The effect of pneumoperitoneum in the steep Trendelenburg position on cerebral oxygenation

Evaluation of the effect of fluid management on intracranial pressure in patients undergoing laparoscopic gynaecological surgery based on the ratio of the optic nerve sheath diameter to the eyeball transverse diameter as measured by ultrasound: a randomised controlled trial

BACKGROUND

During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound.

METHODS

Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay).

RESULTS

There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes.

CONCLUSION

In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF.

TRIAL REGISTRATION

ChiCTR2300079284. Registered on December 29, 2023.

The intraoperative management of robotic-assisted laparoscopic prostatectomy

PURPOSE OF REVIEW

Robotic-assisted laparoscopic radical prostatectomy has become the second most commonly performed robotic surgical procedure worldwide, therefore, anesthesiologists should be aware of the intraoperative pathophysiological consequences. The aim of this narrative review is to report the most recent updates regarding the intraoperative management of anesthesia, ventilation, hemodynamics and central nervous system, during robotic-assisted laparoscopic radical prostatectomy.

RECENT FINDINGS

Surgical innovations and the advent of new technologies make it imperative to optimize the anesthesia management to provide the most holistic approach possible. In addition, an ageing population with an increasing burden of comorbidities requires multifocal attention to reduce the surgical stress.

SUMMARY

Total intravenous anesthesia (TIVA) and balanced general anesthesia are similar in terms of postoperative complications and hospital stay. Reversal of rocuronium is associated with shorter hospital stay and postanesthesia recovery time. Adequate PEEP levels improve oxygenation and driving pressure, and the use of a single recruitment maneuver after the intubation reduces postoperative pulmonary complications. Restrictive intravenous fluid administration minimizes bladder-urethra anastomosis complications and facial edema. TIVA maintains a better autoregulation compared with balanced general anesthesia. Anesthesiologists should be able to optimize the intraoperative management to improve outcomes.

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.

Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure and cerebral blood flow assessed using transcranial doppler: A prospective observational study

Background and Aims

Laparoscopic lower abdominal surgeries involve carbon dioxide (CO2) insufflation and Trendelenburg position. The raised intra-abdominal pressure can increase intracranial pressure (ICP) and alter cerebral blood flow. This study was conducted to determine the effect of pneumoperitoneum and Trendelenburg position on ICP and cerebral perfusion pressure (CPP) measured using transcranial Doppler (TCD).

Material and Methods

A prospective observational study was conducted in 43 patients of either sex, aged between 18 and 60 years with American Society of Anesthesiologists physical status I and II, undergoing elective laparoscopic surgery in Trendelenburg position. After standard anesthesia induction, pneumoperitoneum was created to facilitate surgery, maintaining an intra-abdominal pressure of 10-15 mmHg and Trendelenburg position of 25°-30°. End-tidal carbon dioxide (EtCO2) was maintained between 30 and 35 mmHg. The ICP was assessed non-invasively using TCD-based diastolic flow velocities (FVd) and pulsatility index (PI) of middle cerebral artery. Data was represented as mean ± standard deviation and compared using paired t test. A P value of < 0.05 was considered significant.

Results

Mean ICPPI at baseline was 14.02 ± 0.89 mmHg which increased to 14.54 ± 1.21 mmHg at pneumoperitoneum and Trendelenburg position (P = 0.005). Mean ICPFVd at baseline was 6.25 ± 2.47 mmHg which increased to 8.64 ± 3.79 mmHg at pneumoperitoneum and Trendelenburg position (P < 0.001). There was no statistically significant change in the CPP or mean arterial pressure values intraoperatively.

Conclusions

Laparoscopic procedures with CO2 pneumoperitoneum in Trendelenburg position increase ICP as measured using TCD ultrasonography. The CPP was not significantly altered when EtCO2 was maintained in the range of 30-35 mmHg.

Lateral position does not cause an interhemicerebral difference of cerebral hemodynamic in healthy adult volunteers

Cerebral perfusion is maintained at a consistent value irrespective of changes in systemic blood pressure or disease-induced changes in general physical condition. This regulatory mechanism is effective despite postural changes, working even during changes in posture, such as those from sitting to standing or from the head-down to the head-up position. However, no study has addressed changes in perfusion separately in the left and right cerebral hemispheres, and there has been no specific investigation of the effect of the lateral decubitus position on perfusion in each hemisphere. Surgery, particularly respiratory surgery, is often performed with the patient in the lateral decubitus position, and since intraoperative anesthesia may also have an effect, it is important to ascertain the effect of the lateral decubitus position on perfusion in the left and right cerebral hemispheres in the absence of anesthesia. The effects of the lateral decubitus position on heart rate, blood pressure, and hemodynamic in the left and right cerebral hemispheres assessed by regional saturation of oxygen measured by near-infrared spectroscopy were investigated in healthy adult volunteers. Although the lateral decubitus position causes systemic circulatory changes, it may not cause any difference in hemodynamic between the left and right cerebral hemispheres.

Changes in cerebral oxygen saturation with the Trendelenburg position and increased intraabdominal pressure in laparocopic rectal surgery

Objectives

Position changes and increased intra-abdominal pressure in laparoscopic interventions lead to some physiopathological changes. There is no definite information in the literature regarding cerebral oxygen saturation in patients undergoing colorectal surgery. Our aim was to investigate whether there is oxygen saturation change in the brain tissue in pneumoperitoneum and the Trendelenburg position during laparoscopic rectal surgery.

Material and Methods

Cerebral oxygen saturation was measured in 35 patients who underwent laparoscopic rectal surgery in the Trendelenburg position. Measurements were made under general anesthesia in the pneumoperitoneum and the Trendelenburg position.

Results

The values that are statistically affected by the position are systolic blood pressure, mean arterial blood pressure and cerebral oxygen saturation. The Trendelenburg position does not disturb the cerebral oxygen saturation and it causes an increase in saturation. After pneumoperitoneum occurred, changes in systolic blood pressure, mean arterial blood pressure and brain oxygen saturation were detected. Cerebral oxygen saturation increases with the formation of pneumoperitoneum.

Conclusion

The Trendelenburg position and increased intraabdominal pressure during laparoscopic rectal surgery do not impair brain oxygen saturation.

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.

Extremely low bispectral index value during robotic-assisted laparoscopic prostatectomy: A case report

The steep Trendelenburg position and pneumoperitoneum during surgery may affect intracranial pressure and cerebral oxygenation, which in turn may affect the values of the bispectral index (BIS). Prolonged maintenance of the Trendelenburg position and pneumoperitoneum may impair cerebrovascular autoregulation. We present a case of a patient with an extremely low BIS value during robotic-assisted laparoscopic prostatectomy (RALP). We managed the patient under general anesthesia and he showed a prominent decrease in BIS values 6 h after the start of surgery. Suppression ratio (SR) of electroencephalography (EEG) is also decreased, suggesting that the brain activity decreased. The BIS value increased quickly after the Trendelenburg position was released and the anesthesia was terminated. The patient recovered without any neurological deficits and was discharged. Steep Trendelenburg position and pneumoperitoneum can cause EEG abnormalities.

