Anaesthesia for laparoscopic general surgery

Development of rotational intraperitoneal pressurized aerosol chemotherapy to enhance drug delivery into the peritoneum

This study aims to evaluate the drug distribution, tissue concentrations, penetration depth, pharmacokinetic properties, and toxicities after rotational intraperitoneal pressurized aerosol chemotherapy (RIPAC) in pigs. Because relevant medical devices have not been introduced, we developed our prototype of pressurized intraperitoneal aerosol chemotherapy (PIPAC) and RIPAC by adding a conical pendulum motion device for rotating the nozzle. RIPAC and PIPAC were conducted using 150 ml of 1% methylene blue to evaluate the drug distribution and 3.5 mg of doxorubicin in 50 ml of 0.9% NaCl to evaluate the tissue concentrations and penetration depth, pharmacokinetic properties, and toxicities. All agents were sprayed as aerosols via the nozzle, DreamPen^® (Dalim Biotech, Gangwon, South Korea), with a velocity of 5 km/h at a flow rate of 30 ml/min under a pressure of 7 bars, and capnoperitoneum of 12 mmHg was maintained for 30 min. As a result, RIPAC showed a wider distribution and stronger intensity than PIPAC. Compared with PIPAC, RIPAC demonstrated high values of the tissue concentration in the central, right upper, epigastrium, left upper, left lower, right lower, and right flank regions (median, 375.5-2124.9 vs. 161.7-1240 ng/ml; p ≤ .05), and higher values of the depth of concentrated diffusion and depth of maximal diffusion (median, 232.5-392.7 vs. 116.9-240.1 μm; 291.2-551.2 vs. 250.5-362.4 μm; p ≤ .05) in all regions except for bowels. In RIPAC, the pharmacokinetic properties reflected hemodynamic changes during capnoperitoneum, and there were no related toxicities. Conclusively, RIPAC may have the potential to enhance drug delivery into the peritoneum compared to PIPAC.

Bariatric Surgery Provides a "Bridge to Transplant" for Morbidly Obese Patients with Advanced Heart Failure and May Obviate the Need for Transplantation

BACKGROUND

In patients with advanced heart failure, morbid obesity is a relative contraindication to heart transplantation due to higher morbidity and mortality in these patients.

METHODS

We performed a retrospective analysis of consecutive morbidly obese patients with advanced heart failure who underwent bariatric surgery for durable weight loss in order to meet eligibility criteria for cardiac transplantation.

RESULTS

Seven patients (4 M/3 F, age range 31-56 years) with left ventricular ejection fraction (LVEF) ≤ 25 % underwent laparoscopic bariatric surgery. Median preoperative body mass index (BMI) was 42.8 kg/m(2) (range 37.5-50.8). There were no major perioperative complications in six of seven patients. Median length of hospital stay was 5 days. There was no mortality recorded during complete patient follow-up. At a median follow-up of 406 days, median BMI reduction was 12.9 kg/m(2) (p = 0.017). Postoperative LVEF improved to a median of 30 % (interquartile range (IQR) 25-53 %; p = 0.039). Two patients underwent successful cardiac transplantation. Two patients reported symptomatic improvement with little change in LV function and now successfully meet listing criteria. Three patients showed marked improvement of their LVEF and functional status, thus removing the requirement for transplantation.

CONCLUSIONS

Bariatric surgery can achieve successful weight loss in morbidly obese patients with advanced cardiac failure, enabling successful heart transplantation. In some patients, cardiac transplantation can be avoided through surgical weight loss.

Anaesthesia for minimally invasive surgery

Minimally invasive surgery (MIS) is rising in popularity. It offers well-known benefits to the patient. However, restricted access to the surgical site and gas insufflation into the body cavities may result in severe complications. From the anaesthetic point of view MIS poses unique challenges associated with creation of pneumoperitoneum, carbon dioxide absorption, specific positioning and monitoring a patient to whom the anaesthetist has often restricted access, in a poorly lit environment. Moreover, with refinement of surgical procedures and growing experience the anaesthetist is presented with patients from high-risk groups (obese, elderly, with advanced cardiac and respiratory disease) who once were deemed unsuitable for the laparoscopic technique. Anaesthetic management is aimed at getting the patient safely through the procedure, minimizing the specific risks arising from laparoscopy and the patient's coexisting medical problems, ensuring quick recovery and a relatively pain-free postoperative course with early return to normal function.

