% vs 26.8%; P = 0.01). Obese patients were also more likely to undergo conversion to an open procedure (12.8% vs 5.1%; P = 0.002), but did not experience more post-operative complications (51.6% vs 44.1%; P = 0.06) or high-grade complications (19.2% vs 14.1%; P = 0.11). In the laparoscopic subgroup, however, obesity was associated with a higher prevalence of post-operative complications (47.8% vs 39.3%; P = 0.05) but not high-grade complications (17.6% vs 11.0%; P = 0.07).

CONCLUSION

Surgical resection of CRC in obese individuals is safe. A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Low-Pressure Laparoscopy Using the AirSeal System versus Standard Insufflation in Early-Stage Endometrial Cancer: A Multicenter, Retrospective Study (ARIEL Study)

The aim of our study was to evaluate the benefits of a low-pressure insufflation system (AirSeal) vs. a standard insufflation system in terms of anesthesiologists’ parameters and postoperative pain in patients undergoing laparoscopic surgery for early-stage endometrial cancer. This retrospective study involved five tertiary centers and included 152 patients with apparent early-stage disease who underwent laparoscopic surgical staging with either the low-pressure AirSeal system (8−10 mmHg, n = 84) or standard laparoscopic insufflation (10−12 mmHg, n = 68). All the intraoperative anesthesia variables evaluated (systolic blood pressure, end-tidal CO2, peak airway pressure) were significantly lower in the AirSeal group. We recorded a statistically significant difference between the two groups in the median NRS scores for global pain recorded at 4, 8, and 24 h, and for overall shoulder pain after surgery. Significantly more women in the AirSeal group were also discharged on day one compared to the standard group. All such results were confirmed when analyzing the subgroup of women with a BMI >30 kg/m2. In conclusion, according to our preliminary study, low-pressure laparoscopy represents a valid alternative to standard laparoscopy and could facilitate the development of outpatient surgery.

A Propensity-Matched Analysis of the Postoperative Venous Thromboembolism Rate After Pancreatoduodenectomy Based on Operative Approach

BACKGROUND

The use of minimally invasive approaches for pancreatoduodenectomy has increased in recent years, but the risk of postoperative VTE is undefined. We aimed to compare venous thromboembolism (VTE) rates after open and minimally invasive pancreatoduodenectomy using an administrative dataset.

METHODS

Patients who underwent pancreatoduodenectomy within the National Surgical Quality Improvement Program targeted pancreatectomy database (2016-2018) were identified. VTE was compared between patients who underwent open or minimally invasive pancreatoduodenectomy directly and after propensity score matching 1:1 for demographics, comorbidities, and peri-/intra-operative factors.

RESULTS

A total of 12,227 patients underwent pancreatoduodenectomy during the study period (open: n = 11,217; minimally invasive: n = 1010). Before matching, the VTE rate was higher among patients who underwent minimally invasive pancreatoduodenectomy (5.2% vs. 3.8%, p = 0.033), and minimally invasive resection was independently associated with VTE (OR = 1.46, 95%CI = 1.09-2.06). After matching, there were 916 patients per group without differences in demographics or comorbidities. Patients who underwent minimally invasive pancreatoduodenectomy had longer median operative times (422 vs. 348 min). The VTE rate remained higher following minimally invasive pancreatoduodenectomy after matching (5.1% vs. 2.9%, p = 0.018), mainly driven by a higher DVT rate (3.9% vs. 1.7%, p = 0.005).

CONCLUSIONS

Minimally invasive pancreatoduodenectomy is associated with a higher postoperative VTE rate compared to open pancreatoduodenectomy.

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern

BACKGROUND

Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%.

OBJECTIVE

To estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools.

METHODS

A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19%( 95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists' (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy.

CONCLUSION

VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates.

Effect of inverse ratio ventilation on hemodynamics and respiratory mechanics in obese patients undergoing laparoscopic sleeve gastrectomy

Background

Obesity has become a global epidemic problem affecting every system and is associated with many consequences including coronary artery disease, hypertension, diabetes mellitus, dyslipidemia, obstructive sleep apnea, and socioeconomic and psychosocial impairment. Laparoscopic sleeve gastrectomy is one of the best and most commonly done operations for weight loss. Elevated peak airway pressure and hypoxemia are common problems that anesthesiologists face during laparoscopic surgeries with conventional volume-controlled ventilation. This study aimed at the use of the prolonged I:E ratio as an alternative strategy to improve gas exchange and the respiratory mechanics of obese patients undergoing laparoscopic sleeve gastrectomy.