The effect of different levels of pneumoperitoneum pressures on regional cerebral oxygenation during robotic assisted laparoscopic prostatectomy

Background/aim

This study aimed to evaluate the effect of low- and high-pressure pneumoperitoneum pressures applied during robotic-assisted laparoscopic prostatectomy (RALP) using near-infrared spectroscopy (NIRS) on regional cerebral oxygenation saturation (rSO₂).

Materials and methods

The prospective, comparative, and observational study included patients aged 18–80 years, with the American Society of Anesthesiologists (ASA) physical status I-II, who would undergo elective RALP. The patients were divided into two groups (12 mmHg of pneumoperitoneum pressure group, n=22 and 15 mmHg of pneumoperitoneum pressure group, n=23). Patients’ demographic data, durations of anesthesia, surgery, pneumoperitoneum, and Trendelenburg position, intraoperative estimated blood loss, fluid therapy, urine output, hemodynamic and respiratory data, and rSO₂ values were recorded at regular intervals.

Results

The rSO₂ values increased significantly during the pneumoperitoneum combined with steep Trendelenburg position (from t3 to t6 ) and at the end of the surgery ( t7 ) in both groups, compared to the values 5 min after the onset of pneumoperitoneum in the supine position ( t2 ) (P < 0.05), but no statistical significance was observed between the two groups. No cerebral desaturation was observed in any of our patients. Hemodynamic and respiratory parameters were preserved in both groups. The blood lactate levels were significantly higher in patients operated at high-pressure pneumoperitoneum, compared to those with low-pressure pneumoperitoneum (P < 0.05).

Conclusion

We believe that low-pressure pneumoperitoneum, especially in robotic surgeries, such as robotic-assisted laparoscopic prostatectomy (RALP), can be applied safely.

Forehead Regional Oxygen Saturation (rSO2)-Related Ear-Level Arterial Pressure and Lower Thigh rSO2 in the Steep Trendelenburg Position with CO2 Pneumoperitoneum and the Beach Chair Position

Introduction

Regional oxygen saturation (rSO2) reflects tissue perfusion. This observational study aimed to examine the change in the forehead and lower thigh rSO2 associated with intraoperative posture, anesthesia regimen, or mean arterial pressure (mAP) at heart and external auditory meatus (ear) levels.

Methods

Patients undergoing robot-assisted laparoscopic radical prostatectomy in the Trendelenburg position at 30° with pneumoperitoneum (TPP) or arthroscopic shoulder surgery in the beach chair position at 70° (BCP) under desflurane-remifentanil (D/R) or propofol-remifentanil (P/R) anesthesia were examined. Bilateral forehead and lower thigh rSO2 values and mean radial artery pressure were measured simultaneously at heart and ear levels.

Results

In TPP, there were no differences under anesthesia regimens in the forehead or lower thigh rSO2change, although one patient with an absolute lower thigh rSO2 of ≤50% in the lithotomy position complained of transient limb pain. No correlation was observed between rSO2 and mAP. In BCP, forehead rSO2 decreased and lower thigh rSO2 increased under either of the anesthesia regimens. The coefficient of correlation between forehead rSO2 andheart-level and ear-level mAP was 0.341 and 0.236, respectively.

Conclusions

There were no differences under anesthesia regimens in the changes of forehead rSO2 and lower thigh rSO2. In TPP, significant changes in forehead rSO2 and lower thigh rSO2 were not observed. Monitoring lower thigh rSO2 might be useful for preventing lower extremity pain. In BCP, forehead rSO2 decreased and lower thigh rSO2 increased from the supine position to the BCP. To prevent brain damage, anesthesiologists should pay attention to heart- and ear-level mAP.

Laparoscopic gynaecological surgery in the context of maintaining normal intracranial pressure

A nulliparous patient in her early 20s was referred to a fertility specialist for fertility preservation, before commencing chemo-radiation therapy for a recently diagnosed malignant brain tumour. Two weeks prior, she had presented with seizures and undergone emergency craniotomy and tumour resection. Taking into consideration of the tight time frame and her comorbidities, several measures were undertaken to minimise the potential increase in intracranial pressure that may lead to cerebral oedema during laparoscopy. Preoperatively, the anaesthetist administered 8 mg dexamethasone as prophylaxis. Intraoperatively, the degree of head-down tilt was minimised to 10, which was just adequate to displace bowel cranially for visualisation of pelvic structures. Finally, a shorter operative time was achieved by ensuring the most senior surgeon performed the operation, and the procedure itself was altered from the standard approach of ovarian harvesting to unilateral oophorectomy. The patient made a quick recovery and was discharged home day 1 postoperatively.

Ventilatory response to hypercapnia is increased after 4 h of head down bed rest

Head-down bed rest (HDBR) has previously been shown to alter cerebrovascular and autonomic control. Previous work found that sustained HDBR (≥ 20 days) attenuates the hypercapnic ventilatory response (HCVR); however, little is known about shorter-term effects of HDBR nor the influence of HDBR on the hypoxic ventilatory response (HVR). We investigated the effect of 4-h HDBR on HCVR and HVR and hypothesized attenuated ventilatory responses due to greater carotid and brain blood flow. Cardiorespiratory responses of young men (n = 11) and women (n = 3) to 5% CO₂ or 10% O₂ before and after 4-h HDBR were examined. HDBR resulted in lower HR, lower cardiac output index, lower common carotid artery flow, higher SpO₂, and higher pulse wave velocity. After HDBR, tidal volume and ventilation responses to 5% CO₂ were enhanced (all P < 0.05), yet no other changes in cardiorespiratory variables were evident. There was no influence of HDBR on the cardiorespiratory responses to hypoxia (all P > 0.05). Short-duration HDBR does not alter the HVR, yet enhances the HCVR, which we hypothesize is a consequence of cephalic CO₂ accumulation from cerebral congestion.

Cerebral oxygenation in 45-degree trendelenburg position for robot-assisted radical prostatectomy: a single-center, open, controlled pilot study

BACKGROUND

Within the last decade, robotically-assisted laparoscopic prostatectomy (RALP) has become the standard for treating localized prostate cancer, causing a revival of the 45° Trendelenburg position. In this pilot study we investigated effects of Trendelenburg position on hemodynamics and cerebral oxygenation in patients undergoing RALP.

METHODS

We enrolled 58 patients undergoing RALP and 22 patients undergoing robot-assisted partial nephrectomy (RAPN) (control group) in our study. Demographic patient data and intraoperative parameters including cerebral oxygenation and cerebral hemodynamics were recorded for all patients. Cerebral function was also assessed pre- and postoperatively via the Mini Mental Status (MMS) exam. Changes in parameters during surgery were modelled by a mixed effects model; changes in the MMS result were evaluated using the Wilcoxon signed rank test.