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

BACKGROUND

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

METHODS

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

RESULTS

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

CONCLUSION

Laparoscopic surgeries with normal pressure CO2 pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.

Spinal anesthesia for laparoscopic cholecystectomy: Thoracic vs. Lumbar Technique

AIMS

In our group, after a study showing that spinal anesthesia is safe when compared with general anesthesia, spinal anesthesia has been the technique of choice for this procedure. This is a prospective study with all patients undergoing LC under spinal anesthesia in our department since 2007.

SETTINGS AND DESIGN

Prospective observational.

MATERIALS AND METHODS

From 2007 to 2011, 369 patients with symptoms of colelithiasis, laparoscopic cholecystectomy were operated under spinal anesthesia with pneumoperitoneum and low pressure CO2. We compared 15 mg of hyperbaric bupivacaine and lumbar puncture with 10 or 7.5 mg of hyperbaric bupivacaine thoracic puncture, all with 25 μg fentanyl until the sensory level reached T3. Intraoperative parameters, post-operative pain, complications, recovery, patient satisfaction, and cost were compared between both groups.

STATISTICAL ANALYSIS USED

Means were compared by ANOVA or Kruskal-Wallis test, the percentages of the Chi-square test or Fisher's exact test when appropriate. Time of motor and sensory block in spinal anesthesia group was compared by paired t test or Mann-Whitney test. Differences were considered significant when P ≤ 0.05, and for comparisons of mean pain visual scale, we employed the Bonferroni correction applied to be considered significant only with P ≤ 0.0125.

RESULTS

All procedures were completed under spinal anesthesia. The use of lidocaine 1% was successful in the prevention of shoulder pain in 329 (89%) patients. There were significant differences in time to reach T3, obtaining 15 mg > 10 mg = 7.5 mg. There is a positive correlation between the dose and the incidence of hypotension. The lowest doses gave a decrease of 52.2% in the incidence of hypotension. There was a positive correlation between the dose and duration of sensory and motor block. Sensory block was almost twice the motor block at all doses. With low doses, 60% of patients went from table to stretcher. Satisfaction occurred in 99% of patients.

CONCLUSIONS

Laparoscopic cholecystectomy can be performed successfully under spinal anesthesia with low-pressure pneumoperitoneum of CO2. The use of thoracic puncture and low doses of hyperbaric bupivacaine provided better hemodynamic stability, less hypotension, and shorter duration of sensory and motor blockade than lumbar spinal anesthesia with conventional doses.

Combined spinal and general anesthesia is better than general anesthesia alone for laparoscopic hysterectomy

CONTEXT

Spinal anesthesia (SA) was combined with general anesthesia (GA) for achieving hemodynamic stability in laparoscopic hysterectomy.

AIMS

The aim of our study was to evaluate the impact of SA combined with GA in maintaining hemodynamic stability in laparoscopic hysterectomy. The secondary outcomes studied were requirement of inhaled anesthetics, vasodilators, and recovery profile.

SETTINGS AND DESIGN

We conducted a prospective, randomized study in ASAI/II patients posted for laparoscopic hysterectomy, who were willing to participate in the study.

MATERIALS AND METHODS

Patients were randomly assigned to receive SA with GA (group SGA) or plain GA (group GA). Group SGA received 10 mg bupivacaine (heavy) for SA. GA was administered using conventional balanced technique. Maintenance was carried out with nitrous oxide, oxygen, and isoflurane. Comparison of hemodynamic parameters was carried out during creation of pneumoperitoneum and thereafter. Total isoflurane requirement, need of vasodilators, recovery profile, and regression of SA were studied.

STATISTICAL ANALYSIS USED

Descriptive statistics in the form of mean, standard deviation, frequency, and percentages were calculated for interval and categorical variables, respectively. One-way analysis of variance (ANOVA) was applied for noting significant difference between the two groups, with chi-square tests for categorical variables and post-hoc Bonferroni test for interval variables. Comparison of heart rate (HR), mean arterial pressure (MAP), SPO2, and etCO2 was done with Student's t-test or Mann-Whitney test, wherever applicable.

RESULTS

Patients in group SGA maintained stable and acceptable MAP values throughout pneumoperitoneum. The difference as compared to group GA was statistically significant (P < 0.01). Group GA showed additional requirement of metoprolol (53.33%) and higher concentration of isoflurane (P < 0.001) to combat the increased MAP. Recovery was early and quick in group SGA as against group GA (P = 0.000). There were no adverse/residual effects of SA.