Results

The study was a prospective randomized controlled trial and was performed between April 2019 and March 2020. After the approval of the departmental ethical committee and the informed written consent had been taken from the patients, fifty-two obese patients undergoing laparoscopic sleeve gastrectomy were enrolled in this study. After endotracheal intubation, the patients were randomly divided into the IRV group (n=26) and the VCV group (n=26). Respiratory parameters were adjusted as tidal volume (Vt) 8mL/kg ideal body weight, respiratory rate 12 breaths/min, positive-end expiratory pressure (PEEP) 0, fractional inspired oxygen (FiO₂) 0.6, and I:E ratio 1:2 for the VCV group and 2:1 for the IRV group; hemodynamics and respiratory mechanics were monitored and recorded after intubation (0 min), before pneumoperitoneum (10 mins), and after pneumoperitoneum (20 mins), 30, 40, 50, and 60 mins. IRV significantly improves the respiratory mechanics during pneumoperitoneum in the form of decreasing the peak pressure (Ppeak) and plateau pressure (Pplat) and improving the dynamic compliance, but the mean pressure (Pmean) was increased; it also increased the partial pressure of oxygen (arterial PO₂) significantly. No statistical significance was found regarding the demographic data or the hemodynamics.

Conclusion

IRV is superior to conventional VCV in morbidly obese patients undergoing laparoscopic sleeve gastrectomy as it improves respiratory mechanics and oxygenation.

Severe portal and systemic acidosis during CO2-laparoscopy compared to helium or gasless laparoscopy and laparotomy in a rodent model: an experimental study

BACKGROUND AND AIMS

This experimental study assesses the influence of different gases and insufflation pressures on the portal, central-venous and peripheral-arterial pH during experimental laparoscopy.

METHODS

Firstly, 36 male WAG/Rij rats were randomized into six groups (n = 6) spontaneously breathing during anaesthesia: laparoscopy using carbon dioxide or helium at 6 and 12 mmHg, gasless laparoscopy and laparotomy. 45 and 90 min after setup, blood was sampled from the portal vein, vena cava and the common femoral artery with immediate blood gas analysis. Secondly, 12 animals were mechanically ventilated at physiological arterial pH during 90 min of laparotomy (n = 6) or carbon dioxide laparoscopy at 12 mmHg (n = 6) with respective blood gas analyses.

RESULTS

Over time, in spontaneously breathing rats, carbon dioxide laparoscopy caused significant insufflation pressure-dependent portal acidosis (pH at 6 mmHg, 6.99 [6.95-7.04] at 45 min and 6.95 [6.94-6.96] at 90 min, pH at 12 mmHg, 6.89 [6.82-6.90] at 45 min and 6.84 [6.81-6.87] at 90 min; p < 0.05) compared to laparotomy (portal pH 7.29 [7.23-7.30] at 45 min and 7.29 [7.20-7.30] at 90 min; p > 0.05). Central-venous and peripheral-arterial acidosis was significant but less severely reduced during carbon dioxide laparoscopy. Laparotomy, helium laparoscopy and gasless laparoscopy showed no comparable acidosis in all vessels. Portal and central-venous acidosis during carbon dioxide laparoscopy at 12 mmHg was not reversible by mechanical hyperventilation maintaining a physiological arterial pH (pH portal 6.85 [6.84-6.90] (p = 0.004), central-venous 6.93 [6.90-6.99] (p = 0.004), peripheral-arterial 7.29 [7.29-7.31] (p = 0.220) at 90 min; Wilcoxon-Mann-Whitney test).

CONCLUSION

Carbon dioxide laparoscopy led to insufflation pressure-dependent severe portal and less severe central-venous acidosis not reversible by mechanical hyperventilation.

Obesity and anastomotic leak rates in colorectal cancer: a meta-analysis

PURPOSE

Anastomotic leak (AL) following colorectal cancer resection is associated with considerable morbidity and mortality with an impact on recurrence rates and survival. The impact of obesity on AL rates is debated. This meta-analysis aims to investigate the relationship between obesity and AL.

METHODS

A search was conducted of the PubMed/MEDLINE, and Web of Science databases and included studies were split into Western and Asian groups based on population-specific body mass index (BMI) ranges for obesity. A meta-analysis was performed to assess the impact of obesity on AL rate following colorectal cancer resection.