RESULTS

Preoperative assessment of patient characteristics, standard blood values and vital parameters revealed no difference between the two groups.

CONCLUSIONS

Applying a 45° Trendelenburg position causes no difference in postoperative brain function, and does not alter cerebral oxygenation during a surgical procedure lasting up to 5 h. Further studies in larger patient cohorts will have to confirm these findings.

TRIAL REGISTRATION

German Clinical Trial Registry; DRKS00005094; Registered 12th December 2013-Retrospectively registered; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005094 .

Reverse Trendelenburg position applied prior to pneumoperitoneum prevents excessive increase in optic nerve sheath diameter in laparoscopic cholecystectomy: randomized controlled trial

The aim of this randomized controlled trial was to determine whether applying the reverse Trendelenburg position before pneumoperitoneum has a preventive effect on increased intracranial pressure using optic nerve sheath diameter (ONSD) measurement as a noninvasive parameter. Seventy-nine patients were allocated to two groups according to whether pneumoperitoneum was applied in the supine position (group S, n = 40) or in the reverse Trendelenburg position (group RT, n = 39). The ONSD was measured at the following time points: T0: before anesthesia; T1: after endotracheal intubation; T2: after pneumoperitoneum in group S and after positioning in group RT; T3: after positioning in group S and after pneumoperitoneum in group RT; T4: 30 min after endotracheal intubation, and T5: after desufflation. The end-tidal carbon dioxide (EtCO₂), regional cerebral oxygen saturation (rSO₂), peripheral oxygen saturation (SpO₂), mean arterial pressure (MAP), heart rate (HR), peak inspiratory pressure (Ppeak), and dynamic compliance (Cdyn) were recorded. Background and perioperative characteristics were similar in both groups. In group S, the ONSD was higher at T2, T3, T4, and T5 than that in group RT (p < 0.001, p = 0.002, p = 0.001, and p = 0.012, respectively). In the same group, the number of patients with an ONSD above 5.8 mm was higher at T2, T3, and T4 (p < 0.001, p = 0.042, p = 0.036, respectively). The rSO2 and SpO2 were not different between the groups. The mean arterial pressure was lower in group RT at T2, and the HR was not different between the groups (p < 0.001). In group S, Ppeak was higher and Cdyn was lower at T2 (p < 0.001). The number of patients with nausea was higher in group S (p = 0.027). The present study demonstrates that applying the reverse Trendelenburg position before pneumoperitoneum prevented an increase in the ONSD in patients undergoing laparoscopic cholecystectomy.Trial registration The trial was registered prior to patient enrollment at https://register.clinicaltrials.gov (NCT04224532, Date of the registration: January 8, 2020).

Evaluation of the effect of the mouth gag use on optic nerve sheath diameter of pediatric patients undergoing tonsillectomy or Adenotonsillectomy: An observational study

BACKGROUND

A mouth gag is usually used during tonsillectomy and adenotonsillectomy surgeries, cleft palate repair, obstructive sleep apnea surgery, and intraoral tumor excision. The placement of the gag causes hemodynamic changes similar to laryngoscopy. The aim of this study was to evaluate the effect of mouth gag placement on the optic nerve sheath diameter (ONSD) of pediatric patients. The secondary aim was to assess the relationship between neck extension and changes in ONSD.

METHODS

The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291) on 12.04.2018. This prospective, observational study was performed in a tertiary university hospital operating room between 01.05.2018-01.07.2018. Thirty-five children aged < 18 years, with ASA I status, who were scheduled for tonsillectomy and adenotonsillectomy surgeries were prospectively included in the study. Measurements of ONSD were performed (T0) after induction of anesthesia, (T1) after endotracheal intubation, (T2) after mouth gag placement, and (T3) 20 min after mouth gag placement. After the mouth gag was placed and the head was positioned for surgery, the degree of neck extension was calculated.

RESULTS

All participants completed the study. There were significant differences in ONSD values at time points T1, T2, and T3 (p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.05,-0.02; respectively). The maximum increase in ONSD was after intubation (0.69 ± 0.06 mm) and immediately after mouth gag placement (0.67 ± 0.07 mm). ONSD values continued to increase 20 min after gag placement (0.36 ± 0.04). There was no relation between the degree of neck extension and ONSD values (β = 0.63, p = 0.715).

CONCLUSIONS

The use of a mouth gag causes significant increases in ONSD measurements of children. Therefore, attention to the duration of mouth gag placement should be considered during surgery.

TRIAL REGISTRATION

The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291 ) on 12.04.2018.

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.

Postoperative cognitive dysfunction after robot-assisted radical cystectomy (RARC) with cerebral oxygen monitoring an observational prospective cohort pilot study

Background

The incidence and risk factors of postoperative cognitive dysfunction (POCD) during robot-assisted radical cystectomy (RARC) in extreme Trendelenburg positioning and pneumoperitoneum are still controversial. The aim of this prospective observational study was to find the incidence rate as well as possible risk factors of POCD in RARC with cerebral oxygen monitoring.

Methods

Patients who underwent RARC and open abdominal surgery in horizontal positioning were included. Preoperative and postoperative arterial blood gas (ABG), S-100β, C-reactive protein (CRP), and cognitive dysfunction scales were tested. Also, we used Z score to analyze and comprehensively evaluate POCD. Measurements of heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), end-tidal CO₂ (etCO₂), and cerebral oxygen were immediately obtained after different time points during the surgery.

Results

Here, 24 and 23 patients were included in the RARC group and in the control group, respectively. The incidence of POCD didn’t have significant difference in RARC group (45.8%), in contrast to the control group (26.1%). The laboratory tests of s100β and CRP between two groups didn’t contain significant difference as well. As duration of Trendelenburg and pneumoperitoneum prolonged, the cerebral oxygen saturation in the RARC group increased, which didn’t cause excessive perfusion nevertheless (rSO₂<75%). We compared laboratory tests, age, education status, blood loss, and fluid input between POCD and non-POCD patients. A significant difference was found in the serum concentrations of CRP (72.59 ± 42.09 vs. 48.50 ± 26.53, P = 0.025) and age (69.20 ± 7.033 vs. 65.34 ± 5.228, P = 0.041).

Conclusion

RARC in extreme Trendelenburg positioning and pneumoperitoneum did not significantly increase the incidence of POCD and didn’t cause excessive perfusion. The inflammation marker CRP and age might be independent risk factors of POCD.

Trial registration

Clinicaltrials.gov with registration number NCT03372135. Registered 1 November 2017 (retrospectively registered).