CONCLUSION

The hemodynamic repercussions during pneumoperitoneum can be effectively attenuated by combining SA and GA, without any adverse effects.

Regional anesthesia for laparoscopic surgery: a narrative review

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

Current and future practices in surgical retraction

Retraction of tissues and anatomical structures is an essential component of all forms of surgery. The means by which operative access is gained through retraction are many and diverse. In this article, the various forms of retraction methods currently available are reviewed, with special reference to hand held, self-retaining and compliant techniques. The special challenges posed by laparoscopic surgery are considered and future developments in new retraction techniques are anticipated.

Venous gas embolism: An unusual complication of laparoscopic cholecystectomy

Venous gas embolism (VGE) is a rare but potentially lethal complication of many forms of surgery, especially posterior fossa neurosurgery where the incidence is reported to be up to 80% - it can also occur in laparoscopic surgery. It usually occurs early in the procedure during insufflation of the abdomen. Rapid entry or large volumes of gas entering the venous circulation initiate a predictable chain of pathophysiological events which may continue to cardiovascular collapse. Arterial hypoxaemia, hypercapnia, decreased end-tidal CO₂, arrhythmias, myocardial ischaemia and elevated central venous and pulmonary arterial pressures can occur. The management of VGE relies on a high index of suspicion and close liaison between anaesthetist, surgeon and theatre staff. The authors present a case of venous gas embolism (VGE) during laparoscopic cholecystectomy (LC) which presented without many of the usual clinical features and was diagnosed by auscultation of a millwheel murmur.

Surgical emphysema as a cause of severe hypercapnia during laparoscopic surgery

Surgical emphysema is a well-recognised complication of laparoscopic surgery, but its impact on end-tidal carbon dioxide levels and carbon dioxide elimination is seldom reported and may not be fully appreciated by anaesthetists. Four cases are presented where extensive surgical emphysema occurred during laparoscopic surgery. The visual display of the anaesthetic record using the software program Monitor showed substantial rises in end-tidal carbon dioxide levels and allowed calculation of the carbon dioxide elimination, which increased two- to three-fold above normal levels. Having a visual record of carbon dioxide changes facilitated the recognition of surgical emphysema in three out of the four cases. Strategies such as estimating and tracking changes in carbon dioxide elimination from the minute ventilation and end-tidal carbon dioxide levels may assist in early identification, and palpating for surgical emphysema is recommended during laparoscopy if other causes of increased carbon dioxide levels are excluded.

Dissociative conscious sedation, an alternative to general anesthesia for laparoscopic peritoneal dialysis catheter implantation: a randomized trial comparing intravenous and subcutaneous ketamine

Laparoscopy is an effective method of implantation for peritoneal dialysis (PD) catheters. Use of the laparoscopic technique is increasing because of its potential advantages over other techniques. In most patients, selection for PD is based on negative criteria, and because of the need for general anesthesia, the laparoscopic technique can be life-threatening in these patients. On the other hand, local anesthesia is insufficient for laparoscopic catheter implantation. To avoid the need for general anesthesia and to achieve patient safety and satisfaction, we designed a type of conscious sedation (dissociative conscious sedation) and compared the efficacy of subcutaneous (SC) and intravenous (IV) ketamine added to narcotics in patients scheduled for laparoscopic implantation of a PD catheter.

METHODS

Our prospective randomized double-blind study enrolled 60 adult patients with chronic renal failure who were scheduled for laparoscopic implantation of a PD catheter. Patients were randomly assigned to one of two groups: one receiving IV ketamine, and the other receiving SC ketamine. In both groups, patients were premedicated with IV midazolam 0.015 mg/kg, fentanyl 1-2 μg/kg, and lidocaine 1.5 mg/kg. Patients then received 0.6 mg/kg ketamine either intravenously (IV group) or by subcutaneous injection at the anterior aspect of the forearm (SC group). If systolic blood pressure (BP) increased more than 20% from baseline or exceeded 170 mmHg, IV nitroglycerine (TNG) 50 μg was administered incrementally (repeated 50-μg doses). After a desirable level of conscious sedation was achieved, local anesthesia and nitrous oxide pneumoperitoneum were applied, and the PD catheter was implanted under laparoscopic guidance. Heart rate and BP were measured throughout the procedure. Adverse effects and recovery events were recorded.

