Effects of pneumoperitoneum and steep Trendelenburg position on cerebral hemodynamics during robotic-assisted laparoscopic radical prostatectomy: A randomized controlled study

Assessing Stress Induced by Fluid Shifts and Reduced Cerebral Clearance during Robotic-Assisted Laparoscopic Radical Prostatectomy under Trendelenburg Positioning (UroTreND Study)

In addition to general anesthesia and mechanical ventilation, robotic-assisted laparoscopic radical prostatectomy (RALP) necessitates maintaining a capnoperitoneum and placing the patient in a pronounced downward tilt (Trendelenburg position). While the effects of the resulting fluid shift on the cardiovascular system seem to be modest and well tolerated, the effects on the brain and the blood-brain barrier have not been thoroughly investigated. Previous studies indicated that select patients showed an increase in the optic nerve sheath diameter (ONSD), detected by ultrasound during RALP, which suggests an elevation in intracranial pressure. We hypothesize that the intraoperative fluid shift results in endothelial dysfunction and reduced cerebral clearance, potentially leading to transient neuronal damage. This prospective, monocentric, non-randomized, controlled clinical trial will compare RALP to conventional open radical prostatectomy (control group) in a total of 50 subjects. The primary endpoint will be the perioperative concentration of neurofilament light chain (NfL) in blood using single-molecule array (SiMoA) as a measure for neuronal damage. As secondary endpoints, various other markers for endothelial function, inflammation, and neuronal damage as well as the ONSD will be assessed. Perioperative stress will be evaluated by questionnaires and stress hormone levels in saliva samples. Furthermore, the subjects will participate in functional tests to evaluate neurocognitive function. Each subject will be followed up until discharge. Conclusion: This trial aims to expand current knowledge as well as to develop strategies for improved monitoring and higher safety of patients undergoing RALP. The trial was registered with the German Clinical Trials Register DRKS00031041 on 11 January 2023.

The effects of positive end-expiratory pressure (PEEP) application on optic nerve sheath diameter in patients undergoing laparoscopic cholecystectomy: a randomized trial

BACKGROUND

Positive end-expiratory pressure (PEEP) can overcome respiratory changes that occur during pneumoperitoneum application in laparoscopic procedures, but it can also increase intracranial pressure. We investigated PEEP vs. no PEEP application on ultrasound measurement of optic nerve sheath diameter (indirect measure of increased intracranial pressure) in laparoscopic cholecystectomy.

METHODS

Eighty ASA I-II patients aged between 18 and 60 years scheduled for elective laparoscopic cholecystectomy were included. The study was registered in the Australian New Zealand Clinical Trials (ACTRN12618000771257). Patients were randomly divided into either Group C (control, PEEP not applied), or Group P (PEEP applied at 10 cmH20). Optic nerve sheath diameter, hemodynamic, and respiratory parameters were recorded at six different time points. Ocular ultrasonography was used to measure optic nerve sheath diameter.

RESULTS

Peak pressure (PPeak) values were significantly higher in Group P after application of PEEP (p = 0.012). Mean respiratory rate was higher in Group C at all time points after application of pneumoperitoneum (p < 0.05). The mean values of optic nerve sheath diameters measured at all time points were similar between the groups (p > 0.05). The pulmonary dynamic compliance value was significantly higher in group P as long as PEEP was applied (p = 0.001).

CONCLUSIONS

During laparoscopic cholecystectomy, application of 10 cmH2O PEEP did not induce a significant change in optic nerve sheath diameter (indirect indicator of intracranial pressure) compared to no PEEP application. It would appear that PEEP can be used safely to correct respiratory mechanics in cases of laparoscopic cholecystectomy, with no significant effect on optic nerve sheath diameter.

Deep neuromuscular block attenuates intra-abdominal pressure and inflammation and improves post-operative cognition in prostate cancer patients following robotic-assisted radical prostatectomy

BACKGROUND

Whether neuromuscular block (NMB) affects Intra-abdominal pressure (IAP) and cognition in Prostate cancer (PC) patients with Robotic-assisted laparoscopic radical prostatectomy (RALRP) remains unclear. Here we aimed to compare the effects of deep and moderate NMB on the IAP, inflammation, and cognition.