RESULTS

Two thousand three hundred and four articles were initially screened. Thirty-one studies totaling 32,953 patients were included. Patients with obesity had a statistically significant increase in AL rate in all Western and Asian study groups. However, this increase was only clinically significant in the rectal anastomotic subgroups-Western: 10.8% vs 8.4%, OR 1.57 (1.01-2.44) and Asian: 9.4% vs 7.4%, OR 1.58 (1.07-2.32).

CONCLUSIONS

The findings of this analysis confirm that obesity is a significant risk factor for anastomotic leak, particularly in rectal anastomoses. This effect is thought to be primarily mediated via technical difficulties of surgery although metabolic and immunological factors may also play a role. Obesity in patients undergoing restorative CRC resection should be discussed and considered as part of the pre-operative counselling.

Comparison of a new gasless method and the conventional CO2 pneumoperitoneum method in laparoendoscopic single-site cholecystectomy: a prospective randomized clinical trial

To avoid CO₂ pneumoperitoneum-associated cardiopulmonary side-effects during conventional laparoscopic surgeries, we have developed a gasless laparoscopic operation field formation (LOFF) device for laparoendoscopic single-site surgery. The aim of this study is to analyze the safety and efficacy of the LOFF device for laparoendoscopic single-site cholecystectomy and to verify its advantage of avoiding CO₂ pneumoperitoneum-associated complications. In this prospective, randomized, observer-blinded clinical trial, eligible participants were randomized in a 1:1 ratio to undergo either conventional CO₂ pneumoperitoneum assisted laparoendoscopic single-site cholecystectomy (LESS) or the new gasless LOFF device assisted laparoendoscopic single-site cholecystectomy (LOFF-LESS). Outcomes including intra-operative respiratory and hemodynamic parameters, operation time, conversion rate, complication rate, et al were compared between the two groups. A total of 100 patients were randomized to the LESS group [n = 50; mean (SD) age, 49.5 (13.9) years; 24 (48.0%) women] and the LOFF-LESS group [n = 50, mean (SD) age, 47.4 (13.3) years; 27 (54.0%) women]. Compared with the LOFF-LESS group, the LESS group witnessed significant fluctuations in intra-operative respiratory and hemodynamic parameters. The tracheal extubation time of the LESS group was significantly longer (P = 0.001). The gasless LOFF device is safe and feasible for simple laparoscopic cholecystectomy and has a predominance of avoiding CO₂ pneumoperitoneum-associated cardiopulmonary side-effects. Trial registration number: ChiCTR2000033702.

The impact of the last ten minutes of surgery on hemorrhagic complications after laparoscopic sleeve gastrectomy. Case-control study

INTRODUCTION

Hemorrhagic complications after laparoscopic sleeve gastrectomy (LSG) are among the most common adverse events. The last 10 min of LSG are essential in terms of hemostasis.

AIM

To assess the blood pressure profile in the last 10 min of LSG in patients who experienced hemorrhagic complications after laparoscopic sleeve gastrectomy.

MATERIAL AND METHODS

We performed a retrospective case-control study. The medical records of 867 patients who underwent primary LSG were analyzed. Cases were defined as patients who required surgical revision due to hemorrhagic complications within 72 h. Controls were matched (1 : 1) with cases by age, body mass index, gender, staple line reinforcement, comorbidities and surgeon's experience. Comparison of the last three intraoperative blood pressure measurements at the end of surgery was made.

RESULTS

The bleeding rate was 3.0%. A total of 24 subjects (12 matched pairs) were included in the study. Cases had statistically significant increased mean arterial blood pressure (mm Hg) 5 min before the end of surgery (87.8 ±11.9 vs. 79.4 ±8.8 mm Hg, p = 0.049) and at the end of surgery (89.2 ±11.7 vs. 77.5 ±11.8 mm Hg, p = 0.011). Higher diastolic blood pressure measurements were observed 5 min before the end (72.1 ±10.7 vs. 62.8 ±8.1 mm Hg, p = 0.023) and at the end of surgery (74.2 ±10.0 vs. 60.8 ±11.2 mm Hg, p = 0.004).

CONCLUSIONS

Compared with closely matched control subjects, patients with HC after LSG have increased mean arterial pressure in the last 5 min of surgery. This phenomenon has not been reported in the literature before.

Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients

Objective

To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients.

Methods

This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH.

Results

Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients.