RESULTS

All patients tolerated the procedure well. Administration of TNG was significantly more frequent in the IV ketamine group. Pain intensity during the surgery was similar in both groups. Both groups were comparable with regard to heart rate, but patients in the SC ketamine group had a significantly lower systolic BP at the 2nd measurement and a lower rate-pressure product at the 2nd, 4th, and 5th measurements. All patients in the SC ketamine group were cooperative during surgery and experienced uneventful recoveries; mild hallucinations were observed in 5 patients in the IV ketamine group. In the IV ketamine group, 3 patients lost the ability to cooperate during surgery. All catheters were successfully placed.

CONCLUSIONS

Dissociative conscious sedation is an acceptable alternative to general anesthesia in laparoscopic implantation of the PD catheter. Ketamine by the SC route is as effective as, but safer than, IV ketamine.

Cardiovascular Evaluation and Management of Severely Obese Patients Undergoing Surgery

Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index >30, 40, and 50 kg/m 2 , respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population.

Dealing with complications in laparoscopy

With increasing adoption of laparoscopic surgery in gynaecology, there has been a corresponding rise in the types and rates of complications reported. This article sets out to classify complications associated with laparoscopy according to the phases of the surgery; assess the incidence, the mechanisms, the presentations; and recommend methods for preventing and dealing with complications in laparoscopic surgery. Its aim is to promote a culture of risk management based on the development of strategies to improve patient safety and outcome.

Adaptive support ventilation for gynaecological laparoscopic surgery in Trendelenburg position: bringing ICU modes of mechanical ventilation to the operating room

BACKGROUND AND OBJECTIVE

The aim of the present study was to test the efficacy of adaptive support ventilation (ASV) to automatically adapt the ventilatory settings to the changes in the respiratory mechanics that occur during pneumoperitoneum and Trendelenburg position in gynaecological surgeries.

METHODS

We prospectively studied 22 ASA I women scheduled for gynaecological laparoscopic surgery in the Trendelenburg position. After intravenous induction of general anaesthesia, patients were ventilated with ASV, a closed-loop mode of mechanical ventilation based on the Otis formula, designed to automatically adapt the ventilatory settings to changes in the patient's respiratory system mechanics, while maintaining preset minute ventilation. Respiratory mechanics variables, ventilatory setting parameters and analysis of blood gases were recorded at three time points: 5 min after induction (baseline), 15 min after pneumoperitoneum and Trendelenburg positioning (Pneumo-Trend) and 15 min after pneumoperitoneum withdrawal (final).

RESULTS

A reduction of 44.4% in respiratory compliance and an increase of 29.1% in airway resistance were observed during the Pneumo-Trend period. Despite these changes in respiratory mechanics, minute ventilation was kept constant. ASV adapted the ventilatory settings by automatically increasing inspiratory pressure by 3.2 +/- 0.9 cmH(2)O (+19%), P < 0.01, respiratory rate by 1.3 +/- 0.5 breaths per minute (+9%) and the inspiratory to total time ratio (T(i)/T(tot)) by 43.3%. At final time, these parameters returned towards their baseline values. Adequate gas exchange was maintained throughout all periods. PaCO(2) increased moderately (+13%) from 4.4 +/- 0.6 (baseline) to 5.0 +/- 0.9 kPa (Pneumo-Trend), P < 0.01; and decreased slightly at final time (4.7 +/- 0.8 kPa), P < 0.05. Clinician's intervention was needed in only one patient who showed a moderate hypercapnia (PaCO(2) 6.9 kPa) during pneumoperitoneum.

CONCLUSION

In healthy women undergoing gynaecologic laparoscopy, ASV automatically adapted the ventilatory settings to the changes in the respiratory mechanics, keeping constant the preset minute ventilation, providing an adequate exchange of respiratory gases and obviating clinician's interventions.

Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 480 patients

OBJECTIVES

Laparoscopic total extraperitoneal inguinal hernia repair (TEP) is conventionally performed under general anesthesia (GA), and regional anesthesia is usually preferred in patients where GA is contraindicated. In this paper, we present our experience of over 8 years of using spinal anesthesia (SA) as the first choice with the contention that it is a better alternative to GA.