Changes of Cerebral Blood Volume During Robot-Assisted Laparoscopic Radical Prostatectomy: Observational Prospective Study Using Near-Infrared Time-Resolved Spectroscopy

Purpose: Robot-assisted laparoscopic radical prostatectomy (RARP) requires a steep head-down tilt and pneumoperitoneum, which may cause an increase in cerebral blood volume (CBV). With a new near-infrared time-resolved spectroscopy device, the tNIRS-1, we can measure the absolute value of the cerebral hemoglobin concentration and hence calculate CBV and cerebral oxygen saturation (rSO₂). Using this device, we evaluated the time course of CBV during surgery and also evaluated the changes in rSO₂ simultaneously. Materials and Methods: We performed a prospective observational study of 21 patients scheduled for RARP. We evaluated CBV and rSO₂ by using the tNIRS-1 at 10 time points during surgery. Results: The CBV was 2.92 ± 0.38 mL ·100 g^-1 after the end of anesthetic preparation. It significantly increased to 3.05 ± 0.44 mL ·100 g^-1 after the head-down tilt and was around 3.1 mL ·100 g^-1 until 120 minutes after the head-down tilt. However, just before the return to the horizontal position, it decreased to 2.93 ± 0.46 mL ·100 g^-1 and then decreased more after the return to the horizontal position. Changes in rSO₂ over time were within only 3%, and no significant differences from the control value were observed. Conclusions: The increase in CBV was <10% despite the steep head-down tilt and pneumoperitoneum, and it was compensated for at around the end of surgery. Clinically significant changes in rSO₂ were not observed during the surgery.

Changes of cerebral regional oxygen saturation during pneumoperitoneum and Trendelenburg position under propofol anesthesia: a prospective observational study

BACKGROUND

We evaluated the change of cerebral regional tissue oxygen saturation (rSO₂) along with the pneumoperitoneum and the Trendelenburg position. We also assessed the relationship between the change of rSO₂ and the changes of mean arterial blood pressure (MAP), heart rate (HR), arterial carbon dioxide tension (PaCO₂), arterial oxygen tension (PaO₂), or arterial oxygen saturation (SaO₂).

METHODS

Forty-one adult patients who underwent a robotic assisted endoscopic prostatic surgery under propofol and remifentanil anesthesia were involved in this study. During the surgery, a pneumoperitoneum was established using carbon dioxide. Measurements of rSO₂, MAP, HR, PaCO₂, PaO₂, and SaO₂ were performed before the pneumoperitoneum (baseline), every 5 min after the onset of pneumoperitoneum, before the Trendelenburg position. After the onset of the Trendelenburg position, rSO₂, MAP, HR were recorded at 5, 10, 20, 30, 45, and 60 min, and PaCO₂, PaO₂, and SaO₂ were measured at 10, 30, and 60 min.

RESULTS

Before the pneumoperitoneum, left and right rSO₂ were 67.9 ± 6.3% and 68.5 ± 7.0%. Ten minutes after the onset of pneumoperitoneum, significant increase in the rSO₂ was observed (left: 69.6 ± 5.9%, right: 70.6 ± 7.4%). During the Trendelenburg position, the rSO₂ increased initially and peaked at 5 min (left: 72.2 ± 6.5%, right: 73.1 ± 7.6%), then decreased. Multiple regression analysis showed that change of rSO₂ correlated with MAP and PaCO₂.

CONCLUSIONS

Pneumoperitoneum and the Trendelenburg position in robotic-assisted endoscopic prostatic surgery did not worsen cerebral oxygenation. Arterial blood pressure is the critical factor in cerebral oxygenation.

TRIAL REGISTRATION

Japan Primary Registries Network (JPRN); UMIN-CTR ID; UMIN000026227 (retrospectively registered).

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

BACKGROUND

We evaluated the relationship between ultrasonographical acquired parameters and short-term postoperative cognitive function in patients undergoing robotic-assisted radical prostatectomy (RALP).

METHODS

Ninety elderly patients scheduled for RALP had their optic nerve sheath diameter (ONSD), the cross-sectional area (CSA) of the internal jugular vein (IJV) and the IJV valve (IJVV) competency assessed by ultrasound. The patients were analyzed in 2 groups based on whether displayed IJVV incompetency (IJVVI). The 3 parameters were measured before anesthesia (T0), immediately after induction of general anesthesia (T1), 5 minutes after establishing pneumoperitoneum (T2), 5 minutes after placing the patient in the Trendelenburg position (T3), and 5 minutes after the release of the pneumoperitoneum in the supine position (T4). Regional cerebral tissue oxygen saturation (rSO2) was also measured by near-infrared spectroscopy intraoperatively. The Mini-Mental State Examination (MMSE) and Confusion Assessment Method (CAM) were performed the day before surgery and on postoperative days 1, 3, and 7.

RESULTS

We found that 52% of patients had evidence of IJVVI after being placed in the Trendelenburg position after pneumoperitoneum was established (T4). Patient with IJVVI showed a significant increase of ONSD and CSA at T1, T2, T3, T4 but there was no associated decrease in rSO2. MMSE scores were reduced at postoperative day 1 and the 7 patients that developed postoperative delirium came from Group IJVVI.

CONCLUSIONS

Our observations suggest that elderly patients that show IJVVI after adequate positioning for RALP may develop elevated intracranial pressure as well as mildly compromised postoperative cognitive function in the short term.

Effects of Carbon Dioxide Insufflation and Trendelenburg Position on Brain Oxygenation During Laparoscopy in Children

PURPOSE

Laparoscopic appendectomy has become more popular compared with the open appendectomy in children, but there are limited data on the effects of pneumoperitoneum and Trendelenburg position on cerebral oxygenation. This study was designed to evaluate the changes in cerebral saturation using near-infrared spectroscope during laparoscopic surgery in children.

METHODS

The children underwent laparoscopic (LAP Group, n=22) or open appendectomy (OPEN Group, n=22). Right and left cerebral oxygenation (RScO2-LScO2), heart rate (HR), mean arterial pressure (MAP), end-tidal CO2pressure (PETCO2), and peripheral oxygen saturations (SpO2) were recorded between anesthesia induction (T0, baseline), after induction (T1), after intubation (T2), 5 minutes after intubation (T3), 5 minutes after pneumoperitoneum-15th minute at OPEN (T4), 5 minutes after Trendelenburg-20th minute at OPEN (T5), 30 minutes after pneumoperitoneum-45th minute at OPEN (T6), 5 minutes after supine position-skin suturing at OPEN (T7), 5 minutes postextubation (T8).

RESULTS

Groups were similar with respect to their demographic data. In LAP group, a significant increase in HR was recorded at T5. No significant difference was observed in the MAP, PETCO2, SpO2, RScO2, and LScO2 values between the groups. There was a significant increase in the perioperative T1 to T8 values compared with the T0 values in LScO2 of the LAP group.

CONCLUSIONS

Our results suggest that pneumoperitoneum and Trendelenburg position does not alter the hemodynamic values and can be safely performed in children without altering regional brain oxygenation levels.

