The duration of spinal anaesthesia in elective caesarean section in Trendelenburg and reverse Trendelenburg positions: a randomized clinical trial

Objective

One of the common methods of anaesthesia for caesarean sections (CSs) involves the use of spinal anaesthesia in mothers. Various positions are utilized in this method. This study aims to compare the evaluation of two positions, Trendelenburg and reverse Trendelenburg, in candidates for CS to assess the duration of anaesthesia and changes in vital signs in women.

Methods

This study was a randomized clinical trial in which 60 pregnant mothers who met the inclusion criteria entered the study. These mothers were randomly allocated into two equal groups using block randomization. One group of patients received spinal anaesthesia in the Trendelenburg position, while the other group received it in the Reverse Trendelenburg position. Vital signs (systolic and diastolic blood pressure, heart rate, Apgar score, and SPO2) of participants from both groups were evaluated for 1 h after the induction of anaesthesia. Additionally, sensory level and duration of anaesthesia were measured. Finally, the data from both groups were subjected to statistical analysis using SPSS version 26 software.

Results

The mean (SD) age of participating mothers in the Reverse Trendelenburg and Trendelenburg groups was 28.93 (5.82) and 30.97 (4.94), respectively. The two study groups did not significantly differ in baseline characteristics such as age, BMI, which could potentially impact vital sign outcomes or anaesthesia duration, and education (P>0.05). The mean (SD) duration of anaesthesia in the Trendelenburg position was significantly higher than in the Reverse Trendelenburg position [221.57(min) vs. 159.00(min)] (P<0.0001). There was no significant difference between the two positions, Trendelenburg and Reverse Trendelenburg, in terms of sensory level and its extent (P=0.08). The two study groups did not significantly differ in hemodynamic changes measured 13 times, including heart rate, systolic and diastolic blood pressure, and Apgar score (P>0.05).

Conclusion

In spinal anaesthesia with the Trendelenburg position compared to the Reverse Trendelenburg position, there is a longer duration of anaesthesia. This is while the two positions did not differ in terms of hemodynamic changes and sensory level.

Investigating pelvic drop gait abnormality in adolescent hip pathology patients

BACKGROUND

Trendelenburg gait describes contralateral pelvic drop during single leg stance (SLS) with occasional lateral trunk lean compensation over the stance limb. However, quantitative research on 'uncompensated Trendelenburg' gait (pelvic drop independent of lateral trunk lean) remains sparse among populations that commonly utilize this gait pattern, such as adolescent hip pathology patients.

RESEARCH QUESTION

How prevalent is uncompensated Trendelenburg among various adolescent hip pathologies and how is it related to hip load, hip abduction strength, and self-reported hip pain?

METHODS

Gait, strength, and pain data were collected among 152 pre-operative patients clinically diagnosed with acetabular hip dysplasia, femoroacetabular impingement, Legg-Calvé-Perthes, or slipped capital femoral epiphysis (SCFE). Patients with ≥ 5.4° of dynamic pelvic drop in SLS were divided into a 'pelvic drop' group and screened to exclude those with excessive ipsilateral trunk lean. They were then compared to the 'stable pelvis' patients using a Mann-Whitney test.

RESULTS

Dysplasia patients represented the highest proportion of the pelvic drop group (46%). The pelvic drop group showed a significant increase in self-reported hip pain (p = 0.011), maximum hip abductor moment (p = 0.002), and peak coronal power absorption at the affected hip during SLS loading response, (p < 0.001) while showing no difference in abduction strength (p = 0.381).

SIGNIFICANCE

Uncompensated Trendelenburg gait may lead to increased loading of the affected hip in adolescent hip pathology patients. Disadvantageous hip biomechanics can create increased abductor muscle demand among these pathological populations, with dysplasia patients showing the highest prevalence. Maximal abduction strength did not correlate with pelvic drop. Future work should aim to identify and quantify causal factors. Increased coronal hip power absorption during weight acceptance warrants clinical attention, as there may be a detrimental, over-reliance on passive hip structures to support load among a population that that is already predisposed to hip osteoarthritis.

Is there hip muscle weakness in adults with chronic non-specific low back pain? A cross-sectional study

BACKGROUND

Patients with chronic low back pain may present changes in hip muscles. However, there is still limited and controversial evidence of the association between hip muscle weakness and chronic low back pain and whether this weakness can be assessed with functional tests. The purpose of this study was to assess whether there is hip muscle weakness in patients with non-specific chronic low back pain and whether there is an association between the positive Trendelenburg and Step-Down tests and hip muscle strength.

METHODS

This cross-sectional study included 40 patients with chronic low back pain and 40 healthy participants, assessed in an outpatient clinic in Vitória, Espírito Santo, Brazil. Muscle strength was measured for the hip abductors, adductors, extensors, internal rotators, and external rotators using isometric manual dynamometry and functional stability was measured by the Trendelenburg and Step-Down tests. Muscle strength was compared using the t test for independent samples and the chi-square test. The association between the tests and strength was performed using a binary logistic regression analysis.

RESULTS

Healthy participants showed a statistically significant greater muscle strength for the right hip abductors (mean difference [MD]: 28.1%, 95% confidence interval [CI]: 9.4 to 46.9), right adductors (MD: 18.7%, 95% CI: 6.2 to 31.2), right internal rotators (MD: 8.7%, 95% CI: 1.5 to 15.8), right extensors (MD: 21.1%, 95% CI: 6.2 to 31.2), left abductors (MD: 30.4%, 95% CI: 11.9 to 49), left adductors (MD: 18.4%, 95% CI: 3.7 to 33.2), and left extensors (MD: 21.6%, 95% CI: 6.6 to 36.5). There was no difference between groups for the positive functional tests, and there was no association between the tests and hip muscle strength.

CONCLUSION

Patients with chronic low back pain tend to have hip abductors, adductors, and extensors weakness. Furthermore, the functional tests should not be associated to hip muscle strength in patients with chronic low back pain.

Clinical utility of the Trendelenburg Test in people with multiple sclerosis

BACKGROUND

The clinical utility of the Trendelenburg Test remains unknown in people with multiple sclerosis (MS).

OBJECTIVE

To measure (1) intra-rater reliability, (2) agreement of goniometer-assessed Trendelenburg pelvis-on-femur angle (POF) with motion capture, and (3) concurrent validity of Trendelenburg POF and hip abduction strength with POF during walking and step negotiation.