METHODS

SA was used in 480 patients over the last 8 years, and 464 patients underwent unilateral TEP. Strangulated and obstructed hernia patients were excluded, but irreducible hernia patients were included. Sedation was given if required, and the conversion to GA was done in patients not responding to sedation or with failure of SA. Comparative control included TEP performed under GA in our initial 49 patients.

RESULTS

Three (0.63%) patients required a conversion to GA. Hypotension requiring support was recorded in 75 (15.63%) patients. Postoperatively, 2.08% (10) patients had vomiting, as compared to 30.61% (15 patients) in patients administered GA. In all, 35.83% (172) of patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively, and oral analgesic was required in 301 (62.71%) patients within the first 24 hours, while 89.80% (44) patients operated an under GA required injectable analgesics in the immediate postoperative period and subsequent oral analgesia request was the same as in patients with SA. Postural headache, persisting for an average of 2.6 days, was seen in 25 (5.21%) patients postoperatively. Average time to discharge was 2.3 days. Kernofsky's performance status showed a 98.6% satisfaction level in patients.

CONCLUSIONS

TEP done under SA has a number of advantages over GA and should be used routinely.

Cardiac function during steep Trendelenburg position and CO2 pneumoperitoneum for robotic-assisted prostatectomy: a trans-oesophageal Doppler probe study

BACKGROUND

Haemodynamic changes associated with pneumoperitoneum and steep Trendelenburg position were investigated in non-obese, ASA I-II males, using general anaesthesia (sevoflurane in air/O2, 40%) undergoing robotic-assisted laparoscopic prostatectomy.

METHODS

A trans-oesophageal echo-Doppler probe (Arrow International) measured cardiovascular changes in heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), stroke volume (SV) and aortic diameter (AoD) in 35 of 37 males. Assessments were conducted after induction of general anaesthesia in: the supine position; at 45 degrees Trendelenburg; Trendelenburg + pnuemoperitoneum (intra-abdominal 15 mmHg); and at the end of surgery in the supine position.

RESULTS

The Trendelenburg position increased stroke volume. Trendelenburg position + pneumoperitoneum increased MAP and SVR and decreased AoD.

CONCLUSIONS

Pneumoperitoneum and steep Trendelenburg position significantly increase MAP and SVR. Trendelenburg position increased stroke volume. Pneumoperitoneum decreases aortic diameter. No significant changes in cardiac output or stroke volume were noted.

Short-term effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain

BACKGROUND

In this study the effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain in the postoperative period was evaluated.

METHODS

Between April 2004 and February 2006 we planned to perform 179 laparoscopic cholecystectomies. One hundred of these patients were included in this study. Patients were divided into two groups: group 1 with gallbladder perforation during the operation and group 2 without perforation. Two groups were compared regarding age, gender, comorbidities, mean hospital stay, respiratory function tests, and postoperative pain scores.

RESULTS

Gallbladder perforation occurred in 33 patients (33%). The male-to-female ratio of group I was 5/28. In group 2 the male-to-female ratio was 12/55. Age and perforation had a significant correlation according to Spearman's correlation test (p < 0.05, r = 0.211). Regarding respiratory function tests and arterial blood gases analysis, there was a significant decrease in both groups postoperatively but perforation had no effect on them. No statistically significant difference occurred regarding mean hospital stay and postoperative visual pain scores (p > 0.05).

CONCLUSION

Gallbladder perforation during laparoscopic cholecystectomy had no effect on postoperative respiratory mechanics and depth of pain.

Effects of Positioning in Laparoscopic Adnexal Surgery on QT Dispersion and Heart Rate Variability Under Sevoflurane Anesthesia

PURPOSE

This study compared the intraoperative changes in the corrected QT dispersion and heart rate variability, predictors of autonomic cardiac function, in laparotomic and laparoscopic adnexal surgery.

MATERIALS AND METHODS

The study was conducted on 46 American Society of Anaesthesiologists class I/II patients, aged 33-51 years, randomized to one of two groups, for elective gynecologic laparotomy or laparoscopy for a benign adnexal mass. Anesthesia was induced and maintained with sevoflurane. Corrected QT dispersion and spectral powers of heart rate variability were measured at baseline, before the induction of anesthesia, and intraoperatively during the adnexal surgery for 15 minutes. The lithotomy and Trendelenburg positions were set at 145 degrees and 30 degrees between thigh and body, respectively. Pneunoperitoneum was established at 12 mm Hg. Laparoscopic surgery was performed via one principal and two ancillary ports. Data were analyzed using the Wilcoxon and Mann-Whitney tests.