Propofol attenuates the increase of sonographic optic nerve sheath diameter during robot-assisted laparoscopic prostatectomy: a randomized clinical trial

Background

Robot-assisted laparoscopic prostatectomy (RALP) requires pneumoperitoneum and the Trendelenburg position to optimize surgical exposure, which can increase intracranial pressure (ICP). Anesthetic agents also influence ICP. We compared the effects of propofol and sevoflurane on sonographic optic nerve sheath diameter (ONSD) as a surrogate for ICP in prostate cancer patients who underwent RALP.

Methods

Thirty-six patients were randomly allocated to groups receiving propofol (propofol group, n = 18) or sevoflurane (sevoflurane group, n = 18) anesthesia. The ONSD was measured 10 min after induction of anesthesia in the supine position (T1); 5 min (T2), 30 min (T3), and 60 min (T4) after establishing pneumoperitoneum and the Trendelenburg position; and at the end of surgery after desufflation in the supine position (T5). Respiratory and hemodynamic variables were also evaluated.

Results

The ONSD was significantly different between the propofol group and the sevoflurane group at T4 (5.27 ± 0.35 mm vs. 5.57 ± 0.28 mm, P = 0.007), but not at other time points. The ONSDs at T2, T3, T4, and T5 were significantly greater than at T1 in both groups (all P < 0.001). Arterial carbon dioxide partial pressure, arterial oxygen partial pressure, peak airway pressure, plateau airway pressure, systolic blood pressure, pulse pressure variation, body temperature and regional cerebral oxygen saturation, except heart rate, were not significantly different between the two groups.

Conclusions

The ONSD was significantly lower during propofol anesthesia than during sevoflurane anesthesia 60 min after pneumoperitoneum and the Trendelenburg position, suggesting that propofol anesthesia may help minimize ICP changes in robotic prostatectomy patients.

Trial registration

Clinicaltrials.gov identifier: NCT03271502. Registered August 31, 2017.

Comparisons of Pressure-controlled Ventilation with Volume Guarantee and Volume-controlled 1:1 Equal Ratio Ventilation on Oxygenation and Respiratory Mechanics during Robot-assisted Laparoscopic Radical Prostatectomy: a Randomized-controlled Trial

Background: During robot-assisted laparoscopic radical prostatectomy (RALP), steep Trendelenburg position and carbon dioxide pneumoperitoneum are inevitable for surgical exposure, both of which can impair cardiopulmonary function. This study was aimed to compare the effects of pressure-controlled ventilation with volume guarantee (PCV with VG) and 1:1 equal ratio ventilation (ERV) on oxygenation, respiratory mechanics and hemodynamics during RALP. Methods: Eighty patients scheduled for RALP were randomly allocated to either the PCV with VG or ERV group. After anesthesia induction, volume-controlled ventilation (VCV) was applied with an inspiratory to expiratory (I/E) ratio of 1:2. Immediately after pneumoperitoneum and Trendelenburg positioning, VCV with I/E ratio of 1:1 (ERV group) or PCV with VG using Autoflow mode (PCV with VG group) was initiated. At the end of Trendelenburg position, VCV with I/E ratio of 1:2 was resumed. Analysis of arterial blood gases, respiratory mechanics, and hemodynamics were compared between groups at four times: 10 min after anesthesia induction (T1), 30 and 60 min after pneumoperitoneum and Trendelenburg positioning (T2 and T3), and 10 min after desufflation and resuming the supine position (T4). Results: There were no significant differences in arterial blood gas analyses including arterial oxygen tension (PaO₂) between groups throughout the study period. Mean airway pressure (Pmean) were significantly higher in the ERV group than in the PCV with VG group T2 (p<0.001) and T3 (p=0.002). Peak airway pressure and hemodynamic data were comparable in both groups. Conclusion: PCV with VG was an acceptable alternative to ERV during RALP producing similar PaO₂ values. The lower Pmean with PCV with VG suggests that it may be preferable in patients with reduced cardiovascular function.

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine mode

Background/aim: This study was undertaken to evaluate the effects of positive end-expiratory pressure (PEEP) levels on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to determine the appropriate PEEP level during steep Trendelenburg position combined with pneumoperitoneum.Materials and methods: Ten pigs were included in this study. Pneumoperitoneum and Trendelenburg position were maintained and PEEP titration was initiated. Arterial pressure, heart rate, arterial blood gas, ICP, and CPP were recorded at the following time points: baseline (T0), 30 min after positioning and pneumoperitoneum (T1), PEEP 5 (T2), PEEP 10 (T3), PEEP 15 (T4), and PEEP 20 (T5).Results: MAP significantly increased at T1 compared to T0 and decreased at T4 and T5 compared to T1. ICP was 9.5 mmHg and CPP was 69.3 mmHg at T0. CO2 insufflation and steep Trendelenburg position did not cause any significant difference in ICP and CPP. ICP increased and CPP decreased significantly at T4 and T5 compared to both T0 and T1. PaO2 and PaO2/FiO2 decreased significantly at T1 and T2 compared to T0, while both increased significantly at T3, T4, and T5 compared to T1.Conclusion: PEEP of 10 cmH2O was effective for providing oxygenation while preserving hemodynamic stability, ICP, and CPP in this model.

Changes in cardiac function and hemodynamics during robot-assisted laparoscopic prostatectomy with steep head-down tilt: a prospective observational study

OBJECTIVE

Robot-assisted laparoscopic prostatectomy requires the patient to be placed in a steep head-down tilt. The aim of our study was to investigate changes in cardiac index and left ventricular end-diastolic volume in a steep had-down tilt. This is a prospective observational study. We investigated the influence of steep head-down tilt on cardiac function and hemodynamics without fluid restriction in 12 men of American Society of Anesthesiologists physical status I-II undergoing robot-assisted laparoscopic prostatectomy. We measured left ventricular ejection fraction, left ventricular end-diastolic volume and cardiac index by transesophageal echocardiography, cardiac index using a FloTrac^® sensor, heart rate and arterial blood pressure, before and 5 min after tilting the operating table.

RESULTS

The following variables changed significantly after tilting and establishment of the pneumoperitoneum: left ventricular ejection fraction (before 62.5%, after 55.5%; P = 0.040), systolic blood pressure (before 116 mmHg, after 128 mmHg; P = 0.001) and diastolic blood pressure (before 59 mmHg, after 70 mmHg; P = 0.002). There were no significant changes in cardiac index or left ventricular end-diastolic volume measured by transesophageal echocardiography, or cardiac index by FloTrac^® sensor. Left ventricular ejection fraction decreased, whereas cardiac index and left ventricular end-diastolic volume did not change, indicating that steep head-down tilt and pneumoperitoneum during robot-assisted laparoscopic prostatectomy did not greatly influence cardiac function. This study was registered as a clinical study with the Japanese Official Clinical Trial Registry (Trial Registration Number JMA-IIA00158 on 7th January, 2014).