METHODS

Trendelenburg POF was measured in 20 people with MS using goniometry and motion analysis. In addition, peak POF was measured using motion analysis during walking, step ascent, and step descent. Intra-rater reliability of goniometer-assessed Trendelenburg POF and agreement with motion analysis-assessed POF were analyzed. Pearson's r was used to determine the relationships between Trendelenburg POF and hip abduction strength with peak POF during each functional activity.

RESULTS

Goniometer-assessed Trendelenburg POF demonstrated very strong reliability (ICC: 0.948), strong agreement with 3D motion analysis (ICC: 0.792), correlated moderately with peak POF during walking (r = 0.519) and step ascent (r = 0.572), and weakly with step descent (r = 0.463). Hip abductor strength correlated weakly with peak POF during step ascent (r = -0.307) and negligibly during walking (r = -0.270) and step descent (r = -0.249).

CONCLUSIONS

Goniometer-assessed Trendelenburg POF was reliable, agreed with motion analysis, and may provide insight into hip abduction muscle performance during functional activities in people with MS.

Robotic-assisted gynecologic surgery associated tympanic membrane perforation: A report of two cases and review of the literature

Robotic gynecologic surgery is associated with the use of steep Trendelenburg positioning. Steep Trendelenburg is necessary to provide optimal exposure to the pelvis but is associated with an increased risk of non-surgical complications such as suboptimal ventilation, facial and laryngeal edema, increased intraocular and intracranial pressure as well as neurologic injury. Several case reports have described otorrhagia after robotic assisted surgery; however, there are limited reports on the risk of tympanic membrane perforation. To our knowledge, there are no published reports on tympanic membrane perforation in gynecologic nor gynecologic oncology surgery. We report two cases of perioperative tympanic membrane rupture and bloody otorrhagia associated with robot-assisted gynecologic surgery. In both cases otolaryngology/Ear Nose and Throat (ENT) was consulted, and the perforations resolved with conservative management.

Frequency of Positive Cuff Leak Test Before Extubation in Robotic Surgeries Done in Steep Trendelenburg Position

Anaesthesia for robotic surgeries done in steep trendelenburg position are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24 h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.

Diagnosis and Treatment Options of Abductor Insufficiency After Total Hip Replacement

Abductor insufficiency can cause abnormal gait, lateral hip pain, and abduction weakness in both native and prosthetic hips. In the setting of total hip arthroplasty (THA), abductor insufficiency may occur secondary to iatrogenic injury to the superior gluteal nerve or gluteus medius muscle, adverse local tissue reactions owing to metal-associated prosthetics, and osteolysis owing to bearing wear or infection. Surgical reconstruction of the abductor complex is indicated for patients with chronic tears who have pain, weakness, limp, and/or instability. This article reviews the pearls and pitfalls of surgical reconstruction options for abductor insufficiency following THA.

Heart-Rate-Corrected QT Interval Response to Ramosetron during Robot-Assisted Laparoscopic Prostatectomy: A Randomized Trial

Ramosetron, often used to prevent postoperative nausea and vomiting, might cause heart-rate-corrected (QTc) interval prolongation, as might robot-assisted laparoscopic prostatectomy (RALP), which requires a steep Trendelenburg position and CO2 pneumoperitoneum. This study aimed to determine how ramosetron administration affects the QTc interval in patients treated with RALP. Fifty-six subjects were randomly assigned to ramosetron (n = 28) or control (n = 28) groups. The ramosetron group received 0.3 mg of ramosetron after anesthetic induction, whereas the control group received normal saline. The QTc interval was measured before and after induction; after 5, 30, and 60 min of being placed in the Trendelenburg position; immediately after being returned to a supine position; and at the end of surgery. Linear mixed models were used to compare QT intervals between groups. QTc intervals did not differ significantly between groups over time (Pgroup×time = 0.111). However, they increased significantly in both groups after placement in the Trendelenburg position compared with before induction (Ptime < 0.001). This increase in QTc continued until the end of surgery in both groups. Based on these findings, ramosetron can be safely administered for the prevention of postoperative nausea and vomiting among patients undergoing RALP.

Removal of equine cryptorchid testes through an enlarged umbilical portal in dorsally recumbent horses after intra-abdominal laparoscopic castration

BACKGROUND

Laparoscopic removal of cryptorchid testes has been routinely reported through enlarged parainguinal incisions in dorsally recumbent horses. Outcomes following removal through an extended umbilical incision have not been previously reported.

OBJECTIVE

To describe the surgical technique of removing cryptorchid testes in dorsally recumbent horses through an enlarged umbilical portal after laparoscopic intra-abdominal castration.

STUDY DESIGN

Retrospective case series.

METHODS

Medical records were reviewed for horses that underwent laparoscopic removal of unilateral or bilateral cryptorchid testes from January 2006 to December 2016. Horses were placed under general anaesthesia, positioned in dorsal recumbency and then tilted into Trendelenburg position. Cryptorchid testes were castrated by ligating loop application and/or electrosurgery. The umbilical portal incision was extended along the linea alba for testes removal. All descended testes were removed by routine closed castration with the scrotal incision left to heal by second intention. Perianaesthetic laboratory values, surgical procedure descriptions, surgery and anaesthesia times, and in-hospital perioperative complications were recorded.

RESULTS

A total of 79 horses, aged 1-14 years, with unilateral or bilateral cryptorchidism were included: 90 cryptorchid testes were successfully removed through an enlarged umbilical portal incision. Sixty-eight horses were unilaterally cryptorchid and 11 were bilaterally cryptorchid. Two horses had minor post-operative complications related to the extended umbilical portal incision.

MAIN LIMITATIONS

Retrospective nature of the study, no control population for comparison and no follow-up after hospital discharge.

CONCLUSION

An extended umbilical portal incision is a successful alternative to extending a parainguinal incision for testis removal after laparoscopic castration.

Partial occlusion of left axillary artery in a patient undergoing robot-assisted radical cystectomy

Robot-assisted surgeries are associated with steep positions which provide free operative field to surgeons; however, it becomes more challenging to the anaesthesiologists. In robot-assisted surgery, the patient is not usually accessible after docking in of robot, so monitors, circuits and tubes should be tightly secured and confirmed before handing over the patient to the surgeons. We report a patient with partial left axillary artery occlusion in a patient posted for robot-assisted radical cystectomy.

Clinically derived biomechanical criteria for the Trendelenburg test

BACKGROUND

The Trendelenburg test has been used to assess hip abductor muscle function. A standardized evaluation of the test requires an assessment of both pelvis and trunk coronal plane alignment as the patient stands on one leg for 30 s. Coronal plane biomechanics using motion analysis allows for development of objective criteria to grade the test response. The aim of this study was to develop biomechanical criteria of the pelvis and trunk coronal plane kinematics.

