Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy

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, 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 review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

[The pneumoperitoneum course forecasting and surgery tactic in the group of patients with acute and chronic cholecystitis and concomitant pathology of cardiovascular system]

The share of elderly and senile patients with acute cholecystitis concomitant cardiovascular pathology whom the laparoscopic cholecystectomy has been provided is increased. The heightened intraabdominal pressure has negative influence at the cardiovascular system, so the alternative ways for treatment of this group of patients are used in clinic. We propose the pneumoperitoneum model using the pneumatic belt which is fixed at the abdomen in preoperative period in patients with an acute and chronic cholecystitis. This model is useful to forecast cardiovascular disorders during future laparoscopic cholecystectomy. The arterial pressure level, pulse score and ECG are monitored during the test (90 min). Myocardial ischemia appearance seems that the risk of laparoscopic cholecystectomy with pneumoperitoneum is high. The alternative method of surgery in such group of patients (no pneumoperitoneum is applied) is laparoscopic assisted cholecystectomya from miniaccess. This method allows to reducing frequency of intra- and postoperative complications connected with pneumoperitoneum negative influence at the patients with concomitant pathology of cardiovascular system.

Improvement of cerebral oxygenation during laparoscopy using intermittent sequential compression of legs

The creation of CO₂ pneumoperitoneum during laparoscopy causes a series of adverse effects. Impairment of brain oxygen saturation during laparoscopy is a result of increased intra-abdominal pressure, absorbed CO₂ and increased intracranial pressure. The aim of this study is to investigate the possible effects of pneumatic inter-mittent sequential compression (ISC) of legs on oxygenation of the brain during laparoscopy. 100 patients, ASA groups 1 and 2, subjected to elective laparoscopic cholecystectomy, were included in this study. The patients were divided into two groups consisting of 50 patients each, group I, control group, and group II, where ISC was applied. Oxygen saturation of the mixed venous blood from the internal jugular vein (SjvO₂) is an indirect assessment of cerebral oxygen use (oxygenation of the brain). Blood samples were obtained from the bulb of the right jugular vein, as the dominant side for venous drainage from the brain. Informed consent was obtained from each patient. Blood samples of 2 ml were obtained several times during the operation; the first sample immediately after anesthesia induction in order to establish the baseline values of SjvO₂, the second sample immediately after the creation of the pneumoperitoneum, and then every 15 minutes respectively until the end of the pneumoperitoneum. The last sample was obtained before the extubation of the patients. The ISC in group II was terminated after obtaining the last blood sample. Results showed that the average values of oxygen saturation of the mixed venous blood from the internal jugular vein--SjvO₂ levels were higher in group II where ISC was applied (82.3%→86.4%→85.3%→80.2%→82.8%→80.4%), compared to group I, without ISC (85.5%→77.8%→80.6%→83.8%→84.8%), statistically significant in the second and third measurement for p<0.05 for the second and the third measurement, i.e. after the creation of pneumoperitoneum, when the decreease in the brain oxygenation is most dramatic in the group without ISC. In conclusion, application of intermittent sequential compression of the legs is a simple and safe technique for preserving the brain oxygenation during laparoscopy by restoring the blood return from the legs.

A newly developed morcellator creates a new dimension in minimally invasive surgery

We compared the efficiency and safety of a newly developed morcellator with a conventional device for minimally invasive supracervical hysterectomy. The prospective, randomized parallel-group study was set in a department of obstetrics and gynecology within an Academic Teaching Hospital. Patients included 48 women; 20 treated with an existing laparoscopic morcellator (Group 1); 28 treated with newly developed laparoscopic morcellator (Group 2). The weight-adjusted dissection time was reduced significantly by more than half with the new morcellator (p <.01). Significantly fewer (p <.05) and longer pieces of tissue were removed with the new morcellator. The median weight of morcellated tissue in Group 1 was 120 g (range 35-450 g), and the median operating time to remove the morcellated tissue was 10 minutes (range 2-45 minutes). The corresponding figures in Group 2 were 110 g (range 50-320 g) and 4 minutes (range 0.5-12 minutes). No bladder or intestinal lesions or other iatrogenic organ damage was seen with either morcellator. None of the patients in either group had postoperative complications. All interventions were completed as planned in both groups, and none of the procedures had to be converted to an open operation. Adequate tissue for histologic analysis was obtained from all patients. We concluded that the newly developed morcellator is a safe and effective instrument for laparoscopic supracervical hysterectomy, offering a much shorter operation time for the removal of morcellated tissue than a conventional device and a low risk of injury to surrounding organs and tissue.

The short-term efficacy of fibrin glue combined with absorptive sheet material in visceral pleural defect repair

Tissue sealants can prevent the occurrence of pulmonary air leakage, although few studies have evaluated the seal-breaking pressure properties of the various methods. We developed a new method for repairing visceral pleural defects which combines fibrin glue with a sheet material. We used an animal model to compare its efficacy with that of three current techniques up to 24 h after application. Under thoracotomy, 5 x 20 mm visceral pleural defects with a depth of 3 mm were made in beagles. The defects in the normal lungs were repaired using 1 of 4 methods: Method A, fibrin-glue double layer (fibrinogen solution was dripped, followed by thrombin solution); Method B, pack method (fibrin glue combined with polyglycolic acid sheet); Method C, rubbing and spray (fibrinogen was rubbed, followed by spraying of both fibrinogen and thrombin solutions); Method D, fibrin-glue-coated collagen fleece. The defects were repaired also in an emphysematous lung model using Method A, B or C. In the normal lungs, Method B showed significantly higher pressure resistance compared with the other methods at 5 min, 1 and 3 h post-application. Pressure resistance increased with time for all methods. In the emphysematous lungs, Method B showed significantly higher seal-breaking pressure than Methods A and C. Compared with existing tissue sealant methods, the pack method reliably controlled pulmonary air leakage immediately after application.

