1
|
Mokhtari L, Hosseinzadeh F, Nourazarian A. Biochemical implications of robotic surgery: a new frontier in the operating room. J Robot Surg 2024; 18:91. [PMID: 38401027 DOI: 10.1007/s11701-024-01861-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Abstract
Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.
Collapse
Affiliation(s)
- Leila Mokhtari
- Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran
| | | | - Alireza Nourazarian
- Department of Basic Medical Sciences, Khoy University of Medical Sciences, Khoy, Iran.
| |
Collapse
|
2
|
Rashdan M, Daradkeh S, Al-Ghazawi M, Abuhmeidan JH, Mahafthah A, Odeh G, Al-Qaisi M, Salameh I, Halaseh S, Al-Sabe L, Ahmad YB, Al-Ghazawi T, Al-Said M, Sha'bin S, Mansour H. Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial. BMC Res Notes 2023; 16:235. [PMID: 37770908 PMCID: PMC10540329 DOI: 10.1186/s13104-023-06492-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/03/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers. BACKGROUND The standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12-14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines. METHODS A prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8-10 mmHg) vs. standard-pressure (12-14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed. RESULTS one hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs. 6, p-value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons. CONCLUSION low-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).
Collapse
Affiliation(s)
- Mohammad Rashdan
- Department of General Surgery/ Minimally invasive surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan.
| | - Salam Daradkeh
- Department of General Surgery/Hepatobiliary Division Jordan University Hospital, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mutasim Al-Ghazawi
- Department of Biopharmacutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan
| | | | - Azmi Mahafthah
- Department of Microbiology, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Ghada Odeh
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Mohammad Al-Qaisi
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
- King Hussein Cancer Center, Amman, Jordan
| | - Ikram Salameh
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Shahed Halaseh
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Lana Al-Sabe
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Yousef B Ahmad
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Tuqa Al-Ghazawi
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Mahmoud Al-Said
- Department of Emergancy Medicine, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Shereen Sha'bin
- Department of General Surgery, School of Medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | | |
Collapse
|
3
|
Reijnders-Boerboom GT, Albers KI, Jacobs LM, van Helden E, Rosman C, Díaz-Cambronero O, Mazzinari G, Scheffer GJ, Keijzer C, Warlé MC. Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:1400-1411. [PMID: 37026807 PMCID: PMC10389627 DOI: 10.1097/js9.0000000000000289] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 02/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group. MATERIALS AND METHODS We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay. RESULTS Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73). CONCLUSIONS Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.
Collapse
Affiliation(s)
| | - Kim I. Albers
- Departments of Anesthesiology
- Surgery, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Oscar Díaz-Cambronero
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
| | - Guido Mazzinari
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
| | | | | | | |
Collapse
|
4
|
Abstract
An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.
Collapse
|
5
|
Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery. J Robot Surg 2022; 16:1183-1192. [PMID: 35094219 PMCID: PMC8800847 DOI: 10.1007/s11701-021-01349-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022]
Abstract
The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.
Collapse
|
6
|
Grammens J, Schechter MY, Desender L, Claeys T, Sinatti C, VandeWalle J, Vermassen F, Raes A, Vanpeteghem C, Prytula A, Silay MS, Breda A, Decaestecker K, Spinoit AF. Pediatric Challenges in Robot-Assisted Kidney Transplantation. Front Surg 2021; 8:649418. [PMID: 33842532 PMCID: PMC8030256 DOI: 10.3389/fsurg.2021.649418] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
Kidney transplantation is universally recognized as the gold standard treatment in patients with End-stage Kidney Disease (ESKD, or according to the latest nomenclature, CKD stage 5). Robot-assisted kidney transplantation (RAKT) is gradually becoming preferred technique in adults, even if applied in very few centra, with potentially improved clinical outcomes compared with open kidney transplantation. To date, only very few RAKT procedures in children have been described. Kidney transplant recipient patients, being immunocompromised, might be at increased risk for perioperative surgical complications, which creates additional challenges in management. Applying techniques of minimally invasive surgery may contribute to the improvement of clinical outcomes for the pediatric transplant patients population and help mitigate the morbidity of KT. However, many challenges remain ahead. Minimally invasive surgery has been consistently shown to produce improved clinical outcomes as compared to open surgery equivalents. Robot-assisted laparoscopic surgery (RALS) has been able to overcome many restrictions of classical laparoscopy, particularly in complex and demanding surgical procedures. Despite the presence of these improvements, many challenges lie ahead in the surgical and technical–material realms, in addition to anesthetic and economic considerations. RALS in children poses additional challenges to both the surgical and anesthesiology team, due to specific characteristics such as a small abdominal cavity and a reduced circulating blood volume. Cost-effectiveness, esthetic and functional wound outcomes, minimal age and weight to undergo RALS and effect of RAKT on graft function are discussed. Although data on RAKT in children is scarce, it is a safe and feasible procedure and results in excellent graft function. It should only be performed by a RAKT team experienced in both RALS and transplantation surgery, fully supported by a pediatric nephrology and anesthesiology team. Further research is necessary to better determine the value of the robotic approach as compared to the laparoscopic and open approach. Cost-effectiveness will remain an important subject of debate and is in need of further evaluation as well.