METHODS

The video of 39 subjects with acetabular hip dysplasia performing the test while instrumented with a full-body modified Plug-In-Gait marker set for three-dimensional kinematic analysis, were evaluated by two orthopedic surgeons and one senior level biomechanist. Reviewers as a group assessed whether the subject had a positive test and noted the reason using guidelines outlined in the literature. Coronal plane trunk and pelvic angles of all subjects were analyzed and Receiver Operating Characteristic curves were used to determine optimal kinematic cutoff values for each positive Trendelenburg test reason.

FINDINGS

There were 26/39 patients who reviewers identified as having a positive test. Area under the curve of the receiver operating characteristic curve for trunk and pelvis mean/minimum were greater than 0.75. The curve was used to identify the optimal cut-offs of trunk lean and pelvic obliquity mean/minimum.

INTERPRETATION

The biomechanical criteria developed includes clinically derived coronal plane kinematic cut-offs of the pelvic and trunk angles. The criteria can be used within a motion capture setting for the standardization of the grading of the test response.

The effect of body position on intraocular pressure in anesthetized horses

OBJECTIVE

To evaluate the effect of four recumbent body positions on intraocular pressure (IOP) in anesthetized normal horses.

ANIMALS STUDIED

Ten nonglaucomatous adult horses.

PROCEDURES

Intraocular pressure was measured with a rebound tonometer in both eyes of standing sedated horses (baseline), then under general anesthesia during four randomized recumbent body positions, including Trendelenburg (Tr; 15-degree head down), reverse Trendelenburg (RTr; 15-degree head up), dorsal, and lateral; only the superior eye was measured in lateral positions. The mean of 3 IOP readings was taken at each position, allowing a minimum of 2 minutes of acclimatization after each position change before obtaining measurements. Repeated Measures Analysis with Newman-Keuls Multiple Comparison Post hoc was used to compare IOPs in different positions, and linear regression was used to compare IOP with age and weight cofactors.

RESULTS

When compared to baseline, the greatest change in IOP occurred in Tr (increase of 25.63 ± 8.12 mm Hg). When comparing all recumbent positions to baseline, IOP significantly increased in 3 of 4 body positions (P < .001), with no significant difference identified between RTr and baseline. When comparing all body positions to each other, the greatest IOP difference occurred between the Tr and the RTr positions (increase of 26.95 ± 5.41 mm Hg). Age and weight were not correlated with IOP in any position.

CONCLUSIONS

Recumbent body position significantly increases IOP in normal eyes of horses under injectable anesthesia.

Assessment of head and neck position for optimal ultrasonographic visualisation of the internal jugular vein and its relation to the common carotid artery: A prospective observational study

Background and Aims:

There is a wide variation in the anatomical relationship of the Internal Jugular Vein (IJV) to the Common Carotid Artery (CCA). This makes landmark based techniques of IJV cannulation and head rotation questionable and may lead to accidental arterial puncture. We conducted this study to determine the anatomical relation of the IJV to the CCA using (USG) in patients undergoing IJV cannulation for central venous access, and to analyse the effect of head rotation on this relationship.

Material and Methods:

A prospective observational study was conducted on 100 patients requiring central venous access, in the operation theatre or the intensive care unit. Anatomical relationship of the IJV to CCA at the level of the cricoid cartilage was analysed by noting the segment position (1-12) around the CCA using a high frequency linear USG probe on patients in neutral head position, on both sides and also with the head rotated to the contra lateral side by 15° and 45°.

Results:

Antero-lateral segments 1 and 2 were the most common positions (50% on the right and 73% on the left side). Change in segment causing increase in overlap of IJV and CCA with 15° head rotation was seen in 44% subjects on the right and 39% on the left. Statistically, a higher number of subjects showed overlap with 45° rotation (99% on right and 97% on left, P < 0.05).

Conclusion:

There is a wide variation in anatomical location of the IJV in relation to the CCA as seen by USG. Excessive head rotation causes overlap of IJV over CCA which may cause inadvertent arterial puncture, even under USG guidance. Thus, it is preferable to cannulate the IJV in neutral or near neutral head and neck position.

The effect of prolonged steep head-down laparoscopy on the optical nerve sheath diameter

Both the steep head-down position and pneumoperitoneum increase the intracranial pressure (ICP), and their combination for a prolonged period during laparoscopic radical prostatectomy (LRP) might influence the central nervous system homeostasis. Changes in optic nerve sheath diameter (ONSD) may reflect those in ICP. This study aims to quantify the change in ONSD in response to peritoneal CO₂ insufflation and steep Trendelenburg position during LRP. ONSD was measured by ultrasound in 20 patients undergoing LRP and ten awake healthy volunteers. In patients, ONSD was assessed at baseline immediately after induction of general anesthesia in supine position, 10 and 60 min from baseline in a 25° head-down position during pneumoperitoneum, and after deflation of pneumoperitoneum with the patient supine at 0° angle. ONSD in controls was assessed at baseline with the patient lying supine, after 10 and 60 min of 25° head-down position, and 10 min after repositioning at 0° angle. ONSD increased significantly in both patients and controls (p < 0.0001) without between-group differences. The mean increase was 10.3% (95% CI 7.7-12.9%) in patients versus 7.5% (95% CI 2.5-12.6%) in controls (p = 0.28), and didn't affect the time to recovery from anesthesia. In the studied patients, with a limited increase of end-tidal CO₂ and airway pressure, and low volume fluid infusion, the maximal ONSD was always below the cut-off value suspect for increased ICP. ONSD reflects the changes in hydrostatic pressure in response to steep Trendelenburg position, and its increase might be minimized by careful handling of general anesthesia.

Intraocular pressure change during laparoscopic sacral colpopexy in patients with normal tension glaucoma

INTRODUCTION AND HYPOTHESIS

The steep Trendelenburg position, high pneumoperitoneum pressure, and longer surgical time may lead to significantly increased intraocular pressure (IOP), which could result in unexpected eye disease complications, including perioperative visual loss (POVL). We monitored IOP to induce early laparoscopic sacral colpopexy (LSC) safely.

METHODS

This prospective study enrolled 39 patients with pelvic organ prolapse (POP), including 10 with eye diseases (6 with normal tension glaucoma and 4 with a narrow anterior chamber and normal range IOP). Enrolled patients underwent LSC under the same surgical settings involving a pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15°. We measured IOP at seven time points during surgery and estimated IOP changes with time in patients with or without eye diseases.