METHODS

The Moderate neuromuscular block (MNMB) group (N = 44) and Deep neuromuscular block (DNMB) group (N = 47) were recruited. Intra-abdominal pressure was adjusted to meet RALRP requirements. The expression of pro-inflammatory factors was measured by ELISA. MMSE scores were recorded before the operation, 1 day and 1 week after the operation.

RESULTS

Significant decreases in IAP (p < 0.001) and IL-1β, IL-6, TNF-a, and S-100β (p ≤ 0.01) expressions were found in the DNMB group. The MMSE score in the DNMB group was higher than that in the MNMB group on day one (p = 0.046). The incidence of nausea and vomiting was lower in the DNMB group than that in the MNMB group (p = 0.013).

CONCLUSIONS

DNMB reduces IAP and inflammation and improves post-operative cognitive functions in PC patients with RALRP.

Impact of Remimazolam versus Sevoflurane Anesthesia on Cerebral Oxygenation and Intracranial Pressure during Gynecological Laparoscopy with Mild Hypercapnia

BACKGROUND Remimazolam has the advantage of better hemodynamic stability compared with other anesthetics. We compared the effects of remimazolam and sevoflurane on cerebral oxygenation, intracranial pressure, and intraoperative hemodynamic parameters during mild hypercapnia in patients undergoing laparoscopy in the Trendelenburg position. MATERIAL AND METHODS Sixty-two patients (20-65 years old) scheduled for gynecological laparoscopy were randomly allocated to either the remimazolam (n=31) or sevoflurane (n=31) group. Respiratory and hemodynamic parameters and regional cerebral oxygen saturation (rSO₂) were recorded. Intracranial pressure was measured using the optic nerve sheath diameter (ONSD). RESULTS The change over time in rSO₂ did not differ between groups (P=0.056). The change in ONSD over time showed a significant intergroup difference (P=0.002). ONSD significantly changed over time (P=0.034) in the sevoflurane group but not in the remimazolam group (P=0.115). The changes in mean arterial pressure and heart rate over time showed significant intergroup differences (P=0.045 and 0.031, respectively). The length of stay and the use of rescue antiemetics and analgesics in the postanesthetic care unit were significantly lower in the remimazolam group than in the sevoflurane group (P=0.023, 0.038, and 0.018, respectively). CONCLUSIONS Remimazolam can provide a favorable hemodynamic profile and attenuate the increase in ONSD during gynecological laparoscopy compared with sevoflurane anesthesia during lung-protective ventilation with mild hypercapnia. Remimazolam can provide faster and better postoperative recovery than sevoflurane anesthesia.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Bilateral subgaleal hematoma after a robot-assisted radical prostatectomy: an uncommon complication

Robot-assisted radical prostatectomy is a relatively recent technique. Its advantages include less invasiveness and better pain management, but has specific anesthesia requirements, such as steep Trendelenburg position and pneumoperitoneum. Mild complications are common, e.g., transient hypotension or soft tissue edema. We present a case of a 62-year old male who developed subgaleal hematoma associated with transient neurologic impairment after surgery. Jugular vein insufficiency was suspected as the most likely cause. The patient recovered fully. Robot-assisted radical prostatectomy can be a challenging procedure due to the anesthesia requirements, but most complications are mild and transient. However, patients should be carefully assessed before surgery. We identified potential factors that may have led to this complication: the abnormal prolonged surgical time, the steep Trendelenburg, a non-assessed jugular vein insufficiency, and/or patient`s obesity.