Collapse
Affiliation(s)
- Julien Grammens
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Michal Yaela Schechter
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Liesbeth Desender
- Department of Vascular and Thoracic Surgery, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Tom Claeys
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Céline Sinatti
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Johan VandeWalle
- Department of Pediatric Nephrology and Rheumatology, ERN ERKNet Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Frank Vermassen
- Department of Vascular and Thoracic Surgery, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Ann Raes
- Department of Pediatric Nephrology and Rheumatology, ERN ERKNet Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Caroline Vanpeteghem
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Agnieszka Prytula
- Department of Pediatric Nephrology and Rheumatology, ERN ERKNet Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Mesrur Selçuk Silay
- Division of Pediatric Urology, Department of Urology, Biruni University, Istanbul, Turkey
| | - Alberto Breda
- Department of Urology, Fundació Puigvert, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Karel Decaestecker
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Anne-Françoise Spinoit
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent University, Ghent, Belgium
| |
Collapse
|
7
|
Marton Filho MA, Alves RL, do Nascimento P, Tarquinio GDS, Mega PF, Pinheiro Módolo NS. Effects of pneumoperitoneum on kidney injury biomarkers: A randomized clinical trial. PLoS One 2021; 16:e0247088. [PMID: 33606739 PMCID: PMC7895340 DOI: 10.1371/journal.pone.0247088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/29/2021] [Indexed: 01/22/2023] Open
Abstract
Background Increased intra-abdominal pressure causes hemodynamic changes that may affect renal biomarkers. Methods This randomized, single-blind, single-center clinical trial recruited patients undergoing laparoscopic cholecystectomy at a tertiary care center in Brazil. They were randomly allocated to a standard intra-abdominal pressure group (P10-12, 10–12 mm Hg) and a low intra-abdominal pressure group (P6-8, 6–8 mm Hg). The primary outcome was the change in neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C levels measured at the beginning of the procedure (T0), at the end of the procedure (T1), and 24 hours after the procedure (T2). P-values < 0.05 were considered statistically significant. Results In total, 64 patients completed the study—33 were given standard pressure and 31 were given low pressure. There was no significant difference in the biomarker between the groups (P = 0.580), but there was a significant difference between the time points with elevation at T1 (P < 0.001). Similar to NGAL, cystatin C had an elevation at T1 in both groups (P = 0.021), but no difference was found when comparing the groups. Conclusions In laparoscopic cholecystectomy, pneumoperitoneum increases NGAL and cystatin C levels intraoperatively, and the use of low-pressure pneumoperitoneum does not change the course of these biomarkers.
Collapse
Affiliation(s)
- Marcos Antonio Marton Filho
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
- Centro Universitário Estácio de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
- * E-mail:
| | - Rodrigo Leal Alves
- Department of Anesthesiology, São Rafael Hospital and Federal University of Bahia, Salvador, Brazil
| | - Paulo do Nascimento
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | | | - Paulo Ferreira Mega
- School of Medicine, Pontifícia Universidade Católica de Campinas (PUC-CAMPINAS), Campinas, São Paulo, Brazil
| | - Norma Sueli Pinheiro Módolo
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| |
Collapse
|