Conclusion

TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.

The effects of CO2 pneumoperitoneum at different temperature and humidity on hemodynamic and respiratory parameters and postoperative pain in gynecological laparoscopic surgery: A prospective randomized controlled study

BACKGROUND

It is recommended to heat and humidity CO₂ in laparoscopic surgery to prevent postoperative pain and hypothermia but information about its effects on hemodynamic and respiratory parameters is limited. We aimed to investigate the effects of standard and heated-humidified CO₂ on hemodynamic and respiratory parameters, body temperature and pain in healthy patients.

METHODS

One hundred patients who underwent total laparoscopic hysterectomy for benign pathology were divided into two groups: Group CD (cold-dry) patients were administered standard CO₂, while Group HH (heated-humidified) patients were administered 95% humidified insufflation at 37 °C. Hemodynamic and respiratory parameters, body temperature, pain score and blood count parameters were recorded.

RESULTS

A total of 96 patients were included in the study, taken from the 100 patients. Group HH (n:47) had only higher systolic blood pressure at 75, mean blood pressure at 50 and 55 and a lower heart rate between 15 and 45 min (p:0.049, 0.037, 0.013 respectively). Pain score, morphine consumption, end-tidal CO₂ and arterial blood gas values were not different between the groups, with only body temperature from 40 min and minimum value being significantly higher (at a difference of 0.86-1.04 °C) in Group HH. Postoperative leukocyte, neutrophil and NLR (neutrophil-leukocyte ratio) were found to be higher in this group (p < 0.05).

CONCLUSION

It has been found that both standard and heated-humidified CO₂do not constitute a problem in terms of hemodynamic and respiratory parameters in healthy patients. The heated-humidified CO₂group had only a higher core body temperature and inflammatory response.

TRIAL REGISTRATION

NCT04508387.

Application of the Caprini risk assessment model for deep vein thrombosis among patients undergoing laparoscopic surgery for colorectal cancer

Application of the Caprini risk assessment model was explored in patients with deep vein thrombosis (DVT) after laparoscopic colorectal cancer surgery.This study was a prospective study. The risk factors for DVT were assessed with a survey at baseline and on the morning of surgery, first day after surgery and sixth day by using repeated blood vessels on color Doppler ultrasound of the lower limbs, and the intraoperative and postoperative conditions were recorded.Among 148 surgical patients, 24.3% had asymptomatic DVT. According to the risk stratification, the incidence of DVT was related to the Caprini score (P < .001). The area under the curve of the Caprini model was 0.701 ± 0.047 (95% CI: 0.609-0.793, P<.001). The Youden index was 0.368, while the critical point was 10.5 in the Caprini model, corresponding to a sensitivity of 0.806 and a specificity of 0.563. Age, cardiovascular disease, intraoperative blood loss, postoperative fever, preoperative preparation, and hospital stay were higher in DVT patients than in patients without DVT. Moreover, the incidence of DVT in patients with a lithotomy position was higher than that in patients with a scissors position. In binary logistic regression analysis, the independent risk factors for DVT development were age, intraoperative blood loss, and preoperative preparation time.The Caprini model can be used for the prediction of venous thromboembolism in laparoscopic colorectal cancer surgery patients. The thrombosis risk assessment model must be established in line with patients undergoing endoscopic malignant tumor surgery.

Prophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy could reduce the frequency of portomesenteric venous thrombosis

INTRODUCTION

Portal and mesenteric venous thrombosis is a rare but potentially serious complication after laparoscopic sleeve gastrectomy. There are no consistent studies that prove the safety and effectiveness of oral anticoagulant thromboprophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy. The objective was to evaluate the effect of rivaroxaban on the frequency of portal and mesenteric venous thrombosis and its safety profile after laparoscopic sleeve gastrectomy.

MATERIALS AND METHODS

This retrospective analysis of prospectively collected data includes all laparoscopic sleeve gastrectomies performed by a single surgeon at Pontificia Universidad Católica de Chile Hospital between January 2009 and June 2019. All patients received low molecular weight heparin thromboprophylaxis during the whole hospital stay. Between July 2012 and June 2019, patients received additional post-discharge thromboprophylaxis with rivaroxaban. Patient demographics, impaired renal, post-surgical portal and mesenteric venous thrombosis, and bleeding episodes were registered.