RESULTS

All patients, with or without eye diseases, experienced significantly elevated IOP during LSC. There were no significant differences between these groups. The average maximal IOP reached 20 mmHg at the end of surgery, and recovered to baseline values with the patient in the supine position at the end of anesthesia. No patient had an IOP of >40 mmHg as a critical threshold during surgery, and no substantial clinical eye symptoms were seen after LSC.

CONCLUSIONS

Laparoscopic sacral colpopexy using an pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15° during a 3-h surgical period could be performed within a safe range of IOP.

The Trendelenburg Position and Cognitive Decline: A Case-Control Interventional Study Involving Healthy Volunteers

Background

Postoperative cognitive decline (POCD) is defined as a new cognitive impairment arising after a surgical intervention. Aspects of cognitive function can be assessed using various validated cognitive function tests including the N-back task, the Stroop task, and the lexical decision-making task (LDT). There is some concern that prolonged Trendelenburg positioning during laparoscopic colorectal surgery may cause POCD.

Objective

The objective of this study was to assess the effect of time spent in the Trendelenburg position on cognitive function.

Methods

Volunteers were placed in the Trendelenburg position for 3 hours and, then, supine for 30 minutes. Validated cognitive function tests including 1-, 2-, and 3-back tasks, Stroop test, and LDT were performed at baseline and every 30 minutes after Trendelenburg positioning. Cognitive decline was defined per the International Study of Postoperative Cognitive Dysfunction trial: a decrease in accuracy from the volunteers’ baseline or an increase in response time from the volunteers’ baseline by >2 control group SDs.

Results

We recruited 15 healthy volunteers (8 males, 7 females) with an average age of 69 years (range 57-81) and average body mass index of 27.7 kg/m² (range 20.9-33). Accuracy remained within 2 SDs at all time points. An increase in response time did occur, and of 15 participants, 3 (20%) showed cognitive decline in the Trendelenburg position after 30 minutes, 4 (27%) after 1 hour, 5 (33%) after 90 minutes, 4 (27%) after 120 and 150 minutes, and 6 (40%) after 180 minutes. On moving to a supine position, 33% (5/15) participants showed cognitive decline.

Conclusions

The results of this study indicate that Trendelenburg positioning leads to cognitive decline. This may have implications for patients undergoing prolonged Trendelenburg positioning during laparoscopic colorectal surgery.

Intrathecal Delivery of AAV Vectors in Cynomolgus Macaques for CNS Gene Therapy and Gene Expression Analysis in Microdissected Motor Neurons

This protocol describes a method of delivering adeno-associated viral (AAV) vectors to the intrathecal space of nonhuman primates for CNS-directed gene therapy. It includes the surgical implantation of the catheter, vector infusion, necropsy, laser-capture microdissection of motor neurons, and gene expression analysis. This method allows efficient and reproducible delivery, and would be of interest to test gene therapy vectors for the treatment of disorders of the central nervous system of nonhuman primates. This protocol was tested in cynomolgus macaques and may be adapted for AAV delivery to different species of large animals.

Appraisal of systemic inflammation and diagnostic markers in a porcine model of VAP: secondary analysis from a study on novel preventive strategies

Background

We previously evaluated the efficacy of a ventilatory strategy to achieve expiratory flow bias and positive end-expiratory pressure (EFB + PEEP) or the Trendelenburg position (TP) for the prevention of ventilator-associated pneumonia (VAP). These preventive measures were aimed at improving mucus clearance and reducing pulmonary aspiration of bacteria-laden oropharyngeal secretions. This secondary analysis is aimed at evaluating the effects of aforementioned interventions on systemic inflammation and to substantiate the value of clinical parameters and cytokines in the diagnosis of VAP.

Methods

Twenty female pigs were randomized to be positioned in the semirecumbent/prone position, and ventilated with duty cycle 0.33 and without PEEP (control); positioned as in the control group, PEEP 5 cmH₂O, and duty cycle to achieve expiratory flow bias (EFB+PEEP); ventilated as in the control group, but in the Trendelenburg position (Trendelenburg). Following randomization, P. aeruginosa was instilled into the oropharynx. Systemic cytokines and tracheal secretions P. aeruginosa concentration were quantified every 24h. Lung biopsies were collected for microbiological confirmation of VAP.

Results

In the control, EFB + PEEP, and Trendelenburg groups, lung tissue Pseudomonas aeruginosa concentration was 2.4 ± 1.5, 1.9 ± 2.1, and 0.3 ± 0.6 log cfu/mL, respectively (p = 0.020). Whereas, it was 2.4 ± 1.9 and 0.6 ± 0.9 log cfu/mL in animals with or without VAP (p < 0.001). Lower levels of interleukin (IL)-1β (p = 0.021), IL-1RA (p < 0.001), IL-4 (p = 0.005), IL-8 (p = 0.008), and IL-18 (p = 0.050) were found in Trendelenburg animals. VAP increased IL-10 (p = 0.035), tumor necrosis factor-α (p = 0.041), and endotracheal aspirate (ETA) P. aeruginosa concentration (p = 0.024). A model comprising ETA bacterial burden, IL-10, and TNF-α yielded moderate discrimination for the diagnosis of VAP (area of the receiver operating curve 0.82, 95% CI 0.61–1.00).

Conclusions

Our findings demonstrate anti-inflammatory effects associated with the Trendelenburg position. In this reliable model of VAP, ETA culture showed good diagnostic accuracy, whereas systemic IL-10 and TNF-α marginally improved accuracy. Further clinical studies will be necessary to confirm clinical value of the Trendelenburg position as a measure to hinder inflammation during mechanical ventilation and significance of systemic IL-10 and TNF-α in the diagnosis of VAP.

[Surgical refixation of gluteal tendon tears by mini-open double-row technique]

OBJECTIVE

Stable refixation of gluteal tendons at the anatomic footprint by large-area contact by the means of knotless double-row anchor fixation (HipBridge technique).

INDICATIONS

Symptomatic tear of gluteus medius and/or gluteus minimus tendon with persisting pain after nonsurgical treatment, or primarily reconstructable mass rupture with gluteal insufficiency, revision surgeries.

CONTRAINDICATIONS

Primary nonreconstructable mass ruptures, atrophic or fatty degeneration of gluteal muscles grade Goutallier 4, local infections.