Effect of sevoflurane, propofol and propofol with dexmedetomidine as maintenance agent on intracranial pressure in the Trendelenburg position during laparoscopic surgeries

Background and Aim

Pneumoperitoneum (PP) and the Trendelenburg position (TP) in laparoscopic surgeries are associated with rise in intracranial pressure (ICP). The optic nerve sheath diameter (ONSD) is a surrogate marker of ICP. The study aimed to evaluate the effect of sevoflurane, propofol and propofol with dexmedetomidine as maintenance agent on ICP in TP during laparoscopic surgeries.

Material and Methods

A total of 120 American Society of Anesthesiologists (ASA) physical status I/II patients, aged 18-65 years were randomly allocated into three groups: sevoflurane as group S, propofol as group P, and propofol with dexmedetomidine as group PD. The intra-abdominal pressure (IAP) was kept in the range of 12-14 mmHg and TP varied between 15°- 45° angle. The primary objective was comparison of ICP and secondary objectives were IOP, intraoperative hemodynamic and postoperative recovery characteristics among groups. The ONSD and IOP were measured in both eyes 10 min after endotracheal intubation (T0), 5 min after CO2 insufflation (T1), 5 min after TP (T2) and 5 min after deflation of gas (T3). The data were analyzed by using the Statistical Package for Social Sciences version 23.

Results

ONSD and IOP at T1 and T2 were significantly higher than T0 in all groups, but no significant difference was found among the intergroup groups. Significantly lower heart rate and mean blood pressure were observed in PD group at T1 and T2 compared to group S and group P.

Conclusion

The rise in ICP was comparable among sevoflurane, propofol, and propofol-dexmedetomidine combination as a maintenance agent during laparoscopic surgeries in TP.

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery

Background

We aimed to evaluate the effects of internal jugular vein (IJV) catheterization on intracranial pressure (ICP) and postoperative delirium (POD) during robot-assisted laparoscopic surgery by measuring the optic nerve sheath diameter (ONSD).

Methods

Data from a prospective single-center cohort study, conducted from October 2021 to February 2022, were used. Forty out of 80 patients scheduled for laparoscopic radical hysterectomy or prostatectomy were assigned to the group receiving IJV catheterization (Group I), and the other 40 only received peripheral venous cannulation (Group C) according to clinical need of patients. Ultrasonography of ONSDs, the proportion of regurgitation time in a cardiac cycle, and hemodynamic parameters were measured at four time points: immediately after induction of anesthesia in the supine position (T0), 30 min (T1), 60 min (T2) after orienting to the Trendelenburg position, and before returning to the supine position at the end of surgery (T3). Time to eye opening and emergence stay, POD, and QoR-15 were compared.

Results

The ONSDs increase gradually as the surgery progressed. Group I showed a higher value of ONSD at T1 (4.72 ± 0.29 mm vs. 4.5 ± 0.33 mm, p = 0.0057) and T3 (5.65 ± 0.33 mm vs. 5.26 ± 0.31 mm, p < 0.0001). The proportions of the regurgitation time of IJVV were greater in Group I than those in Group C at T1 (14.95, 8.5%-18.9% vs. 9.6%, 0%-17.2%, p < 0.0001) and T3 (14.3, 10.6%-18.5% vs. 10.4%, 0%-16.5%, p = 0.0003). Group I had a delayed time to eye opening (10.7 ± 1.72 min vs. 13.3 ± 2.35 min, p < 0.0001) and emergence stay (32.2 ± 5.62 min vs. 39.9 ± 6.7 min, p < 0.0001). There were no significant differences in POD and QoR-15 between the two groups on day three.

Conclusion

IJV cannulation may not be the preferred approach in robot-assisted laparoscopic surgery as it was risk factor for IJVV regurgitation, ICP elevation, emergence delayed.