Effects of Pneumoperitoneum and the Steep Trendelenburg Position on Heart Rate Variability and Cerebral Oxygenation during Robotic Sacrocolpopexy

STUDY OBJECTIVE

The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy.

DESIGN

Prospective study (Canadian Task Force classification III).

SETTING

Rambam Health Care Campus.

PATIENTS

Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse.

INTERVENTIONS

Robotic sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

A 5-minute computerized electrocardiogram, cerebral O₂ saturation (cSO₂), systemic O₂ saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO₂ tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO₂ at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms²/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms²/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation.

CONCLUSION

This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.

Less Invasive Endometrial Cancer Surgery with Extraperitoneal Pelvic and Para-aortic Lymphadenectomy via a Small Midline Abdominal Incision and the Retroperitoneal Approach

[Objective] To achieve less invasive lymphadenectomy in endometrial cancer patients, we performed extraperitoneal pelvic and para-aortic lymphadenectomy via a small midline abdominal incision with retroperitoneal approach. The feasibility and safety of this method were investigated.

[Methods] Inclusion criteria were 1) endometrioid adenocarcinoma diagnosed by preoperative biopsy, 2) myometrial invasion by magnetic resonance imaging, and 3) no peritoneal dissemination or distant metastasis by computed tomography. Systematic extraperitoneal dissection of pelvic and para-aortic lymph nodes was performed via an approximately 12-cm midline lower abdominal incision, after which hysterectomy and bilateral salpingo-oophorectomy were done (extraperitoneal group). The historical control group was patients who underwent standard transperitoneal lymphadenectomy followed by hysterectomy and bilateral salpingo-oophorectomy. The two groups were compared for demographic characteristics, perioperative factors, and complications.

[Results] A total of 62 patients were enrolled. Demographic and clinicopathological factors showed no differences between the extraperitoneal group (n = 34) and the historical control group (n = 28). The median number of pelvic (30 vs. 28) and para-aortic (14 vs. 17) nodes dissected was also similar. However, median intraoperative blood loss was significantly smaller in the extraperitoneal group than the control group (220 vs. 573 g). Median operating time (265 vs. 323.5 min), median laparotomy time (60 vs. 295 min), and median initial flatus time (8 vs. 32 hours) were all significantly shorter in the extraperitoneal group, while complications and severe postoperative pain were significantly less frequent.

[Conclusions] Our new technique was feasible, safe, and less invasive than standard laparotomy. It is an alternative to laparoscope-assisted or robotic procedures.

Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study

BACKGROUND AND OBJECTIVES

Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children.

METHODS

The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5).

RESULTS

There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value.

CONCLUSIONS

Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

Preoperative mannitol infusion improves perioperative cerebral oxygen saturation and enhances postoperative recovery after laparoscopic cholecystectomy

Objectives:

To test the effect of preoperative mannitol infusion on perioperative decreased cerebral oxygen saturation (rSO₂) during laparoscopic cholecystectomy.

Methods:

Forty patients scheduled for laparoscopic cholecystectomy were enrolled in this study conducted at Dammam Hospital of the University, Dammam, Kingdom of Saudi Arabia from December 2013 to June 2014. Patients received either 0.5 g/kg of 20% intravenous mannitol infusion over 10 minutes before induction of anesthesia (group M), or an equal volume of normal saline instead (group C). Primary outcome variable was rSO₂. Other variables included extubation time, clinical assessment of consciousness recovery using the Modified Observer’s Assessment of Alertness/Sedation Scale (OAA/S), and the mini-mental state examination (MMSE) for cognitive evaluation.

Results:

Anesthesia induction increased rSO₂ in both groups. Pneumoperitoneum decreased rSO₂ in group C, but not in group M. This drop in rSO₂ in the group C reached its maximum 30 minutes after extubation, and was significantly less than the preinduction value. Time to extubation in group M was significantly shorter compared to group C (p=0.007). The OAAS in group M at 10 min after extubation was significantly higher compared to group C. No differences were found between the 2 groups in cognitive function as measured by MMSE score.

Conclusion:

Preoperative mannitol infusion maintains perioperative rSO₂ during laparoscopic cholecystectomy and shortens extubation time with earlier resurgence of OAAS.

[Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study]

BACKGROUND AND OBJECTIVES

Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children.

METHODS

The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5).

RESULTS

There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value.

CONCLUSIONS

Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

Changes in cerebral oxygen saturation and early postoperative cognitive function after laparoscopic gastrectomy: a comparison with conventional open surgery

BACKGROUND

Laparoscopic gastrectomy requires a reverse-Trendelenburg position and prolonged pneumoperitoneum and it could cause significant changes in cerebral homeostasis and lead to cognitive dysfunction. We compared changes in regional cerebral oxygen saturation (rSO2), early postoperative cognitive function and hemodynamic variables in patients undergoing laparoscopic gastrectomy with those patients that underwent conventional open gastrectomy.

METHODS

Sixty patients were enrolled in this study and the patients were distributed to receive either laparoscopic gastrectomy (laparoscopy group, n = 30) or open conventional gastrectomy (open group, n = 30). rSO2, end-tidal carbon dioxide tension, hemodynamic variables and arterial blood gas analysis were monitored during the operation. The enrolled patients underwent the mini-mental state examination 1 day before and 5 days after surgery for evaluation of early postoperative cognitive function.

RESULTS

Compared to baseline value, rSO2 and end-tidal carbon dioxide tension increased significantly in the laparoscopy group after pneumoperitoneum, whereas no change was observed in the open group. No patient experienced cerebral oxygen desaturation or postoperative cognitive dysfunction. Changes in mean arterial pressure over time were significantly different between the groups (P < 0.001).

CONCLUSIONS

Both laparoscopic and open gastrectomy did not induce cerebral desaturation or early postoperative cognitive dysfunction in patients under desflurane anesthesia. However, rSO2 values during surgery favoured laparoscopic surgery, which was possibly related to increased cerebral blood flow due to increased carbon dioxide tension and the effect of a reverse Trendelenburg position.

Bilateral Blindness due to Ischemic Optic Nerve Neuropathy After Abdominal Surgery

Postoperative blindness is an unpredictable, devastating, and yet not-uncommon complication of anesthesia. We present the case of a patient who suffered bilateral loss of eyesight after surgery. The diagnostic evidence led us to believe that it was bilateral posterior ischemic optic neuropathy; however, the true mechanisms of damage remain a matter of speculation.