SURGICAL TECHNIQUE

Lateral position, longitudinal skin incision over greater trochanter, longitudinal incision of iliotibial band, resection of trochanteric subgluteus maximus bursa, longitudinal splitting of gluteal tendons over tear, debridement and mobilisation of tendons for sufficient distalisation to tendon footprint at anterior and lateral trochanteric facet, debridement of sclerotic greater trochanter, punching and tapping of proximal row, placement of two proximal anchors loaded with nonresorbable suture tape, fan-shaped four times gluteal tendon perforation at myotendinous transition zone, double-V-shape crossing of suture tapes, punching and tapping of distal row, fixation of crossed tapes with two distal knotless suture anchors under mild pretensioning of gluteal tendons, side-to-side tendon suture, vastogluteal and iliotibial band closure, wound closure.

POSTOPERATIVE MANAGEMENT

Stage-dependent physiotherapy with partial weight-bearing with 20 kg for 6 weeks, no active abduction, no adduction and no external rotation in flexion for 6 weeks after surgery. From week 7 after surgery, free range of motion, active-assisted abduction and increase in weight-bearing by 15 kg/week. No peak load for 4 months. Thromboembolic prophylaxis until full weight-bearing is reached.

RESULTS

Success rates of 80-90% can be expected in cases with no or only minor muscle atrophy.

Evaluating the Variation of Intraocular Pressure With Positional Change During Colorectal Laparoscopic Surgery: Observational Study

Background

The incidence of perioperative visual loss following colorectal surgery in the US is quoted as 1.24 per 10,000. Raised intraocular pressure (IOP) during extreme Trendelenburg position leading to reduced optic nerve perfusion is thought to be a cause.

Objective

To assess the effect of the degree of Trendelenburg tilt and time spent in Trendelenburg on IOP during laparoscopic colorectal surgery.

Methods

Fifty patients undergoing laparoscopic colorectal surgery were recruited. A Tonopen XL applanation tonometer was used to take IOP measurements hourly during surgery, and each time the operating table was tilted. A correlation coefficient for the degree of Trendelenburg tilt and IOP was calculated for each patient. Group 1 included patients undergoing a right-sided colonic procedure, and Group 2 included all left-sided colonic operations.

Results

The mean age of Group 1 participants (n=25) was 69 years (SD 14), and Group 2 (n=25) was 63 years (SD 16; P>.05). The average length of surgery for Group 1 was 142 minutes (SD 48), and Group 2 was 268 minutes (SD 99; P≤.05). The mean maximum degree of Trendelenburg tilt in Group 1 was 10 (SD 7) and Group 2 was 19 (SD 6; P≤.05). The mean IOP increase was 9 mm Hg (SD 5) for Group 1 and 15 mm Hg (SD 5) in Group 2 (P≤.05). An overall correlation coefficient for the degree of Trendelenburg tilt and IOP change (n=48) was .78.

Conclusions

There is a strong correlation between IOP elevation during laparoscopic colorectal surgery and the degree of Trendelenburg tilt. This may be significant for patients undergoing prolonged surgery and especially those with glaucoma.

Can the SENSIMED Triggerfish® lens data be used as an accurate measure of intraocular pressure?

PURPOSE

The SENSIMED Triggerfish^® contact lens sensor (CLS) has an embedded micro-sensor that captures spontaneous circumferential changes at the corneoscleral junction and transmits them via an antenna to a device where these measurements are stored. During laparoscopic colorectal surgery, patients are placed in Trendelenburg position which has been shown to increase intraocular pressure (IOP). Laparoscopic colorectal surgery requires both pneumoperitoneum and Trendelenburg positioning; therefore, IOP can vary significantly. We aimed to assess whether circumferential changes in the corneoscleral area can be correlated to IOP changes measured using Tono-pen^® XL applanation tonometer during laparoscopic colorectal surgery.

METHOD

Patients undergoing laparoscopic colorectal resections were included. On the day of surgery, baseline IOP was taken and the SENSIMED Triggerfish^® CLS was then set up in one eye of the patient. During surgery (whilst under general anaesthetic), IOP measurements were taken in the contralateral eye using a Tono-pen^® XL applanation tonometer every hour and any time the table was moved to record the fluctuations of IOP during surgery and any association with position change. The timings of these readings were documented.

RESULTS

Twenty patients were included in this study (six males, 14 females). Average age was 64.6 years (SD = 16.3). The fluctuation in IOP measured in the reference eye ranged between 6.3 and 46.7 mmHg. The mean correlation coefficient between CLS output measurements and these IOP measurements was r = 0.291 (95% CI).

CONCLUSION

Our results showed a weak correlation between the SENSIMED Triggerfish^® CLS data output and IOP measurements taken using the Tono-pen^® XL applanation tonometer.

Variation in intraocular pressure caused by repetitive positional changes during laparoscopic colorectal surgery: a prospective, randomized, controlled study comparing propofol and desflurane anesthesia

Laparoscopic surgery is often prolonged and requires positional changes to facilitate surgical access. Previous studies reported intraocular pressure (IOP) changes in one fixed position. This study investigated the effect of desflurane and propofol anesthesia on IOP during repeated positional changes. A total of 46 patients undergoing laparoscopic colorectal surgery were randomized into desflurane or propofol groups. IOP was measured using a handheld tonometer at seven time points: before induction (baseline), after endotracheal intubation, after pneumoperitoneum, after the first Trendelenburg and right tilt position, after reverse Trendelenburg and right tilt position, after the second Trendelenburg and right tilt position and before endotracheal extubation. Trendelenburg positioning raised IOP in both groups. In the desflurane group, IOP at the first Trendelenburg position was 6.27 and 8.48 mmHg higher than baseline IOP in left and right eye, respectively; IOP at the second Trendelenburg position was 7 and 9.44 mmHg higher than baseline in left and right eye, respectively. In the propofol group, IOP at the first Trendelenburg position was 2.04 and 4.04 mmHg higher than baseline in left and right eyes, respectively. It was 3.04 and 4.87 mmHg higher than baseline in left and right eye, respectively, at the second Trendelenburg position. In the desflurane group, 56.52% patients exhibited high IOP (≥ 25 mmHg) compared with 13.04% in the propofol group at the second Trendelenburg position in the right eyes (P = 0.005). There was a positive correlation between IOP and peak inspiratory pressure (P < 0.001). Propofol anesthesia mitigated wide variations in IOP caused by repetitive positional changes during laparoscopic colorectal surgery.