RESULTS

A significant increase was observed in intraoperative standard deviation of RR interval values of heart rate variability in both groups compared to preoperative values (P < 0.05). The corrected QT dispersion and low and high frequency heart rate variability showed no significant changes between the two groups.

CONCLUSION

Gynecologic laparoscopy with pneumoperitoneum in the lithotomy and Trendelenburg positions is as safe as laparatomy and seems not to deteriorate the autonomic cardiac function.

Anesthesia for operative endoscopy

Developments in both instruments and techniques have led to an increasing popularity of endoscopic surgery during the last two decades. Even though there are numerous advantages to using endoscopic surgery, life threatening surgical and anesthetic complications still exist. Precautions must be taken to cope with the potential complications. Anesthetic technique must provide optimal surgical conditions and lead to early recovery of the patient. Monitorization must allow safety of the patient during these potentially hazardous procedures. Both the anesthesiologist and the surgeon must be thoroughly aware of the potential complications of the procedure. This review discusses the physiological alterations occurring during operative endoscopy, the principles of anesthetic management and complications related both to surgery and to anesthesia techniques.

Laparoscopic fundoplication in children: anaesthetic experience of 51 cases

We report the anaesthetic management and outcomes of our first 51 laparoscopic fundoplications. Case records of the 50 patients (one redo), median age 6 years (5 months to 20 years), were reviewed. Median duration of anaesthesia was 120 (60-300) min. During the procedure, the heart rate and blood pressure increased by more than 20% over baseline in 18% and 12% cases, respectively. Median increase in PECO2 was 1.0 (0.3-2.3) kPa [7.6 (2.3-18) mmHg]. After surgery, all but one of the patients were managed on a normal surgical ward. Postoperative analgesia requirement was oral or rectal analgesics in 89% of patients and ceased within 48 h of surgery in 95% patients. Median time to discharge home from day of operation was 2 (1-9) days. We conclude that laparoscopic fundoplication in children is well tolerated, there is no requirement for routine postoperative high dependency care and analgesic requirements are minimal.

An unexpected death during oxygen-ozone therapy

An unexpected death is described that was caused by gas embolism that occurred during oxygen-ozone (O2/O3) therapy administered by autohemotransfusion for psoriasis. This unusual complication suggests the necessity of investigating benefits and adverse effects of medical ozone application.

The cardiorespiratory effects of laparoscopic procedures in infants

We assessed the cardiorespiratory effects of laparoscopic procedures in 27 infants aged between 36 and 365 days. Infants were monitored and anaesthetised in a standardised manner. Heart rate, mean arterial pressure, end-tidal carbon dioxide and oxygen saturation were recorded, and blood gases were measured at 5 min after intubation, 15 and 30 min after carbon dioxide pneumoperitoneum, 5 min after desufflation and after extubation. The pH, PaO2, base excess, SaO2 and SpO2 decreased, and PCO2 increased by insufflation of carbon dioxide intraperitoneally, and improved following deflation. Changes in pH and PaO2 during the study were statistically significant (p < 0.0001). The increase in PaCO2 30 min after pneumoperitoneum was statistically significant when compared with initial values. Transient arrhythmias were observed in 10 infants 1 min after pneumoperitoneum. There were no statistically significant alterations in heart rate and systolic blood pressure.

Anesthesia for gynecologic laparoscopy

Despite developments in instruments and improvements in surgical and anesthesia techniques, laparoscopy is still associated with complications that may be lethal, including those related to anesthesia. Both anesthesiologist and surgeon must thoroughly understand potential complications of the procedure, including physiologic alterations, principles of anesthetic management and postoperative pain control, and problems related to anesthesia. (J Am Assoc Gynecol Laparosc 6(3):245-258, 1999)