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

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

Relationship between Middle Cerebral Artery Pulsatility Index and Delayed Neurocognitive Recovery in Patients undergoing Robot-Assisted Laparoscopic Prostatectomy

A steep Trendelenburg (ST) position combined with pneumoperitoneum may cause alterations in cerebral blood flow with the possible occurrence of postoperative cognitive disorders. No studies have yet investigated if these alterations may be associated with the occurrence of postoperative cognitive disorders. The aim of the study was to evaluate the association between an increased middle cerebral artery pulsatility index (Pi), measured by transcranial doppler (TCD) 1 h after ST combined with pneumoperitoneum, and delayed neurocognitive recovery (dNCR) in 60 elderly patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Inclusion criteria were: ≥65 years; ASA class II-III; Mini-Mental Examination score > 23. Exclusion criteria were: neurological or psychiatric pathologies; any conditions that could interfere with test performance; severe hypertension or vascular diseases; alcohol or substance abuse; chronic pain; and an inability to understand Italian. dNCR was evaluated via neuropsychological test battery before and after surgery. Anesthesia protocol and monitoring were standardized. The middle cerebral artery Pi was measured by TCD, through the trans-temporal window and using a 2.5 MHz ultrasound probe at specific time points before and during surgery. In total, 20 patients experiencing dNCR showed a significantly higher Pi after 1 h from ST compared with patients without dNCR (1.10 (1.0-1.19 95% CI) vs. 0.87 (0.80-0.93 95% CI); p = 0.003). These results support a great vulnerability of the cerebral circulation to combined ST and pneumoperitoneum in patients who developed dNCR. TCD could be used as an intraoperative tool to prevent the occurrence of dNCR in patients undergoing RALP.

Relationships between common carotid artery blood flow and anesthesia, pneumoperitoneum, and head-down tilt position: a linear mixed-effect analysis

This study investigated the effects of pneumoperitoneum and the head-down tilt position on common carotid artery (CCA) blood flow in surgical patients.

METHODS

This prospective observational study included 20 patients who underwent gynecological surgery. CCA blood flow was measured using Doppler ultrasound at four-time points: awake in the supine position [T1], 3 min after anesthesia induction in the supine position [T2], 3 min after pneumoperitoneum in the supine position [T3], and 3 min after pneumoperitoneum in the head-down tilt position [T4]. Hemodynamic and respiratory parameters were also recorded at each time point. Linear mixed-effect analyses were performed to compare CCA blood flow across the time points and assess its relationship with hemodynamic parameters.

RESULTS

Compared with T1, CCA blood flow decreased significantly at T2 (345.4 [288.0-392.9] vs. 293.1 [253.0-342.6], P = 0.048). CCA blood flow were also significantly lower at T3 and T4 compared with T1 (345.4 [288.0-392.9] vs. 283.6 [258.8-307.6] and 287.1 [242.1-321.4], P = 0.005 and 0.016, respectively). CCA blood flow at T3 and T4 did not significantly differ from that at T2. Changes in CCA blood flow were significantly associated with changes in cardiac index and stroke volume index (P = 0.011 and 0.024, respectively).

CONCLUSION

CCA blood flow was significantly decreased by anesthesia induction. Inducing pneumoperitoneum, with or without the head-down tilt position, did not further decrease CCA blood flow if the cardiac index remained unchanged. The cardiac index and stroke volume index were significantly associated with CCA blood flow.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov (NCT04233177, January 18, 2020).

Influence of pneumoperitoneum and head-down maneuver on the cerebral microvasculature in rabbits

BACKGROUND

With recent advances in robot-assisted techniques, an increasing number of surgeries are being performed with pneumoperitoneum and head-down maneuver (HDM) that may affect the cerebral microcirculation. For the first time, this study investigated the direct influence of pneumoperitoneum and HDM on the cerebral microvasculature in rabbits.

METHODS

Adult male rabbits were randomly allocated to the following groups (n = 7 each): control, pneumoperitoneum alone (P), and pneumoperitoneum with HDM (P + HDM) for 120 min. A closed cranial window was installed above the parietal bone to visualize the pial microvasculature. Pial arteriolar diameter and hemodynamic and blood gas parameters were measured during the 140-min observation period. Brain edema was assessed by evaluation of the brain water content at the end of the experiment.

