Abdominal Compliance and Laparoscopy: A Review

Physiological and Anesthetic Considerations of Safe and Optimal Pneumoperitoneal Pressures for Laparoscopic Surgeries in Children

Context

In the era of minimally invasive surgeries, pediatric laparoscopic surgeries are now becoming the standard of care.

Aim

In this study, we aim to determine the safe and optimal pneumoperitoneal pressures (PPs) for laparoscopic surgery in children aged 1-5 years, along with the technical ease for the surgeon.

Settings and Design

Prospective, randomized, single-blinded study was conducted at SGPGI Lucknow.

Materials and Methods

Children aged 1-5 years were randomized into Group I (n = 24): PP = 6-8 mmHg and Group II: (PP) = 9-10 mmHg. Hemodynamic, ventilatory, and blood gas changes were measured before CO2 insufflation (T0), 20 min after insufflation (T1), before desufflation (T2), and 10 min after desufflation (T3). Surgeon's technical ease of surgery, postoperative pain, the requirement of rescue analgesia, time to resume feeding, and complications were recorded and analyzed.

Statistical Analysis Used

Paired t-test, Mann-Whitney test, and Wilcoxon signed-rank test were used for nonparametric/parametric data. Chi-square/Fisher's test was used for nominal data.

Results

Partial pressure of CO2 (PaCO2) was significantly higher in Group II at T1, T2, and T3, requiring frequent changes in ventilatory settings. Postoperative pain scores were higher in Group II at 1, 6, and 12 h, requiring rescue analgesia. Surgeon's scores and hemodynamics were similar in both groups.

Conclusions

Higher PP in Group II caused significant changes in PaCO2, end-tidal CO2, and postoperative pain requiring rescue analgesia, but blood gas changes were clinically insignificant and there were no significant changes in hemodynamic parameters. Since the surgeon's ease of performing surgery was similar in both groups, we recommend that laparoscopy in children aged 1-5 years can be started with lower PPs of 6-8 mmHg, which can be increased if needed based on the surgeon's comfort and the patient's body habitus.

Evaluation of the TraumaGuard Balloon-in-Balloon Catheter Design for Intra-Abdominal Pressure Monitoring: Insights from Pig and Human Cadaver Studies

Introduction: Intra-abdominal pressure (IAP) monitoring is crucial for the detection and prevention of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). In the 1970s, air-filled catheters (AFCs) for urodynamic studies were introduced as a solution to overcome the limitations of water-perfused catheters. Recent studies have shown that for correct IAP measurement with traditional AFC, the bladder needs to be primed with 25 mL of saline solution to allow pressure wave transmission to the transducer outside of the body, which limits continuous IAP monitoring. Methods: In this study, a novel triple balloon, air-filled TraumaGuard (TG) catheter system from Sentinel Medical Technologies (Jacksonville, FL, USA) with a unique balloon-in-balloon design was evaluated in a porcine and cadaver model of IAH via laparoscopy (IAPgold). Results: In total, 27 and 86 paired IAP measurements were performed in two pigs and one human cadaver, respectively. The mean IAPTG was 20.7 ± 10.7 mmHg compared to IAPgold of 20.3 ± 10.3 mmHg in the porcine study. In the cadaver investigation, the mean IAPTG was 15.6 ± 10.8 mmHg compared to IAPgold of 14.4 ± 10.4 mmHg. The correlation, concordance, bias, precision, limits of agreement, and percentage error were all in accordance with the WSACS (Abdominal Compartment Society) recommendations and guidelines for research. Conclusions: These findings support the use of the TG catheter for continuous IAP monitoring, providing early detection of elevated IAP, thus enabling the potential for prevention of IAH and ACS. Confirmation studies with the TraumaGuard system in critically ill patients are warranted to further validate these findings.