Prevalence and impact of incompetence of internal jugular valve on postoperative cognitive dysfunction in elderly patients undergoing robot-assisted laparoscopic radical prostatectomy

Internal jugular vein (IJV) is the main pathway of cerebral venous drainage and its valves prevent regurgitation of blood to the brain. IJV valve incompetence (IJVVI) is known to be associated with cerebral dysfunctions. It occurs more often in male over 50 years old, conditions elevating intra-abdominal or intra-thoracic pressure. In robot-assisted laparoscopic radical prostatectomy (RALRP), elderly male undergoes surgery in Trendelenburg position with pneumoperitoneum applied. Therefore, we assessed the IJVVI during RALRP and its influence on postoperative cognitive function. 57 patients undergoing RALRP were enrolled. Neurocognitive tests including Mini-Mental State Examination (MMSE), Auditory Verbal Learning Test, Digit Symbol Substitution Test, Color Word Stroop Test, digit span test, and grooved pegboard test were performed the day before and 2 days after surgery. During surgery, IJVVI was assessed with ultrasonography in supine position with and without pneumoperitoneum, and Trendelenburg position with pneumoperitoneum. 50 patients underwent sonographic assessment and 41 patients completed neurocognitive examination. A total of 27 patients presented IJVVI, 19 patients in supine position without pneumoperitoneum, 7 patients in supine position with pneumoperitoneum and 1 patient in Trendelenburg position with pneumoperitoneum. In neurocognitive tests, patients with IJVVI showed statistically significant decline of score in MMSE postoperatively (p<0.05). IJVVI occurred in 38% in supine position but the incidence was increased to 54% after Trendelenburg position and pneumoperitoneum. Patients with IJVVI did not show significant differences in cognitive function tests except MMSE. Clinical and neurological significance of physiologic changes associated RALRP should be studied further.

Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study

Objectives:

To compare the effects of CO₂ insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.

Materials and Methods:

Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO₂ insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Student's two–t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables.

Results:

The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO₂ pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it.

Conclusions:

This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO₂ reabsorption and risk of acidosis.

Retrospective evaluation of the effect of carotid artery stenosis on cerebral oxygen saturation during off-pump coronary artery bypasses grafting in adult patients

Background

It is unknown whether cerebral oxygenation in patients with carotid artery stenosis (CAS) undergoing off-pump coronary artery bypass grafting (CABG) differs from that in patients without CAS. Thus, the effect of the presence of CAS ≥ 50 % on cerebral oxygenation during off-pump CABG in adult patients was evaluated retrospectively.

Methods

Eleven patients with CAS ≥ 50 % and 14 patients without CAS ≥ 50 % were enrolled. Regional cerebral tissue oxygen saturation (rSO₂) was quantified using near-infrared spectroscopy. Mean arterial pressure, cardiac index, central venous pressure (CVP), and rSO₂ at specific points were collected, and significant changes in each parameter were detected using repeated analysis of variance. Mean rSO₂ and minimum rSO₂ during anastomosis were analyzed by one-way analysis of variance. Multiple logistic regression analysis was used to estimate the odds ratio (OR) with 95 % confidence interval (CI) for cerebral desaturation (a decrease in rSO₂ ≥ 10 % from preoperative value).

Results

Two patients with CAS ≥ 50 % who received complete carotid artery stenting preoperatively were excluded from the analyses. In both patients with and without CAS, a decrease in rSO₂ and cardiac index and an increase in CVP were observed during anastomosis. Mean (SD) maximum decrease in rSO₂ from preoperative value was 9.2 (12.7) % on the left side and 8.1 (11.7) % on the right side in patients with CAS ≥ 50 %, and 13.5 (11.3) % on the left side and 16.1 (9.8) % on the right side in patients without CAS ≥ 50 % (p = 0.316). Neurological complications were not identified in both patients with and without CAS ≥ 50 %. In multiple logistic regression analysis, CAS ≥ 50 % was not associated with an increased risk of cerebral desaturation (OR 0.160, 95 % CI 0.036–0.707, p = 0.016), and rSO₂ decreased with decreasing cardiac index < 2.0 l/min/m² (OR 3.287, 95 % CI 2.218–5.076, p < 0.001).

Conclusions

CAS ≥ 50 % was not an independent risk factor of cerebral desaturation during off-pump CABG. Our results suggest that maintaining cardiac output can prevent a decrease in cerebral oxygenation in both patients with and without CAS ≥ 50 %.

Cerebral tissue O2 saturation during prolonged robotic surgery in the steep Trendelenburg position: an observational case series in a diverse surgical population

Demands associated with the Trendelenburg position (TP) are well known yet there is little attention given to regional cerebral tissue O2 saturation (SctO2) in those undergoing robotic surgery in the TP with CO2 insufflation (C-INSF). This is the first study to report on SctO2 in a wide range of patients undergoing lengthy TP and robotic surgery. We measured SctO2 during robotic surgery in patients in the TP with C-INSF, as well as a control robotic thyroid surgery group who were supine with no C-INSF. We recorded relevant variables and periods of cerebral desaturation (CD). We studied 42 patients in 25°-45° of TP for ≥125 min. Management was at the providers' discretion. The INVOS(®) 5100C Cerebral Oximeter (Covidien, Boulder, CO) recorded SctO2. CD was defined as a >20 % decrease from baseline SctO2 or a value ≤55 % for ≥10 min. Patients were assessed for adverse outcome. The sample consisted of 13 males and 29 females aged 22-73, BMI 22-36 had general (N = 3), urological (N = 14) and gynecological (N = 25) surgery; two patients had CD lasting 150 and 190 min and two had episodic CD lasting 10-35 min. The four were female aged 22-60 in 38°-45° of TP. Eleven cases had multiple episodic CD for ≤15 min, 27 TP cases had no CD. Other observations included a consistent fall in SctO2 with phenylephrine; an increased SctO2 with ephedrine; and FiO2 and EtCO2 being generally strong, direct modifiers of SctO2. High MAP was inconsistently associated with high SctO2. BMI had no observed effect on SctO2. Pulse oximetry was ≥97 % in all cases. We observed no adverse cerebral events on follow-up. Additional clinical studies are warranted.

10 cm H2O PEEP application in laparoscopic surgery and cerebral oxygenation: a comparative study with INVOS and FORESIGHT

INTRODUCTION

In the present study, changes in hemodynamic parameters and cerebral oxygen saturation (rSO2) associated with 10 cm H2O PEEP application were investigated, which is assumed beneficial for the respiratory functions and oxygenation during laparoscopic cholecystectomy (LC) applied at 30° head-up left side position. Data gathered via two devices, namely INVOS and FORESIGHT, were compared.

METHODS

After both the ethics committee approval from the hospital and patients' written consents were obtained, patients undergoing elective laparoscopic surgery (only ASA I-II) were randomly divided into two groups (Clinical trials protocol NCT02071550). Sensors of INVOS and FORESIGHT devices were placed on the right side at the forehead region. In total, 11 evaluation periods were formed, namely pre-induction (1st period), post-induction (2nd period), abdominal insufflation outset (3rd period), post-insufflation at 5-min intervals (4th, 5th, 6th, 7th, and 8th period), at the end of insufflation (9th period), at the end of operation (10th period), and at the end of anesthesia (11th period). While one of the groups did not receive PEEP (ZEEP group), the other group received 10 cm H2O along with abdominal insufflation (PEEP group). Demographic data, hemodynamic values, and rSO2 values were recorded for both groups at all 11 periods.