RESULTS

Rabbits in the P and P + HDM groups exhibited a similar degree of immediate pial arteriolar dilation following the initiation of both P and P + HDM (P: 1.11 ± 0.03, p = 0.0044 and P + HDM: 1.07 ± 0.02, p = 0.0004, relative changes from the baseline value by defining the baseline as one). In the P + HDM group, pial arteriole diameter returned to the baseline level following the discontinuation of pneumoperitoneum and HDM (1.05 ± 0.03, p = 0.0906, vs. baseline). In contrast, the pial arterioles remained dilated as compared to the baseline level in the P group after discontinuation of pneumoperitoneum. There were no changes in pial arteriole diameter in the animals in the control group. Heart rate, blood gas parameters, and brain water content were not significantly different between the groups.

CONCLUSION

The pial arterioles dilated immediately after pneumoperitoneum with or without HDM. The pial arterioles remained dilated 20 min after discontinuation of pneumoperitoneum alone but constricted upon discontinuation of pneumoperitoneum plus HDM. Pneumoperitoneum and HDM for 2 h did not cause brain edema.

Optic Nerve Changes Detected with Ocular Ultrasonography during Different Surgical Procedures: A Narrative Review

Ultrasonographic appraisal of the optic nerve sheath diameter has become popular in recent years as a useful diagnostic tool to detect intracranial pressure variations. Intracranial hypertension is a life-threatening disease with possible poor clinical outcomes and can be caused by a variety of neurological and non-neurological conditions. Considering the latter, increases in intracranial pressure have also been described during several surgical procedures. Ocular ultrasonography might be utilized to identify intracranial pressure increases by evaluating optic nerve sheath diameter variations. The aim of this review is to provide a wide overview on the use of the optic nerve ultrasound evaluation to detect intracranial pressure changes during surgical procedures, also discussing the pitfalls of the B-scan technique, the most widely used for such a purpose. PubMed medical database, Web of Science and Scopus were used to carry out this review. The present review showed that ocular ultrasonography could be considered a valuable diagnostic tool in the surgical setting to indirectly assess intracranial pressure. However, the use of the B-scan ultrasound should always be coupled with the standardized A-scan technique for a more accurate, precise and trustworthy ultrasound assessment.

Effect of dexmedetomidine on intracranial pressure in patients undergoing gynecological laparoscopic surgery in Trendelenburg position through ultrasonographic measurement of optic nerve sheath diameter

OBJECTIVE

To evaluate the effect of dexmedetomidine on intracranial pressure (ICP) in patients undergoing gynecological laparoscopic surgery in Trendelenburg position through ultrasonographic measurement of optic nerve sheath diameter (ONSD).

METHODS

Ninety patients underwent total laparoscopic hysterectomy were selected as research subjects in this prospective study. These patients were divided into a dexmedetomidine group (n=45) and a control group (n=45) using a random number table. The dexmedetomidine group was pumped with 0.5 μg/kg dexmedetomidine (20041731, Yangtze River Pharmaceutical Group, China) 10 min before the anesthesia induction, followed by a continuous pump of 0.5 μg/(kg·h) until the end of the surgery, and the control group was pumped with 0.5 μg/(kg·h) 0.9% sodium chloride solution. Patients in both groups were assisted with mechanical ventilator after endotracheal intubation by rapid induction. Intraoperatively, the pneumoperitoneum pressure was maintained at 14 mmHg, and the bispectral index was maintained at 40 to 60. We recorded ONSD measured with ultrasonography in both groups at 5 min before induction of anesthesia in supine position (T1), 5 min after CO₂ pneumoperitoneum in Trendelenburg position (T2), 30 min after CO₂ pneumoperitoneum in Trendelenburg position (T3), 60 min after CO₂ pneumoperitoneum in Trendelenburg position (T4) and 5 min after the close of pneumoperitoneum in supine position (T5). The cerebral oxygen metabolism indicators of the two groups at different time periods were compared, including jugular venous oxygen saturation (SjvO₂), arterial content and arterial-to-internal jugular difference (Da-jvO₂), cerebral oxygen extraction rate (CERO₂). Heart rate (HR) and mean arterial pressure (MAP) were also recorded at T1-T5. Besides, American Society of Anesthesiologists (ASA) grade, time of endotracheal extubation, recovery time for orientation and postoperative adverse reactions were recorded in each group.