Total laparoscopic hysterectomy four-handed ergonomic technique: description of an original surgical procedure for the reduction of learning curve

The aim of this study was to propose the four-handed technique for total laparoscopic hysterectomy (TLH), with or without adnexectomy. From our point of view this is a more ergonomic, efficient, and effective technique that can contribute to the training of specialists in obstetrics/gynecology. In fact, teacher and learner have both an active role on the surgical field using two laparoscopic instruments each. They are alternately, mutually, and symmetrically first operator and assistant, reducing number of attempts needed for laparoscopic hysterectomy learning curve. The detailed description of all the surgical steps of TLH, "four-handed technique" (FHT), with or without adnexectomy, make sure that it can be effectively reproduced step by step safely, by transposing "FHT" surgical steps of laparotomic approach. This may allow easy access to anatomical spaces inserting trocars in different ways. By clearly knowing the steps of TLH, "FHT" it is possible to favor minimally invasive routes so that patients benefit from its multiple proven benefits. Operating this way, operative time, blood loss, use of analgesics and hospitalization can be significantly reduced. In conclusion benefits of TLH have already been widely demonstrated in literature. It is a real opportunity that young specialists become confident with this innovative "FHT," a procedure that allows them to be surgeon first assistant, and in which they can learn faster real intraoperative stereotaxis and surgical steps sequence, familiarizing with the anatomy of retroperitoneal space.

Distribution of surgical smoke particles within a simulated laparoscopic cavity utilizing an AirSeal® system

An exploratory study was performed to determine the distribution of surgical smoke particulate matter (SSPM) and evacuation times within an AirSeal® System and a traditional insufflation access system in various simulated surgical scenarios. Identified trends showed statistical significance when setting the AirSeal® System to Low smoke evacuation that it reduces the percentage of particulate matter at the Access Port opening. Additionally, it was observed that when utilising a laparoscopic tool a similar trend in particle distributions were seen between either insufflation and access system at the opening of the Access Port and trocar. Evacuation times for SSPM removal within the AirSeal® System showed an overall average to ≥95% reduction of 5.64 min within the surgical cavity, 3.69 min at the Access Port opening, and 3.61 min within the smoke evacuation line. The overall average for the traditional insufflation and access system was 9.38 min within the surgical cavity and 6.06 min at the trocar opening. Results showed that when using the traditional system compared to the AirSeal® System, it resulted in a percent change increase in evacuation times of 66.31% within the surgical cavity and 64.23% at the trocar opening.

Comparison of the effect of general anesthesia and spinal anesthesia technique combined with general anesthesia on intraabdominal volume during gynecological laparoscopy

PURPOSE

We aimed to investigate the effect of spinal anesthesia which will be performed simultaneously with general anesthesia on the site of operation with the same pressure.

MATERIAL AND METHOD

This study was conducted as a randomized, prospective clinical study on 40 patients who were randomly divided into two groups. Twenty women underwent general anesthesia (Group GA) and 20 women underwent spinal anesthesia with general anesthesia (Group SGA). For all cases, preoperative height, weight, waist circumference, body mass index (kg/m² ), the distance between both spina iliaca anterior superior, the distance of the intersection of both ribs with an imaginary line drawn over the anterior axillary line, suprapubic bone-umbilical, umbilical-xiphoid, and suprapubic bone-xiphoid distance from the midline of the abdomen were measured. Moreover, while the patient was lying in the neutral position on the operating table, the height of the highest point of the abdomen to the operating table was also measured. These measurements were repeated at intra-abdominal pressure (IAP) 14 and 25 mmHg. The amount of intra-abdominal insufflated CO₂ was also recorded at IAP 14 and 25 mmHg.

RESULTS

When the intra-abdominal insufflation volumes of both groups were compared at 14 and 25 mmHg, respectively, there was no statistical difference (p: 0.54, p: 0.40). When 14 and 25 mmHg were compared in all cases, a statistically significant difference was observed in other measurements except in xiphoid-umbilical distance (p < 0.05).

CONCLUSION

We found that spinal anesthesia combined with GA had no effect on the abdominal volume and anthropometric measurements in laparoscopic procedures.

A novel method for monitoring abdominal compliance to optimize insufflation pressure during laparoscopy

BACKGROUND

Abdominal compliance describes the ease of expansion of the abdominal cavity. Several studies highlighted the importance of monitoring abdominal compliance (Cab) during the creation of laparoscopic workspace to individualize the insufflation pressure. The lack of validated clinical monitoring tools for abdominal compliance prevents accurate tailoring of insufflation pressure. Oscillometry, also known as the forced oscillation technique (FOT), is currently used to measure respiratory mechanics and has the potential to be adapted for monitoring abdominal compliance. This study aimed to define, develop and evaluate a novel approach which can monitor abdominal compliance during laparoscopy using endoscopic oscillometry.