RESULTS

A total of 44 patients in two groups, each group containing 22 individuals, were included in the study. Systolic, diastolic, and mean arterial pressures, etCO2 and SO2 values, and demographic data were found to be similar in both groups. Heart rate was observed to be higher in the PEEP group starting with the PEEP administration. INVOS rSO2 values were found similar in both groups. However, FORESIGHT rSO2 values were found to be higher in the PEEP group compared to the ZEEP group. No patient had cerebral desaturation in both groups throughout the study.

DISCUSSION

Application of PEEP with 10 cm H2O during abdominal insufflation could increase the rSO2 value and heart rate in patients undergoing laparoscopic cholecystectomy. However, all changes observed were within normal limits. FORESIGHT device yielded more compatible results with hemodynamic data compared to INVOS.

Sonographic optic nerve sheath diameter as a surrogate measure for intracranial pressure in anesthetized patients in the Trendelenburg position

BACKGROUND

It remains to be elucidated whether the Trendelenburg position increases intracranial pressure (ICP). ICP can be evaluated by measuring the sonographic optic nerve sheath diameter (ONSD). We investigated the effect of the isolated Trendelenburg position on ONSD in patients undergoing robot-assisted laparoscopic radical prostatectomy. Additionally, we evaluated the effect of the Trendelenburg position combined with pneumoperitoneum on ONSD.

METHODS

Twenty-one patients scheduled for robot-assisted laparoscopic radical prostatectomy were enrolled. Sonographic ONSDs and hemodynamic parameters were measured at specific time points: in the supine position after induction of anesthesia, 3 min after the steep Trendelenburg position (35° incline), 3 min after the steep Trendelenburg position combined with pneumoperitoneum, and in the supine position after desufflation of the pneumoperitoneum.

RESULTS

The ONSD 3 min after the steep Trendelenburg position was significantly higher than that of the supine position after induction of anesthesia (5.1 ± 0.3 mm vs. 4.5 ± 0.4 mm). In addition, the ONSD 3 min after the steep Trendelenburg position combined with pneumoperitoneum was higher than that of the supine position after induction of anesthesia (4.9 ± 0.4 mm vs. 4.5 ± 0.4 mm). The ONSD in the supine position after desufflation of the pneumoperitoneum was similar to that in the supine position after induction of anesthesia.

CONCLUSIONS

Use of the isolated steep Trendelenburg position, for even a short duration, increased the sonographic ONSD, providing a better understanding of the effect of only a transient steep Trendelenburg position on ONSD as a surrogate measure for ICP.

Bilateral otorrhagia: a rare complication of laparoscopic abdominopelvic surgery

An 80-year-old woman without any previous otological symptoms underwent laparoscopic abdominoperineal resection for T3N0M0 low rectal carcinoma 4-5 cm from the anal verge. The total operative time was 6 h, of which she spent long hours in the Trendelenburg (35°) position due to difficult pelvic dissection. Midway through the procedure, she developed spontaneous non-traumatic bilateral otorrhagia. This case highlights the potential risk of increased intracranial pressure during prolonged periods of being in a steep Trendelenburg position caused either by the position itself or in combination with carbon dioxide pneumoperitoneum. We also consider the effect of a sudden change from this position to supine as a potential risk.

Cerebral oxygenation measured by near-infrared spectroscopy and jugular vein oxygen saturation during robotic-assisted laparoscopic radical prostatectomy under total intravenous anaesthesia

BACKGROUND

The effects of total intravenous anaesthesia (TIVA) on cerebral oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) have not been investigated. We examined the changes in jugular venous oxygen saturation (SjvO₂ ) and regional cerebral tissue oxygen saturation (rSO₂ ) during RALP under TIVA. Whether rSO₂ could reflect SjvO₂ was also examined.

METHODS

Forty patients (ASA 1-2) undergoing RALP were enrolled. Measurements were obtained at eight time points during the operation.

RESULTS

SjvO₂ did not decrease at any measurement point, whereas rSO₂ fell significantly 120 min after pneumoperitoneum in a steep Trendelenburg position (p <0.01). There was a weak correlation between SjvO₂ and rSO₂ (Pearson correlation coefficient =0.34; p <0.01). Bland-Altman analysis showed a wide interval for the limit of agreement (47%) between the two measurements.

CONCLUSIONS

These findings suggested that TIVA could be safely used for RALP. It was also demonstrated that rSO₂ did not accurately reflect SjvO₂ during RALP. Copyright © 2014 John Wiley & Sons, Ltd.

Robotic assisted prostatic surgery in the Trendelenburg position does not impair cerebral oxygenation measured using two different monitors: A clinical observational study

BACKGROUND

Robotic assisted prostatic surgery is frequently used because of its reduced side-effects compared with conventional surgery. During surgery, an extreme Trendelenburg position and CO2 pneumoperitoneum are necessary, which may lead to cerebral oedema, can potentially reduce brain perfusion and therefore could impair cerebral oxygenation. Cerebral oxygen saturation can be measured non-invasively using near-infrared spectroscopy (NIRS).

OBJECTIVE

The hypothesis of the present study was that steep Trendelenburg positioning during robotic assisted prostatic surgery impairs cerebral oxygen saturation measured using two different NIRS monitors.

DESIGN

Clinical observational study.

SETTING

Primary care university hospital, study period from March 2012 to February 2013.

PATIENTS

A total of 29 patients scheduled for robotic assisted prostatic surgery in a steep Trendelenburg position.

INTERVENTIONS

Cerebral oxygen saturation was measured throughout anaesthesia using the INVOS sensor (a trend monitor using two infrared wavelengths) for one hemisphere and the FORE-SIGHT sensor (a monitor using four wavelengths of laser light to calculate absolute oxygen saturation) for the other hemisphere in an alternate randomisation.

MAIN OUTCOME MEASURE

Changes in cerebral oxygenation of more than 5% during surgery in the Trendelenburg position.

RESULTS

The median duration of Trendelenburg positioning was 190 (interquartile range 130 to 230) min. Cerebral oxygen saturation decreased with INVOS from 74 ± 5% at baseline to a lowest value of 70 ± 4% with a slope of -0.0129 min(-1) (P < 0.01) and with FORE-SIGHT from 72 ± 5% at baseline to a nadir of 70 ± 3% with a slope of -0.008 min(-1) (P < 0.01). Comparing INVOS with FORE-SIGHT, there was a good association, with a slope of 0.86 ± 0.04 (P < 0.01).

CONCLUSION

Both monitors showed a clinically irrelevant decrease in cerebral oxygen saturation of less than 5% over 4 h in a steep Trendelenburg position combined with CO2 pneumoperitoneum in patients undergoing robotic assisted prostatic surgery. This extreme positioning seems to be acceptable with regard to cerebral oxygenation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: ID NCT01275898.