RESULTS

There were significant differences in ONSD at T2 ((4.77±0.14) mm vs. (4.98±0.13) mm), T3 ((5.19±0.15) mm vs. (5.53±0.14) mm), T4 ((5.10±0.11) mm vs. (5.27±0.13) mm) and T5 ((4.71±0.12) mm vs. (4.4±0.16) mm) between the two groups (all P<0.05), and obvious differences were also found within groups when comparing the ONSD at T2-T5 to that at T1 (P<0.05). There were also significant differences in SjvO₂, Da-jvO₂ and CERO₂ between the control group and the dexmedetomidine group at T2-T5 (all P<0.05), and obvious differences were found within groups when comparing the indices at T2-T5 to those at T1 (P<0.05). The incidences of postoperative dizziness (20.00%), nausea and vomiting (17.78%), and headache (13.33%) in the dexmedetomidine group and were significantly lower than those in the control group (55.56%, 48.89% and 42.22%, respectively; all P<0.05). At T2-T5, dexmedetomidine group had lower HR than control group (P<0.05), while no differences were found in MAP between the two groups (P>0.05). There were also no differences in ASA grade, time of endotracheal extubation, and recovery time for orientation between the two groups (both P>0.05).

CONCLUSION

Dexmedetomidine can effectively decrease the occurence of increased ICP in patients undergoing gynecological laparoscopic surgery in Trendelenburg position, improve brain oxygen metabolism, and reduce the incidences of postoperative dizziness, nausea and vomiting as well as headache (China Clinical Trials Registration Center, registration number: ChiCTR2100052046, https://www.chictr.org.cn).

Valveless Trocar Versus Standard Pneumoperitoneum Insufflation System in Minimally Invasive Surgery: Impact on Postoperative Pain. A Systematic Review and Meta-Analysis

Background: The benefits of a valid pneumoperitoneum in laparoscopic surgery are counterbalanced by the possible negative effects of increased abdominal pressure and carbon dioxide (CO₂) insufflation, which are crucial factors in causing postoperative pain. The purpose of this work is to evaluate the effectiveness of the valveless trocar (VT) insufflation system in decreasing postoperative pain and influencing operative time, compared to a standard insufflation system. Methods: A systematic research was performed using MEDLINE, EMBASE, Central Cochrane Library, and CINAHL Plus for studies published up to June 2020. Randomized controlled trials (RCTs) on adult population evaluating the effects of VT versus a standard insufflation system in laparoscopic surgery and reporting postoperative pain level and operative time were included in the analysis. Data and study quality indicators were extracted independently by 2 authors using a standardized form. Statistical analysis was based on a random effect model, using the inverse variance method. Results: We identified 3 RCTs for a total of 245 patients. The meta-analysis showed a statistically significant reduction in shoulder pain with the use of VT at 24 hours: mean difference (MD) -7.9% (95% confidence interval [95% CI]: -1.29 to 0.29; z = 3.08; P = .002) and a nonstatistically significant increase in operation time: MD 5.80 (95% CI: -8.93 to 20.54; P = .44). Conclusion: Our study suggests a better shoulder pain control at 24 hours postoperation using new-generation VT for laparoscopic surgery compared to standard insufflation system. Weak evidence of increased operating time with the VT was observed considering only two of the three RCTs. PROSPERO registration number: CRD42020191835.