Laparoscopic adhesiolysis in patients with chronic abdominal pain

PURPOSE OF REVIEW

The purpose of this review was to evaluate the indications, safety, and efficacy of laparoscopic adhesiolysis and its prevention in patients with chronic abdominal pain.

RECENT FINDINGS

The safety of laparoscopic adhesiolysis can be improved by using an optic trocar for laparoscopy, by using an ultrasonic technique for adhesiolysis, and by taking care with regard to risk factors. Although many studies have reported pain reduction after laparoscopic adhesiolysis, a recent randomized study showed no more pain relief than with diagnostic laparoscopy alone. The regrowth of adhesions after adhesiolysis is less after the laparoscopic technique compared with open surgery. Liquid products can prevent the formation of adhesions, but their clinical efficacy has not yet been proved in randomized studies in humans.

SUMMARY

Older patients with a greater number of previous abdominal operations are more prone to complications in laparoscopic surgery. The introduction of a Veress needle into the ninth intercostal space, the use of an optic trocar and ultrasonic dissection can reduce the incidence of iatrogenic bowel perforations. For chronic pain, diagnostic laparoscopy is encouraged, but laparoscopic adhesiolysis is no longer recommended; its benefit being no greater than that of diagnostic laparoscopy alone.

Role of dopamine in renal dysfunction during laparoscopic surgery

BACKGROUND

Sympathetic vascular insult and hemodynamic changes represent the most reliable explanation of renal impairment resulting from acute intraabdominal pressure. We evaluated the effects of low-dose dopamine administration during a long-lasting surgical laparoscopic procedure.

METHODS

For this study 40, patients submitted to a colorectal laparoscopic procedure with 15 mmHg of intraabdominal pressure were randomly allocated to two groups: 20 receiving 2 mg/kg/min of dopamine and 20 receiving the same perfusion of saline. Hemodynamic parameters, renal function, urinary output, and creatinine clearance, were studied.

RESULTS

The hemodynamic parameters were similar in both groups. The urinary output decreased during the intraoperative period only the saline group (p = 0.4). Then 2 h postoperatively, it increased in both groups, and no statistically significant differences were found between the groups. The creatinine clearance decreased in both groups during the intraoperative time, but it was worse in the saline group (-28 +/- 120 vs -194 +/- 106; p = 0.022). During the postoperative period, both groups showed improvement, but in control group the values remained lower than at baseline (p = 0.04), and significantly lower than in the dopamine group (230 +/- 337 vs 100 +/- 192; p = 0.012).

CONCLUSIONS

An intrabdominal pressure of 15 mmHg induces a time-limited renal dysfunction, and low doses of dopamine could prevent this undesirable effect.

Prevention of postoperative air leakage from lungs using a purified human collagen membrane-polyglycolic acid sheet

BACKGROUND

Human amnion has useful biomedical applications because it contains a large amount of human collagen fibers. We prepared purified human collagen membrane (HCM) from human amnion and used it to develop a new sheet by combining it with synthetic bioabsorbable polyglycolic acid (PGA) mesh. We evaluated its efficacy in preventing air leakage from the lungs of dogs.

METHODS

In 20 dogs, HCM-PGA sheet (n = 5), sheets using fibrin glue with a separate application method (n = 5), a mixed application method (n = 5), and fibrin glue alone (n = 5), were used as dressing materials after partial lung resection.

RESULTS

The HCM-PGA sheet using fibrin glue with a separate application method was shown to be significantly more effective by an air leakage pressure test than the other three methods. These results indicate that the HCM-PGA sheet is useful for preventing air leakage from the lung.

CONCLUSIONS

The HCM-PGA sheet is more effective than conventional fibrin glue for controlling postoperative air leakage.

Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery

BACKGROUND

Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used.

METHODS

A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases.

RESULTS

The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma).

CONCLUSIONS

The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.

High-flow laparoscopic insufflators

In this Update of our July 1995 Evaluation (Health Devices 24[7]), we tested three high-flow laparoscopic insufflators not covered in the original study. In this issue, we are again using the Product Profile Evaluation format that we introduced in our August 1996 (25[8]) Update Evaluation of automated external defibrillators; see the inset on page 14 for a detailed explanation of this new format. In brief, we evaluated the three new units using the same criteria and test methods as in the July 1995 study and rated and ranked the units according to the same overall scheme. Because our criteria and test methods have not changed since the original study, we have not repeated them in this issue; readers should refer to the July 1995 issue for that information. Instead, in a series of Product Profiles, we present the characteristics, test results, and ratings for each newly evaluated unit individually. Following the profiles, a comprehensive Conclusions section details how the newly evaluated units compare with those evaluated in our original study. One of the units evaluated in this issue is rated Acceptable. The other two are rated Conditionally Acceptable because of their inability to provide adequate pressure relief; a secondary gas source should not be applied in the pneumoperitoneum while these units are in use. Of the 16 units we have evaluated to date, nine are rated Acceptable and seven are rated Conditionally Acceptable.