Patient positioning for robot-assisted laparoscopic benign gynecologic surgery: A review

Robotic surgical platforms are now in widespread use in the practice of gynecology all over the world. The introduction of robotic surgery has required some modifications of patient positioning when compared to standard laparoscopic surgery. Optimal patient positioning is likely to be the most essential step of robotic surgery as it provides the technical feasibility to have adequate access to the pelvic structures for performing the surgery. It is prudent to pay attention to preventing patient shifting in Trendelenburg position because of tendency of sliding down toward the direction of the head. Inappropriate patient positioning is associated with inadequate exposure of the operative field as well as detrimental complications that may lead to long-term side effects. These issues can be reduced with use of proper or strategic positioning technique. The purpose of this review is to highlight important points to properly position patient for robot-assisted laparoscopic benign gynecologic surgery and protect patient from position-related injuries.

Is the Trendelenburg position the only way to better visualize internal jugular veins?

Background.

A larger cross-sectional area (CSA) of the internal jugular vein (IJV) makes catheterization easier and the Trendelenburg position is used to achieve this. Unfortunately, it is not comfortable for conscious patients. The aim was to evaluate the impact of alternative manoeuvres on the enlargement of the CSA of the IJV and to compare these manoeuvres with the Trendelenburg position.

Materials and methods.

A prospective study of 63 healthy volunteers was conducted. Two-dimensional ultrasound images of right IJV (RIJV) and left IJV (LIJV) were recorded at the level of the cricoid cartilage in the supine position with and without head rotation by 30 degrees during various manoeuvres.

Results.

The CSA of the RIJV and the LIJV significantly increased using hold of deep breath (mean size (cm²) RIJV 1.59 ± 0.82, LIJV 1.07 ± 0.64; both p < 0.001) and the Trendelenburg position (mean size (cm²) RIJV 1.5 ± 0.68, LIJV 0.99 ± 0.54; both p < 0.001). The 45-degree passive leg raise increased the CSA of only the RIJV (mean size (cm²) 1.17 ± 0.61, p = 0.024). These manoeuvres were compared with the Trendelenburg position. There was no significant difference in the size of the CSA using hold of deep breath on the LIJV (p = 0.08) and the RIJV (p = 0.203). The passive leg raise had a significantly weaker impact on the size of the CSA (p < 0.001 for both sides).

Conclusions.

Hold of deep breath and 45-degree passive leg raise (the latter limited for the right side only) are alternative manoeuvres to improve visualization of internal jugular veins for conscious patients. Hold of deep breath was as effective as the Trendelenburg position.

Does Restrictive Fluid Strategy during Robotic Pelvic Surgeries Obtund Intraoperative Rise in Intraocular Pressure?

Background:

Robotic pelvic surgeries require steep Trendelenburg position which may result in rise in intraocular pressure (IOP).

Aim:

The aim of this study was to compare the changes that occur in IOP during robotic pelvic surgeries in steep Trendelenburg position with a restrictive intravenous fluid administration.

Settings and Design:

This prospective observational study was conducted in a tertiary care institution.

Subjects and Methods:

Twenty consenting patients scheduled for pelvic robotic gynecological surgeries were enrolled. All patients received general anesthesia following a standardized protocol. IOP was measured before induction of anesthesia, immediately after induction and intubation, at the end of surgery immediately after making the patient supine and immediately after extubation. Ringer's lactate was administered intravenously at a rate of 4 mL/kg/h targeting a mean arterial pressure of >65 mmHg and urine output of >0.5 mL/kg/h.

Statistical Analysis Used:

Paired t-test was used in this study.

Results:

There was a fall in IOP soon after induction from baseline which was not significant. Immediately, following intubation, there was a significant rise in IOP. At the end of surgery, though IOP remained high, it was not statistically significant. However, following extubation, IOP rose further and the difference from the baseline became statistically significant. Although there was a moderate increase in peak airway pressure and highest EtCO₂ levels during Trendelenburg from baseline values, the differences were statistically insignificant.

Conclusion:

During robotic pelvic surgeries, adopting a restrictive intravenous fluid strategy with the maintenance of normal end-tidal carbon dioxide levels could abate effects of steep Trendelenburg position on IOP.

The Effect of Posture on Intraocular Pressure and Systemic Hemodynamic Parameters in Treated and Untreated Patients with Primary Open-Angle Glaucoma

PURPOSE

To assess intraocular pressure (IOP), systolic, diastolic, and mean arterial blood pressure (SBP, DBP, MAP) changes in the sitting, supine, and 20° head-down (Trendelenburg) position in treated (tPOAG) and untreated (uPOAG) primary open-angle glaucoma patients and healthy controls.

METHODS

All participants underwent IOP and systemic BP measurements in the sitting, supine, and Trendelenburg positions during office hours. IOP and BP readings in the sitting, supine, and Trendelenburg positions were analyzed.

RESULTS

Twenty-one tPOAG patients, 17 uPOAG patients, and 21 controls were enrolled in the study. Compared to controls, eyes in the tPOAG and uPOAG groups had significantly larger posture-induced IOP elevation upon changing from the sitting to the supine position (P = 0.020 and P = 0.032, respectively). Compared to controls, the IOP elevation in the Trendelenburg position was statistically higher for the tPOAG (P = 0.003), but not the uPOAG group (P = 0.840). All 3 groups had a similar pattern of SBP, DBP, and MAP changes.

CONCLUSIONS

Compared to controls, posture-induced IOP changes are more pronounced in treated and untreated POAG patients.

Intracranial Hypotension Following Traumatic Brain Injury: A Diagnostic and Therapeutic Challenge

BACKGROUND

Intracranial hypotension (IH) is a recognized cause of coma; however, the diagnosis is often challenging, especially in patients with superimposed traumatic brain injury.

CASE DESCRIPTION

A 67-year-old woman became comatose following evacuation of bilateral acute subdural hematomas with concurrent respiratory failure. Imaging and intraparenchymal intracranial pressure monitoring confirmed secondary IH. She was managed with an epidural blood patch and a 72-hour period in the Trendelenburg position guided by intracranial pressure monitoring and clinical assessment. She subsequently made an excellent neurologic recovery from an initial Glasgow Coma Scale score of 3 to a score of 15.

CONCLUSIONS

Secondary IH can easily be missed in patients who have sustained a primary brain injury. In patients with a poor neurologic recovery, clinicians should rule out secondary IH as a potential cause, as immediate treatment can lead to profound clinical improvement.