MATERIALS AND METHODS

Endoscopic oscillometry was evaluated in a porcine model for laparoscopy. A custom-built insufflator was developed for applying an oscillatory pressure signal superimposed onto a mean intra-abdominal pressure. This insufflator was used to measure the abdominal compliance at insufflation pressures ranging from 5 to 20 hPa (3.75 to 15 mmHg). The measurements were compared to the static abdominal compliance, which was measured simultaneously with computed tomography imaging.

RESULTS

Endoscopic oscillometry recordings and CT images were obtained in 10 subjects, resulting in 76 measurement pairs for analysis. The measured dynamic Cab ranged between 0.0216 and 0.261 L/hPa while the static Cab based on the CT imaging ranged between 0.0318 and 0.364 L/hPa. The correlation showed a polynomial relation and the adjusted R-squared was 97.1%.

CONCLUSIONS

Endoscopic oscillometry can be used to monitor changes in abdominal compliance during laparoscopic surgery, which was demonstrated in this study with a comparison with CT imaging in a porcine laparoscopy model. Use of this technology to personalize the insufflation pressure could reduce the risk of applying excessive pressure and limit the drawbacks of insufflation.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos)

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.

PATIENTS AND METHODS

Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.

RESULTS

The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.

CONCLUSIONS

The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

The effect of different pressures of pneumoperitoneum on the dimensions of internal jugular vein – A prospective double-blind, randomised study

Background and Aims:

During laparoscopic surgeries, pneumoperitoneum increases intraabdominal pressure (IAP) which can increase the central venous pressure (CVP), and significant haemodynamic changes. In this study, we evaluated the effect of two different pressures of pneumoperitoneum, standard (13-15 mmHg), and low (6-8 mmHg) on the cross-sectional area (CSA) of the internal jugular vein (IJV) using ultrasonography, haemodynamic changes and duration of surgery. Surgeon’s comfort and feasibility of performing laparoscopic surgeries with low pressure pneumoperitoneum was also studied.

Methods:

This prospective, double-blind, randomised study included 148 patients of American Society of Anesthesiologists physical status class I and II undergoing laparoscopic surgeries. They were allocated into two groups: group S (standard) (number (n) = 73) had the IAP maintained between 13-15 mmHg; group L (low) had an IAP of 6-8 mmHg (n = 75). CSA of right IJV was measured before induction of anaesthesia (T1), 5 min after intubation (T2), 5 min after pneumoperitoneum (T3), before desufflation (T4) and 5 min prior to extubation (T5). Chi-square test, and Student’s paired and unpaired t test were used for statistical analysis.

Results:

The increase in IJV CSA at T3 when compared to T2 was statistically significant in both the groups (P < 0.001). On desufflation, the change in IJV CSA showed significant decrease in T5 value than T4 value in both the groups (P < 0.001). However, the percentage change in the IJV CSA was more in group S (35.4%) than group L (21.2%).

Conclusion:

CSA of IJV increased significantly even with lower IAP of 6-8 mmHg. Laparoscopic surgery can be performed conveniently even at low IAP.

The "Dark Side" of Pneumoperitoneum and Laparoscopy

Laparoscopic surgery has been one of the most common procedures for abdominal surgery at pediatric age during the last few decades as it has several advantages compared to laparotomy, such as shorter hospital stays, less pain, and better cosmetic results. However, it is associated with both local and systemic modifications. Recent evidence demonstrated that carbon dioxide pneumoperitoneum might be modulated in terms of pressure, duration, temperature, and humidity to mitigate and modulate these changes. The aim of this study is to review the current knowledge about animal and human models investigating pneumoperitoneum-related biological and histological impairment. In particular, pneumoperitoneum is associated with local and systemic inflammation, acidosis, oxidative stress, mesothelium lining abnormalities, and adhesion development. Animal studies reported that an increase in pressure and time and a decrease in humidity and temperature might enhance the rate of comorbidities. However, to date, few studies were conducted on humans; therefore, this research field should be further investigated to confirm in experimental models and humans how to improve laparoscopic procedures in the spirit of minimally invasive surgeries.

Preperitoneal insufflation pressure of the abdominal wall in a porcine model

BACKGROUND

Most complications and adverse events during laparoscopic surgery occur during initial entry into the peritoneal cavity. Among them, preperitoneal insufflation occurs when the insufflation needle is incorrectly placed, and the abdominal wall is insufflated. The objective of this study was to find a range for static pressure which is low enough to allow placement of a Veress needle into the peritoneal space without causing preperitoneal insufflation, yet high enough to separate abdominal viscera from the parietal peritoneum.