RESULTS

A total of 516 patients were identified; 95 patients were excluded. Results for 421 patients were analysed: 198 received only intrahospital thromboprophylaxis (group 1) and 223 received additional post-discharge thromboprophylaxis with rivaroxaban (group 2). There was no statistically significant difference between the two groups concerning age, sex and body mass index. In group 1, four cases of portal and mesenteric venous thrombosis were registered and no cases were reported in group 2 (p < 0.05). All cases occurred before 30 days after surgery. No bleeding episodes and no adverse reactions were detected in group 2.

CONCLUSIONS

Thromboprophylaxis during the whole hospital stay (two to three days), followed by rivaroxaban 10mg once daily for 10 days after discharge (completing in total 13-14 days of prophylaxis), could reduce cases of post-surgical portal and mesenteric venous thrombosis without an increase in bleeding complications.

Efficacy and safety of laparoscopic hepatectomy for hepatocellular carcinoma comorbid with cirrhosis

Introduction

Laparoscopic hepatectomy (LH) is very difficult to perform in patients with cirrhosis because of the haemorrhagic and fibrotic nature of the liver, although there are various advantages to laparoscopic surgery.

Aim

To investigate the surgical outcomes, and efficacy and safety of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) resection.

Material and methods

A total of 112 patients with cirrhosis, who underwent hepatectomy, were analysed retrospectively. We investigated the safety and efficacy of LH for HCC with cirrhosis. Student's t and χ² tests, Mann-Whitney's U test, Wilcoxon's signed-rank test, and Fisher's exact test were used in the statistical analysis.

Results

Seventy-one patients underwent LH, and 41 underwent OH. The conversion rate from LH to OH was 12.7%. After propensity score matching, the estimated blood loss was significantly lower in the LH group than in the OH group (25 vs. 310 ml; p < 0.001), and there was a significant difference between the groups in the operative time (p = 0.091). The LH group had complication rates of 3.6% and 0% for refractory ascites and pleural effusion, respectively, while those were 17.9% and 10.7%, respectively, in the OH group (p = 0.019 and p = 0.005, respectively). The LH group had no mortality, whereas the OH group had a mortality rate of 10.7% (p = 0.038). The postoperative length of stay was significantly longer in the LH group than in the OH group (9 days vs. 14 days) (p = 0.002).

Conclusions

LH can be performed safely for HCC with cirrhosis. More favourable results are achieved with LH than with OH in terms of surgical outcomes.

Prospective randomized controlled trial on comparison of standard CO2 pressure pneumoperitoneum insufflator versus AirSeal®

Background

AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO₂ recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO₂ insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO₂ insufflators in patients undergoing the most frequently performed laparoscopic procedures.

Methods

One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO₂ insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien–Dindo grade complications, surgical side effect and length of hospital stay.

Results

Patients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56–94] in group A vs. 69 min [52–93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0–3] in group S vs. 2 [0–4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay.

Conclusion

This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO₂ insufflator for short elective surgeries.

ClinicalTrials.gov (NCT01740011).

Non-Invasive Versus Invasive Blood Pressure Monitoring in Patients During Laparoscopic Bariatric Surgery: a Prospective Method-Comparison Study

Introduction: Intra-operative blood pressure monitoring in morbidly obese patients using standard non-invasive blood pressure (NIBP) oscillometric technique with upper arm cuffing is often inaccurate. Invasive arterial blood pressure (IABP) monitoring is the gold standard but is not without complications. The purpose of this study was done to assess the degree of agreement between the forearm and upper arm NIBP with the IABP during laparoscopic bariatric surgery. Patients and Methodsm The study was conducted in our university hospital. A total of 36 morbidly obese patients undergoing laparoscopic bariatric surgery were studied. The radial artery was cannulated for IABP monitoring on one upper limb while NIBP monitoring was done on the contralateral upper arm and forearm. The NIBP and its corresponding IABP readings were recorded at selected time points at 10 minutes post-induction; 5, 15, and 30 minutes post-insufflation and 15 minutes post- exsufflation. Results: The mean arterial pressure (MAP) has narrower limits of agreement compared to the systolic blood pressure (SBP) and diastolic blood pressure (DBP) for each method of measurement used. Forearm NIBP showed better agreement with IABP compared to upper arm NIBP. Repeated measures ANOVA showed a similar pattern of changes in SBP, DBP, and MAP measured by NIBP and IABP during the surgery. Conclusion: Similar patterns of blood pressure changes were observed with IABP, upper arm, and forearm NIBP measurements at all time points. The forearm NIBP showed better agreement to IABP as compared to upper arm NIBP and may be adequate to monitor patterns of blood pressure changes during laparoscopic bariatric surgery. Keywords: Weight loss surgery, intraoperative BP monitoring, Obesity, Hypertension, Forearm and upper arm BP monitoring, IABP, NIBP