Bilateral Otorrhagia after Robotically Assisted Gynecologic Surgery in the Setting of a Reduced Trendelenburg Position and Low-Pressure Pneumoperitoneum: A Case Report and Review of the Literature

Perioperative otorrhagia in association with nonotolaryngologic surgery is rare. The cause is typically attributed to the physiologic derangements associated with the Trendelenburg position and pneumoperitoneum during laparoscopic surgery. The most well-accepted etiology is an increase in arterial and venous pressures causing the rupture of subcutaneous capillaries, although the exact etiology remains unclear. We present the first reported case of bilateral spontaneous otorrhagia associated with robotically assisted laparoscopic surgery involving a reduced Trendelenburg position and low-pressure pneumoperitoneum. Perioperative hypertension, female gender, advanced age, and increased bleeding risk may contribute to the development of this rare complication.

[Hemodynamic and respiratory conditions of patients with obstetric fistulae operated under spinal anesthesia at the Regional Reference Hospital in Manakara, Madagascar]

L'objectif était d'évaluer les états hémodynamiques et respiratoires des opérées de fistules obstétricales et rapporter nos expériences sur la prise en charge de ces malades. Il s'agit d'une étude transversale descriptive effectuée au Bloc opératoire et Réanimation du CHRR Manakara allant du 20 au 30 aout 2013. Etaient incluses les patientes opérées de fistules obstétricales sous rachianesthésie. Nous avons exclu les patientes classées ASA >2 et celles ayant des tares cardio-vasculaires ou respiratoires. Après consultations préanesthésiques, et bilans préopératoires, nous avons administré chez les patientes 12,5mg de bupivacaïne adrénalinée 0,5% isobare en intrathécal. Elles étaient mises en position de Trendelenburg 5 minutes après l'injection du produit anesthésique et durant toute l'intervention. Le niveau sensitif, la pression artérielle, la fréquence cardiaque, la fréquence respiratoire et la saturation pulsée en oxygène (SpO2) étaient enregistrés pendant l'intervention. Nous avons retenues 57 malades. Le bloc sensitivomoteur était excellent pour toutes les malades. Un niveau métamérique supérieur à T6 était atteint chez 56,36% des malades. A part quelques épisodes d'hypertension artérielle et tachycardie, nous n'avons trouvé aucune difficulté respiratoire ni cardiovasculaire en rapport avec la position. Seuls, le niveau sensitif et la fréquence respiratoire présentaient une corrélation (p=0,01). Cette étude suggère que la position de Trendelenburg est réalisable au cours de la rachianesthésie en utilisant un produit anesthésique approprié, en faisant attention, notamment aux changements de position et en tenant compte de l'examen préanesthésique.

Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study

QUESTION

What are the functional differences between people with greater trochanteric pain syndrome (GT), hip osteoarthritis (OA) or an asymptomatic population as measured by walking, Time Up and Go, single leg standing and strength?

DESIGN

Cross sectional study with blinded measurers.

PARTICIPANTS

38 participants with GT, 20 with end stage hip OA and 21 asymptomatic healthy control (AS) participants. All participants were women.

OUTCOME MEASURES

Pain (numeric rating scale), Walking speed (m/s), cadence (steps/min) and step length (m) measured via the 10m walk test and the Timed Up and Go; balance via single leg stance (s) duration; and hip abduction, adduction, medial and lateral rotation strength, standardized to body mass (BM) via the body mass average index (BMavg), measured via a wall mounted dynamometer.

RESULTS

The two symptomatic groups reported similar pain levels (p=0.226), more pain then the AS group (p<0.000). Compared to the AS participants, participants with GT or hip OA demonstrated lower walking speed (10mwt and TUG, p<0.001), lower cadence and shorter duration single leg stance on the affected leg (p<0.05). Participants with GT or hip OA also demonstrated bilaterally weaker hip abduction than the AS group (p≤0.005). Compared to AS and GT participants, participants with hip OA demonstrated adduction weakness on the affected side (p=0.008 and p=0.002 respectively).

CONCLUSION

There is a significant level of dysfunction and impairments associated with GT and hip OA. As activity limitations do not appear to be differentiated by structural impairments, we suggest that pain, rather than the underlying pathology may be the driving impairment that leads to walking and single leg standing dysfunction.

Comparison of volume controlled ventilation and pressure controlled ventilation in patients undergoing robot-assisted pelvic surgeries: An open-label trial

Background and Aims:

Although volume controlled ventilation (VCV) has been the traditional mode of ventilation in robotic surgery, recently pressure controlled ventilation (PCV) has been used more frequently. However, evidence on whether PCV is superior to VCV is still lacking. We intended to compare the effects of VCV and PCV on respiratory mechanics and haemodynamic in patients undergoing robotic surgeries in steep Trendelenburg position.

Methods:

This prospective, randomized trial was conducted on sixty patients between 20 and 70 years belonging to the American Society of Anesthesiologist Physical Status I–II. Patients were randomly assigned to VCV group (n = 30), where VCV mode was maintained through anaesthesia, or the PCV group (n = 30), where ventilation mode was changed to PCV after the establishment of 40° Trendelenburg position and pneumoperitoneum. Respiratory (peak and mean airway pressure [AP_peak, AP_mean], dynamic lung compliance [C_dyn] and arterial blood gas analysis) and haemodynamics variables (heart rate, mean blood pressure [MBP] central venous pressure) were measured at baseline (T₁), post-Trendelenburg position at 60 min (T₂), 120 min (T₃) and after resuming supine position (T₄).

Results:

Demographic profile, haemodynamic variables, oxygen saturation and minute ventilation (MV) were comparable between two groups. Despite similar values of AP_mean, AP_peak was significantly higher in VCV group at T2 and T3 as compared to PCV group (P < 0.001). C_dyn and PaCO₂ were also better in PCV group than in VCV group (P < 0.001 and 0.045, respectively).

Conclusion:

PCV should be preferred in robotic pelvic surgeries as it offers lower airway pressures, greater C_dyn and a better-preserved ventilation-perfusion matching for the same levels of MV.

Respiratory dynamics and dead space to tidal volume ratio of volume-controlled versus pressure-controlled ventilation during prolonged gynecological laparoscopic surgery

BACKGROUND

Laparoscopic operations have become longer and more complex and applied to a broader patient population in the last decades. Prolonged gynecological laparoscopic surgeries require prolonged pneumoperitoneum and Trendelenburg position, which can influence respiratory dynamics and other measurements of pulmonary function. We investigated the differences between volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) and tried to determine the more efficient ventilation mode during prolonged pneumoperitoneum in gynecological laparoscopy.