Cerebral venous congestion exacerbates cerebral microhemorrhages in mice

Cerebral microhemorrhages (CMHs; microbleeds), which are small focal intracerebral hemorrhages, importantly contribute to the pathogenesis of cognitive decline and dementia in older adults. Although recently it has been increasingly recognized that the venous side of the cerebral circulation likely plays a fundamental role in the pathogenesis of a wide spectrum of cerebrovascular and brain disorders, its role in the pathogenesis of CMHs has never been studied. The present study was designed to experimentally test the hypothesis that venous congestion can exacerbate the genesis of CMHs. Increased cerebral venous pressure was induced by internal and external jugular vein ligation (JVL) in C57BL/6 mice in which systemic hypertension was induced by treatment with angiotensin II plus L-NAME. Histological analysis (diaminobenzidine staining) showed that mice with JVL developed multiple CMHs. CMHs in mice with JVL were often localized adjacent to veins and venules and their morphology was consistent with venous origin of the bleeds. In brains of mice with JVL, a higher total count of CMHs was observed compared to control mice. CMHs were distributed widely in the brain of mice with JVL, including the cortical gray matter, brain stem, the basal ganglia, subcortical white matter, cerebellum, and the hippocampi. In mice with JVL, there were more CMHs predominantly in cerebral cortex, brain stem, and cerebellum than in control mice. CMH burden, defined as total CMH volume, also significantly increased in mice with JVL. Thus, cerebral venous congestion can exacerbate CMHs. These observations have relevance to the pathogenesis of cognitive impairment associated with right heart failure as well as elevated cerebral venous pressure due to jugular venous reflux in older adults.

Effects of Increased Optic Nerve Sheath Diameter on Inadequate Emergence from Anesthesia in Patients Undergoing Robot-Assisted Laparoscopic Prostatectomy: A Prospective Observational Study

(1) Background: Robot-assisted laparoscopic prostatectomy (RALP) is preferred over open prostatectomy because it offers superior surgical outcomes and better postoperative recovery. The steep Trendelenburg position and pneumoperitoneum required in Robot-assisted laparoscopic prostatectomy, however, increase intracranial pressure (ICP). The present study aimed to evaluate the effects of elevated ICP on the quality of emergence from anesthesia. (2) Methods: Sixty-seven patients undergoing RALP were enrolled. We measured optic nerve sheath diameter at four timepoints during surgery. Primary outcome was inadequate emergence in the operating room (OR). Secondary outcomes were postoperative neurologic deficits of dizziness, headache, delirium, cognitive dysfunction, and postoperative nausea and vomiting (PONV). (3) Results: A total of 69 patients were screened for eligibility and 67 patients completed the study and were included in the final analysis. After establishing pneumoperitoneum with the Trendelenburg position, ONSD increased compared to baseline by 11.4%. Of the 67 patients, 36 patients showed an increase of 10% or more in optic nerve sheath diameter (ONSD). Patients with ΔONSD ≥ 10% experienced more inadequate emergence in the OR than those with ΔONSD < 10% (47.2% vs. 12.9%, p = 0.003). However, other variables related to the quality of emergence from anesthesia did not different significantly between groups. Similarly, neurologic deficits, and PONV during postoperative day 3 showed no significant differences. (4) Conclusions: ICP elevation detected by ultrasonographic ONSD measurement was associated with a transient, inadequate emergence from anesthesia.

Perioperative adverse events and functional outcomes following open and robot-assisted prostatectomy in patients over age 70

AIM

To evaluate the safety (perioperative adverse events) of robot-assisted radical prostatectomy (RARP) and functional outcomes (continence and erectile dysfunction) of open and robotic radical prostatectomy in elderly patients.

METHODS

The data of patients (≥70 years old) who underwent open retropubic radical prostatectomy (ORRP) and RARP within the period from November 2014 to February 2019 were evaluated retrospectively. The perioperative adverse events and the functional outcomes of both surgical approaches were evaluated.

RESULTS

A total of 149 men (59.3%) underwent ORRP, and 102 men (41.7%) underwent RARP. The mean age in the ORRP group was 73.6 ± 3.2 years, and that in the RARP group was 74.7 ± 4.1 years. The rate of grade 3 or higher (major) complications for the ORRP group was 4.7% (7 out of 149), and that for the RARP group was 4.9% (5 out of 102). The 24 months full continence and potency rates of the ORRP and RARP groups were 78.5% vs 79.4% and 21.8% vs 22.6%, respectively.