Assessment of the Effect of Perioperative Venous Lidocaine on the Intensity of Pain and IL-6 Concentration After Laparoscopic Gastroplasty

BACKGROUND AND OBJECTIVES

Opioids are associated with sedation and respiratory depression. The primary objective of this study was to assess pain intensity after gastric bypass with lidocaine. The secondary objective was to assess the IL-6 concentration, consumption of morphine, time to morphine request, time to extubation, and side effects.

METHODS

Sixty patients aged 18 to 60 years, with ASA (American Society of Anesthesiologists) scores of 2 or 3, who underwent bariatric surgery were allocated to two groups. Patients in group 1 were administered lidocaine (1.5 mg/kg) 5 min before the induction of anesthesia, and group 2 was administered 0.9% saline solution in an equal volume. Subsequently, lidocaine (2 mg/kg/h) or 0.9% saline was infused during the entire surgical procedure. Anesthesia was performed with fentanyl (5 μg/kg), propofol, rocuronium, and sevoflurane. Postoperative patient-controlled analgesia was provided with morphine. The following were evaluated: pain intensity, IL-6, 24-h consumption of morphine, time to the morphine request, time to extubation, and adverse effects.

RESULTS

The lidocaine group had a lower pain intensity than the saline group for up to 1 h, with no differences between groups in IL-6 and time to extubation. The lidocaine group consumed less morphine within 24 h, had a longer time until the first supplemental morphine request, and had a lower incidence of nausea.

CONCLUSIONS

Lidocaine reduced the intensity of early postoperative pain, incidence of nausea, and consumption of morphine within 24 h and increased time to the first morphine request, without reducing the plasma concentrations of IL-6.

The impact of the AirSeal® valve-less trocar system in robotic colorectal surgery: a single-surgeon retrospective review

BACKGROUND

Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSeal^® is a valve-less trocar system that overcomes these flaws by utilizing a system of laminar flow and CO₂ recirculation. The purpose of this paper is to examine the effect of the AirSeal^® versus a traditional trocar system in operative time, EBL and post-operative complications. To the best of our knowledge, this is the first analysis of this system in robotic colorectal surgery.

METHODS

A single surgeon's database was reviewed and all LAR and right hemicolectomy robotic cases from 2014-2015 and 2017-2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS.

RESULTS

Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014-2015 and 232 ± 74.6 min in 2017-2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014-2015 and 150 ± 173.9 cc in 2017-2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014-2015 and 2017-2018. Length of stay was reduced in both populations between 2014-2015 and 2017-2018; however, it neither reached statistical significance.

CONCLUSION

In patients undergoing low anterior resections, the AirSeal^® trocar system demonstrated a statistically significant reduction in mean operative time and EBL compared to the traditional trocar system. There was also a trend towards decreased length of stay and post-operative complications with AirSeal^® use in low anterior resections and right hemicolectomies. In patients undergoing distal colorectal procedures, the AirSeal^® trocar system should be considered.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Comparison of volume-controlled, pressure-controlled, and pressure-controlled volume-guaranteed ventilation during robot-assisted laparoscopic gynecologic surgery in the Trendelenburg position

Background: Pressure-controlled ventilation volume-guaranteed (PCV-VG) is being increasingly used for ventilation during general anesthesia. Carbon dioxide (CO₂) pneumoperitoneum in the Trendelenburg position is routinely used during robot-assisted laparoscopic gynecologic surgery. Here, we hypothesized that PCV-VG would reduce peak inspiratory pressure (Ppeak), compared to volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). Methods: In total, 60 patients were enrolled in this study and randomly assigned to receive VCV, PCV, or PCV-VG. Hemodynamic variables, respiratory variables, and arterial blood gases were measured in the supine position 15 minutes after the induction of anesthesia (T0), 30 and 60 minutes after CO₂ pneumoperitoneum and Trendelenburg positioning (T1 and T2, respectively), and 15 minutes after placement in the supine position at the end of anesthesia (T3). Results: The Ppeak was higher in the VCV group than in the PCV and PCV-VG groups (p=0.011). Mean inspiratory pressure (Pmean) was higher in the PCV and PCV-VG groups than in the VCV group (p<0.001). Dynamic lung compliance (Cdyn) was lower in the VCV group than in the PCV and PCV-VG groups (p=0.001). Conclusion: Compared to VCV, PCV and PCV-VG provided lower Ppeak, higher Pmean, and improved Cdyn, without significant differences in hemodynamic variables or arterial blood gas results during robot-assisted laparoscopic gynecologic surgery with Trendelenburg position.