METHODS

A pressure test was performed on twelve fresh porcine carcasses to determine the minimum preperitoneal insufflation pressure and the minimum initial peritoneal cavity insufflation pressure. Each porcine model had five needle placement categories. One category tested the initial peritoneal cavity insufflation pressure beneath the umbilicus. The four remaining categories tested the preperitoneal insufflation pressure at four different anatomical locations on the abdomen that can be used for initial entry. The minimum initial insufflation pressures from each carcass were then compared to the preperitoneal insufflation pressures to obtain an optimal range for initial insufflation.

RESULTS

Increasing the insufflation pressure increased the probability of preperitoneal insufflation. Also, there was a statistically significant difference (p < 0.05) between the initial peritoneal cavity insufflation pressures (8.83 ± 4.19 mmHg) and the lowest preperitoneal pressures (32.54 ± 7.84 mmHg) (mean ± SD).

CONCLUSION

Pressures greater than 10 mmHg resulted in initial cavity insufflation and pressures greater than 20 mmHg resulted in preperitoneal insufflation in porcine models. By knowing the minimum pressure required to separate the layers of the abdominal wall, the risk of preperitoneal insufflation can be mitigated while obtaining safe and efficient entry into the peritoneal cavity. The findings in this research are not a guideline for trocar or Veress needle placement, but instead reveal preliminary data which may lead to more studies, technology, etc.

Anaesthetic Challenges and Transesophageal Echocardiography-Guided Perioperative Management in a Patient with Uncorrected Adult Congenital Heart Disease Presenting for Emergency Laparoscopic Hysterectomy

Anaesthetic management of a patient with adult congenital heart disease with a single ventricle physiology presenting for an emergency laparoscopic surgery is challenging. The importance of a multidisciplinary approach, astute understanding of the pathophysiology and optimisation of intraoperative hemodynamic goals cannot be overemphasised. The present report describes the anaesthetic challenges and the role of transoesophageal echocardiography in perioperative management of a patient with uncorrected tetralogy of Fallot with pulmonary atresia, who successfully underwent an emergency laparoscopic hysterectomy under general anaesthesia.

Prehabilitation of complex ventral hernia patients with Botulinum: a systematic review of the quantifiable effects of Botulinum

PURPOSE

Complex ventral hernia repair (CVHR) encompasses patient optimization, primary fascial closure (PFC), mesh reinforcement and component separation technique (CST), if needed. High rates of complications after CST are still reported. Prehabilitation by managing pre-operative modifiable risk factors, like abdominal wall compliance, possibly reduces these rates. Compliance can be modified by intramuscular injection of Botulinum in the lateral abdominal wall muscles (LAWM). Paralysis leads to elongation of these muscles, which may facilitate PFC and/or prevent CST. Evidence to use Botulinum in hernia patients is scarce and fragmented. An update of evidence for the effect of Botulinum is presented.

METHODS

A multi-database search was conducted for Botulinum studies in ventral hernia patients. A systematic review was performed to describe its primary effect on compliance (LAWM elongation) and secondary effects like PFC ± CST rate, complications and recurrence.

RESULTS

14 studies were included (377 patients) with a HDW of median 12 (10-15) cm. A typical intervention consisted of 200-300 U Botulinum in 3 points per hemi-abdomen under US guidance, > 2 weeks pre-operatively and evaluated by CT just before the operation. The primary effect was a median LAWM elongation of 4.0 cm per side without complications of the injection (four studies, 107 patients). The median PFC rate was 100%, CST rate 38%, wound-related complications 19%, medical complications 18% and recurrence 0% (14 studies).

CONCLUSION

Botulinum safely elongates the abdominal wall muscles, but the level of evidence available remains low. Any patient in whom PFC is expected to be difficult, could be a candidate for prehabilitation with Botulinum.

Carbon dioxide gas endoscopy of the deep gluteal space

The treatment of hip and pelvic pain associated with abnormalities of the deep gluteal space has evolved and increasingly involves endoscopic techniques with a saline expansion medium. This investigation presents a surgical technique utilizing carbon dioxide as the insufflation medium for deep gluteal space endoscopy in 17 cadaveric hips. This technique was successful in 94% (16/17) of the hips, allowing for visualization of the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, branch of the inferior gluteal artery crossing the sciatic nerve, piriformis muscle, hamstring tendon origin, and lesser trochanter. Our experience suggests that gas expansion presents several advantages over fluid expansion.