CONCLUSION

The perioperative adverse events are similar in elderly patients undergoing ORRP and in RARP. The continence rates are favourable and reasonable, although the potency rates are low in elderly men who underwent prostatectomy. The results of the present study may be useful for surgeons in their decision making and counselling of elderly patients.

Beneficial Effects of Intravenous Magnesium Administration During Robotic Radical Prostatectomy: A Randomized Controlled Trial

INTRODUCTION

Robotic radical prostatectomy requires prolonged pneumoperitoneum and a steep Trendelenburg position. Magnesium can attenuate the stress response and hemodynamic perturbations. This study aimed to evaluate the effects of intravenous magnesium administration on hemodynamics and the stress response in patients undergoing robotic radical prostatectomy.

METHODS

In this prospective, double-blind, randomized controlled study, 52 patients undergoing robotic radical prostatectomy were randomized into two groups: 26 in the magnesium group and 26 in the control group. The patients in the magnesium group received magnesium sulfate 50 mg/kg intravenously, followed by infusion at a rate of 10 mg/kg/h during surgery. The patients in the control group received an equal volume of 0.9% saline. The primary outcomes were the changes in heart rate and mean arterial pressure (MAP) during surgery. The serum stress hormones (adrenocorticotropic hormone, cortisol, epinephrine, and norepinephrine) were also measured.

RESULTS

MAP showed a significant intergroup difference over time (P_group*time = 0.017); it increased significantly at 5 min after Trendelenburg position in the control group and decreased significantly at 30 min after Trendelenburg position in the magnesium group. The intergroup difference in the change in cortisol concentrations was significant over time (P_group*time = 0.006). The cortisol concentration decreased significantly from baseline to 24 h after surgery in the magnesium group but did not change significantly in the control group. The requirement for intraoperative remifentanil was 35% lower in the magnesium group (P = 0.011), and the severity of postoperative pain at 30 min and 6 h after surgery was also lower in the magnesium group (P = 0.024 and P = 0.015).

CONCLUSION

There is a possibility that intravenous magnesium administration during robotic radical prostatectomy reduces the increases in arterial pressure, cortisol concentrations, opioid requirements, and postoperative pain.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02833038.

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis

INTRODUCTION AND HYPOTHESIS

It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly.

METHODS

The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications.

RESULTS

A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications.

CONCLUSION

ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

The effect of prolonged steep head-down laparoscopy on the optical nerve sheath diameter

Both the steep head-down position and pneumoperitoneum increase the intracranial pressure (ICP), and their combination for a prolonged period during laparoscopic radical prostatectomy (LRP) might influence the central nervous system homeostasis. Changes in optic nerve sheath diameter (ONSD) may reflect those in ICP. This study aims to quantify the change in ONSD in response to peritoneal CO₂ insufflation and steep Trendelenburg position during LRP. ONSD was measured by ultrasound in 20 patients undergoing LRP and ten awake healthy volunteers. In patients, ONSD was assessed at baseline immediately after induction of general anesthesia in supine position, 10 and 60 min from baseline in a 25° head-down position during pneumoperitoneum, and after deflation of pneumoperitoneum with the patient supine at 0° angle. ONSD in controls was assessed at baseline with the patient lying supine, after 10 and 60 min of 25° head-down position, and 10 min after repositioning at 0° angle. ONSD increased significantly in both patients and controls (p < 0.0001) without between-group differences. The mean increase was 10.3% (95% CI 7.7-12.9%) in patients versus 7.5% (95% CI 2.5-12.6%) in controls (p = 0.28), and didn't affect the time to recovery from anesthesia. In the studied patients, with a limited increase of end-tidal CO₂ and airway pressure, and low volume fluid infusion, the maximal ONSD was always below the cut-off value suspect for increased ICP. ONSD reflects the changes in hydrostatic pressure in response to steep Trendelenburg position, and its increase might be minimized by careful handling of general anesthesia.