Lung compliance during laparoscopic surgery in paediatric patients

Insufflation of CO2 and positioning of patients induces changes in cardiovascular and respiratory function during laparoscopic procedures. This study was initiated to assess respiratory mechanics such as lung compliance and peak airway pressure (PIP) during laparoscopic surgery in paediatric patients. Ten consecutive patients (age 1-15 years) scheduled for laparoscopic procedure were included in this open prospective single-group study. Anaesthesia was induced and maintained with intravenous infusions of propofol and alfentanil. Vecuronium was administered to maintain muscle relaxation. Head down tilt induced a mean decrease of 17% in lung compliance, which was further decreased by 27% from the baseline during insufflation of intraabdominal CO2 (intraabdominal pressure 12 mmHg). Coincidently, PIP increased by 19% and 32% from the baseline during Trendelenburg position and peritoneal insufflation. Lung compliance and PIP returned to their respective baseline values after removal of CO2 from the peritoneal cavity. Endtidal CO2 increased from a baseline value of 4.3 kPa to 5.4 kPa (33-42 mmHg) during surgery when ventilator settings were not altered. We conclude that insufflation of CO2 induces significant increases in peak airway pressure with simultaneous decreases in lung compliance.

Biomechanical and histological evaluation of a laparoscopic stapled gastropexy technique in dogs

The biochemical holding strength and histological characteristics of a laparoscopic stapled gastropexy (LG) adhesion were compared with that of an incisional gastropexy (IG) adhesion. An LG was performed in 14 dogs and an IG was performed in six dogs. During the LG procedure, the abdomen was insufflated with carbon dioxide and three cannulae were placed in the caudal aspect of the right side of the abdomen. A 35 mm laparoscopic stapler was used to staple the gastric antrum to the adjacent right lateral abdominal wall. The IG procedure was performed through ventral midline celiotomy. A 35 mm IG was made by apposing the gastric antrum to the adjacent right lateral abdominal wall with two continuous rows of suture. Half of each group of dogs was euthanatized at 7 and 30 days after surgery. The mean tensile load to failure at 7 days was 44.86 +/- 18.54 N for the LG group and 85.33 +/- 23.59 N for the IG group (P < .05). At 30 days the values were 72.39 +/- 18.01 N for the LG group and 71.17 +/-12.11 N for the IG group (P = .41). The gastropexy adhesions in the 7-day postoperative group contained variable amounts of fibrin, hemorrhage, mononuclear cell inflammation, loose fibrovascular tissue, and mature collagenous connective tissue. Adhesions in the 7-day postoperative group were divided subjectively into three histological subgroups based on the relative amounts of mature connective tissue within the adhesion. The LG and IG adhesions were randomly distributed among these subgroups (P = 1.0). Adhesions in the 30-day postoperative group contained well-organized fibrous connective tissue. No difference in the amount of connective tissue could be detected histologically in the LG or IG adhesions. Complications with the LG procedure included stomach perforation (2 cases), splenic puncture (2 cases), and subcutaneous emphysema (4 cases).

Cardiopulmonary effects of using carbon dioxide for laparoscopic surgery in dogs

Cardiopulmonary effects of laparoscopic surgery were investigated in five crossbred dogs (21 +/- 1.9 kg). Premedicated dogs were anesthetized with thiopental and maintained with halothane at 1.5 times minimum alveolar concentration in oxygen. Controlled ventilation maintained partial pressure of end-tidal CO2 at 40 +/- 2 mm Hg. Vecuronium was used for skeletal muscle relaxation. After instrumentation and stabilization, baseline measurements were made of cardiac output (thermodilution technique), mean systemic, mean pulmonary arterial and pulmonary wedge pressures, heart rate, saphenous vein and central venous pressures, and minute ventilation. Baseline arterial and mixed venous blood samples were drawn for analysis of pH, PaO2, PaCO2, PvO2, PvCO2, and bicarbonate concentrations. Systemic and pulmonary vascular resistances, oxygen delivery and consumption, shunt fraction, and dead space ventilation were calculated using standard formulas. Abdominal insufflation using CO2 to a pressure of 15 mm Hg for 180 minutes resulted in significant (P < .05) increases in heart rate (15 to 180 minutes), minute ventilation (75 to 135 minutes), and saphenous vein pressure (15 to 180 minutes), and decreases in pH (60 to 180 minutes) and PaO2 (60 to 180 minutes). For 30 minutes after desufflation, there was a significant decrease in PaO2, and increases in cardiac output, O2 delivery, and heart rate, compared with baseline. There was a significant increase in shunt fraction and decrease in pH at 15 minutes after desufflation only. The changes were within physiologically acceptable limits in these healthy, ventilated dogs.