The Effect of sevoflurane, desflurane and propofol on respiratory mechanics and integrated pulmonary index scores in laparoscopic sleeve gastrectomy. A randomized trial

Objectives:

To compare the effects of sevoflurane, desflurane, and propofol on respiratory mechanics, and integrated pulmonary index (IPI) scores in patients undergoing laparoscopic sleeve gastrectomy.

Methods:

A total of 60 patients with a body mass index of ≥40 kg/m², who underwent laparoscopic sleeve gastrectomy between September 2015 and September 2016 at Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey were included in this randomized prospective study. After induction, anesthesia was maintained by sevoflurane in group S, desflurane in group D, and propofol in group P. Peak inspiratory pressure (PIP), plateau pressure (P_plateau), compliance (Cdyn), respiratory resistance (Rrs), and IPI values were recorded. Mann-Whitney U, Kruskal-Wallis, Dunn’s, Friedman, and Fisher-Freeman-Halton tests were performed for statistical analysis. A p value of <0.05 was considered statistically significant.

Results:

A significant increase was found in PIP in group S (T₁: 25; T₂: 27 cmH₂O), and group D (T₁: 25; T₂: 29,5 cmH₂O) during pneumoperitoneum. Dynamic compliance decreased in all groups during pneumoperitoneum. In group S, the decrease in Cdyn was also statistically significant after pneumoperitoneum (T₁: 43.65; T₅: 41.25 ml/cmH₂O). Comparison between groups the values of PIP, P_plateau, Cdyn, Rrs, and IPI were similar.

Conclusion:

In morbidly obese patients, sevoflurane, desflurane, and propofol are similar in terms of the intraoperative respiratory mechanics, and perioperative respiratory parameters provided with IPI.

[Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial]

BACKGROUND

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

OBJECTIVES

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

METHODS

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5 minutes after induction, 30 minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

RESULTS

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

CONCLUSIONS

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial

Background

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

Objectives

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

Methods

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5minutes after induction, 30minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

Results

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

Conclusions

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position

Background and objectives

The aim of this study was to investigate the efficacy of the pressure-controlled, volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position.

Methods

Patients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40 kg.m⁻² were randomized to receive either VCV or PCV-VG ventilation. The tidal volume was set at 8 mL.kg⁻¹, with an inspired oxygen concentration of 0.4 with a Positive End-Expiratory Pressure (PEEP) of 5 mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO₂, arterial blood gas analysis, heart rate and mean arterial pressure at 5 minutes after induction of anesthesia in the and at 5, 30 and 60 minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded.

Results

The PCV-VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO₂ levels were significantly higher in the PCV-VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position.

Conclusions

The PCV-VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV-VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.

Multimodal non-invasive monitoring to apply an open lung approach strategy in morbidly obese patients during bariatric surgery

To evaluate the use of non-invasive variables for monitoring an open-lung approach (OLA) strategy in bariatric surgery. Twelve morbidly obese patients undergoing bariatric surgery received a baseline protective ventilation with 8 cmH₂O of positive-end expiratory pressure (PEEP). Then, the OLA strategy was applied consisting in lung recruitment followed by a decremental PEEP trial, from 20 to 8 cmH₂O, in steps of 2 cmH₂O to find the lung's closing pressure. Baseline ventilation was then resumed setting open lung PEEP (OL-PEEP) at 2 cmH₂O above this pressure. The multimodal non-invasive variables used for monitoring OLA consisted in pulse oximetry (SpO₂), respiratory compliance (Crs), end-expiratory lung volume measured by a capnodynamic method (EELV_CO2), and esophageal manometry. OL-PEEP was detected at 15.9 ± 1.7 cmH₂O corresponding to a positive end-expiratory transpulmonary pressure (P_L,ee) of 0.9 ± 1.1 cmH₂O. ROC analysis showed that SpO₂ was more accurate (AUC 0.92, IC95% 0.87-0.97) than Crs (AUC 0.76, IC95% 0.87-0.97) and EELV_CO2 (AUC 0.73, IC95% 0.64-0.82) to detect the lung's closing pressure according to the change of P_L,ee from positive to negative values. Compared to baseline ventilation with 8 cmH₂O of PEEP, OLA increased EELV_CO2 (1309 ± 517 vs. 2177 ± 679 mL) and decreased driving pressure (18.3 ± 2.2 vs. 10.1 ± 1.7 cmH₂O), estimated shunt (17.7 ± 3.4 vs. 4.2 ± 1.4%), lung strain (0.39 ± 0.07 vs. 0.22 ± 0.06) and lung elastance (28.4 ± 5.8 vs. 15.3 ± 4.3 cmH₂O/L), respectively; all p < 0.0001. The OLA strategy can be monitored using noninvasive variables during bariatric surgery. This strategy decreased lung strain, elastance and driving pressure compared with standard protective ventilatory settings.Clinical trial number NTC03694665.

Case series: Portomesenteric venous thrombosis complicating laparoscopic bariatric procedures

•

Portomesenteric vein thrombosis is a rare but potentially fatal complication of bariatric surgery.

•

Portomesenteric venous thrombosis complicated 3 of 1030 cases (0.29%).

•

Management is primarily with anticoagulants, but surgery is required if the patient shows signs of sepsis.

•

A high index of suspicion, early diagnosis and subsequent adequate management is required.

Introduction

Portomesenteric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide.

Methods

A retrospective analysis was performed on all bariatric procedures performed in our center between July 2012 & December 2017 to identify cases complicated by portomesenteric venous thrombosis. The cases were compared in terms of operative details, patient presentation, diagnosis, patient risk factors for developing thrombosis, demographics and thrombophilia analysis & subsequent treatment and prognosis.

Results

A total of 1030 bariatric procedures were performed between July 2012 & December 2017. Portomesenteric venous thrombosis complicated 3 of these cases (0.29%). Two of these cases had underwent a laparoscopic sleeve gastrectomy while the third had underwent a gastric band removal and a conversion to a single anastomosis gastric bypass. Amongst these patients, 2 were female while 1 was male with an average BMI 38.9 kg/m². Only one of these patients was a smoker while none of them tested positive for thrombophilias. The diagnosis of portomesenteric venous thrombosis was confirmed with a contrast CT of the abdomen as all patients were re-admitted between 4–20 days post operatively after being discharged on postoperative day 2. All three cases were managed with systemic anticoagulants and none underwent invasive procedures or were re-explored surgically. All were subsequently discharged in good condition.

Conclusion

Portomesenteric venous thrombosis is an uncommon yet potentially fatal complication of bariatric surgery. A high index of suspicion, early diagnosis and subsequent adequate management is required. Based on this case series and the potential risk of portomesenteric venous thrombosis, we altered our clinical practice to include a 1 week course of low molecular weight heparin to be administered to all patients after discharge.

Laparoscopic liver resection for patients with cardiac disease

Introduction

The gravest problem facing medicine is caring for an aging society and the comorbidities that develop with age, including an increasing prevalence of cardiac disease. Unrecognized or untreated cardiac disease increases the risk of complications in patients undergoing laparoscopic liver resection (LLR). We herein describe the preoperative status, perioperative outcomes, and postoperative courses of patients with or without cardiac disease who undergo LLR.

Material and methods

The data of 339 patients who underwent LLR at a single institution between 2010 and 2018 were retrospectively reviewed. Their preoperative status, surgical outcomes, and postoperative courses were analyzed.

Results

Of 339 patients who underwent LLR, one was excluded for pre-existing severe valvular disease. Of the remaining 338 patients, 16 had coexisting cardiac disease and 322 did not. The patients with coexisting cardiac disease had a mean left ventricular ejection fraction of 66% (22–74%). LLR was performed after cardiac function was controlled in the patients with cardiac disease; there were no instances of increased central venous pressure (CVP) or destabilized vital signs during surgery. Intraoperative CVP did not differ between the groups (p = 0.521). There were no significant differences in the demographics except for age, operative characteristics, and surgical outcomes between the groups.

Conclusions

Patients with non-severe or controlled severe cardiac disease do not exhibit different postoperative courses compared to patients without coexisting cardiac disease. Uncontrolled severe cardiac disease can lead to unstable vital signs during surgery, such as increased CVP. In such cases, treating the cardiac disease should be prioritized.