Experimental carbon dioxide pulmonary embolization after vena cava laceration under pneumoperitoneum

The potential for pulmonary embolization following major venous laceration occurring during laparoscopic surgery has never been evaluated. Five anesthetized dogs were hemodynamically monitored with an arterial line and Swan-Ganz catheter. Observation by transesophageal echocardiography (TEE) allowed comparison with pulmonary artery pressure (PAP) recording. Under pneumoperitoneum, a 1-cm venotomy was performed in the infrarenal vena cava and a total of 11 events were evaluated upon unclamping the venotomy. These results were compared with intravenous (i.v.) bolus injections of 15 cc of CO2 (15 events) and of 100 cc of CO2 (12 events). The animals were maintained euvolemic. In 2 out of the 11 (18%) events which followed unclamping the venotomies, a few CO2 bubbles were seen in the right heart cavities. However, the quantity of gas was much less important than that seen after i.v. injection of 15 cc and 100 cc of CO2. There was no significant elevation of the PAP from pre-event values after venotomy or after i.v. injection of 15 cc of CO2. However, there was a significant difference (P < 0.05) when these results were compared to the PAP values recorded after i.v. injection of 100 cc of CO2. No dog died after these episodes of embolization. Massive i.v. injection of CO2 (> 300 cc) led to appearance of gas bubbles in the left heart cavities and death. This experiment suggests that caution should be exerted when laparoscopic surgery is performed beside large veins. Nevertheless, the observation that no gas embolism occurred in 82% of the cases after unclamping venotomies was unexpected. In contrast, many more gas bubbles were detected in the right heart after i.v. injection of only 15 cc of CO2. TEE is a more sensitive indicator of pulmonary embolization than elevation of PAP.

Laparoscopic antireflux surgery; the merits and problems

The development of laparoscopic techniques has enhanced interest in surgical treatment of gastro-oesophageal reflux disease. The goal of laparoscopic surgery in this context is to achieve the same results as in open surgery with fewer complications, shortened hospital stay and reduced sick leave. Several surgical procedures, based on surgical rearrangement of the oesophageal gastric junction or placement of prosthesis, are available. Most of these procedures are applicable in laparoscopic surgery. Surgical treatment of gastro-oesophageal reflux is highly effective although postoperative gas bloat syndrome, dysphagia and recurrence may occur in a small number of patients. In published series short-term results of laparoscopic antireflux surgery have been excellent. The benefits of minimal invasive surgery, such as less painful postoperative course, shortened hospital stay and rapid recovery have been confirmed. Because of the enthusiasm for laparoscopic technique, surgeons not familiar with the surgical treatment of gastro-oesophageal reflux may be tempted to embark on this procedure. This type of surgery is, however, technically demanding and should be performed only by surgeons with significant experience with both laparoscopic surgery in general and open antireflux surgery. A sufficiently long learning period is mandatory if serious complications are to be avoided. Taking into account these premises, laparoscopic antireflux surgery is safe and represents a viable alternative to conventional antireflux surgery.

Caudal epidural block for analgesia following herniorrhaphy with laparoscopy in children

This study prospectively evaluated the efficacy of caudal epidural block in providing analgesia following inguinal herniorrhaphy and laparoscopy. Laparoscopy was used only to inspect the contralateral side to determine if a second hernia was present. No surgical manipulation was performed through the telescope. Following mask induction with halothane in nitrous oxide and oxygen, a caudal epidural block was performed with 1.2 mL/kg of 0.25% bupivacaine. Pain scores were obtained at four points during the in-hospital postoperative course, and the need for supplemental analgesic agents was assessed. A total of 45 patients were studied. Caudal epidural block could not be performed in 1 patient, and this patient was excluded from further consideration. There were 34 boys and 10 girls, ranging in age from 2 to 84 months (mean +/- SD 37.4 +/- 18.2 months) and weighing from 3.4 to 34 kg (mean +/- SD 14.2 +/- 5.8 kg). Thirty-six of 44 patients (82%) did not require supplemental analgesic agents during their in-hospital postoperative course and had pain scores of 2 or less at all four evaluation points. Six of 8 patients required a single dose of intravenous fentanyl (0.5 microgram/kg) to maintain scores of 2 or less. No significant complications related to caudal epidural block were noted in any patient. Caudal epidural block provides effective analgesia following inguinal herniorrhaphy and laparoscopy in children.