METHODS

Twenty-six patients scheduled for laparoscopic radical hysterectomy combined with or without laparoscopic pelvic lymphadenectomy were randomly allocated to be ventilated by either VCV or PCV. Standard anesthesic management and laparoscopic procedures were performed. Measurements of respiratory and hemodynamic dynamics were obtained after induction of anesthesia, at 10, 30, 60, and 120 min after establishing pneumoperitoneum, and at 10 min after return to supine lithotomy position and removal of carbon dioxide. The logistic regression model was applied to predict the corresponding critical value of duration of pneumoperitoneum when the Ppeak was higher than 40 cmH₂O.

RESULTS

Prolonged pneumoperitoneum and Trendelenburg position produced significant and clinically relevant changes in dynamic compliance and respiratory mechanics in anesthetized patients under PCV and VCV ventilation. Patients under PCV ventilation had a similar increase of dead space/tidal volume ratio, but had a lower Ppeak increase compared with those under VCV ventilation. The critical value of duration of pneumoperitoneum was predicted to be 355 min under VCV ventilation, corresponding to the risk of Ppeak higher than 40 cmH₂O.

CONCLUSIONS

Both VCV and PCV can be safely applied to prolonged gynecological laparoscopic surgery. However, PCV may become the better choice of ventilation after ruling out of other reasons for Ppeak increasing.

The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children

INTRODUCTION

We compared the effects of various surgical positions, with and without the Valsalva manoeuvre, on the diameter of the right internal jugular vein (RIJV).

METHODS

We recruited 100 American Society of Anesthesiologists physical status class I patients aged 2-12 years. The patients' heart rate, blood pressure, peripheral oxygen saturation and end-tidal CO2 pressure were monitored. Induction of anaesthesia was done using 1% propofol 10 mg/mL and fentanyl 2 µg/kg, while maintenance was achieved with 2% sevoflurane in a mixture of 50/50 oxygen and air (administered via a laryngeal mask airway). The RIJV diameter was measured using ultrasonography when the patient was in the supine position. Thereafter, it was measured when the patient was in the supine position + Valsalva, followed by the Trendelenburg, Trendelenburg + Valsalva, reverse Trendelenburg, and reverse Trendelenburg + Valsalva positions. A 15° depression or elevation was applied for the Trendelenburg position, and an airway pressure of 20 cmH2O was applied in the Valsalva manoeuvre. During ultrasonography, the patient's head was tilted 20° to the left.

RESULTS

When compared to the mean RIJV diameter in the supine position, the mean RIJV diameter was significantly greater in all positions (p < 0.001) except for the reverse Trendelenburg position. The greatest increase in diameter was observed in the Trendelenburg position with the Valsalva manoeuvre (p < 0.001).

CONCLUSION

In paediatric patients, the application of the Trendelenburg position with the Valsalva manoeuvre gave the greatest increase in RIJV diameter. The reverse Trendelenburg position had no significant effect on RIJV diameter.

The use of the trendelenburg position in the surgical treatment of extreme cerebellar slump

BACKGROUND

State-of-the-art treatment for Chiari Malformation I (CM-I) consists of decompression by posterior fossa craniectomy. A rare but severe complication that develops over months to years after this procedure is cerebellar slump. Treatment options for this condition are limited. We present a new and promising approach to treat this rare condition.

METHODS

The patients were placed in the Trendelenburg position to facilitate ascent of the cerebellum. After almost complete dissolution of neurologic symptoms, surgical reconstruction was performed by tonsillar resection and the creation of a new structural support using a bone graft.

RESULTS

Both patients experienced good clinical and morphological outcomes immediately after surgery, and for two years thereafter.

CONCLUSIONS

Neurological symptoms related to cerebellar or brainstem slump can be adequately reversed by placing the patient in the Trendelenburg position. After uneventful gravitational reversal of the slump, safe surgical reconstruction of the cerebellar support can be performed to securely preserve the anatomical reversal.

[Otorrhagia. A complication of laparoscopic hemicolectomy]

The fast and increasing advance in surgical technology during the last decades has led to a remarkable development in laparoscopic surgery. "Minimally invasive" surgery has become very popular in the last few years, not only in gynecological procedures but also in general surgery, orthopedics, thoracic and urological procedures. Gas inflation into the abdominal cavity and patient position provokes physiological changes, as well as complications that are not seen in open surgery. Pneumoperitoneum and the Trendelenburg position beyond 35° cause hemodynamic changes, resulting in an increase in arterial and central venous pressure. The external auditory canal vessels are directly affected by these changes, and postoperative otorrhagia after a prolonged laparoscopic surgery may be present. A case is presented of postoperative bilateral otorrhagia after laparoscopic left hemicolectomy.

Cardiac and Liver Marker Alterations After Laparoscopic Gynaecologic Operations

OBJECTIVE

In our study, we aimed to investigate the effect of laparoscopic procedures in which the abdominal cavity at a Trendelenburg position of 15 degrees was insufflated with CO2 on cardiac and liver markers.

METHODS

Forty patients scheduled for laparoscopic gynaecological surgery were included in the study. Venous blood samples were taken the day before operation and 6 hours after surgery, and later, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase-MB (CK-MB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), myoglobin (MY) and d-dimer (d-D) were measured.

RESULTS

There was no statistically significant difference in the values of preoperative and postoperative ALT (16.8±9.4 and 17.8±9.3; p=0.579), AST (19.4±7 and 20.9±7.6; p=0.361) and ALP (65.2±16.2 and 63.3±16.9; p=0.609), but LDH (385.1±117.3 and 460.6±156.3; p=0.003), CK (113.8±138.5 and 247.9±283.5; p=0.0001), CK-MB (22.8±13.3 and 28.7±16; p=0.011), MY (28.1±12.9 and 138.8±129; p=0.0001) and d-D (509.5±815: 1026±1054; p=0.0001) increased significantly.

CONCLUSION

After laparoscopic operations in the Trendelenburg position, postoperative serum ALT, AST and ALP levels, remained unchanged, when compared to preoperative values, but LDH, CK, CK-MB, myoglobin and d-dimer values increased significantly.

A Prospective, double-blinded randomized controlled study comparing two different Trendelenburg tilts in laparoscopically assisted vaginal hysterectomy positioning

BACKGROUND

Bispectral index (BIS) used for intra-operative depth assessment under general anesthesia (GA) can be altered by different factors. This study was designed to detect the alteration in BIS reading with two different Trendelenburg (TBG) tilt in laparoscopically assisted vaginal hysterectomy (LAVH) procedure.

MATERIALS AND METHODS

A prospective, double-blinded, randomized controlled study was designed involving 40 American Society of Anesthesiologists Grade I and II female patients, aged 35-60 years, scheduled to undergo LAVH under GA. Patients were divided into two groups with TBG >30° and TBG <30°. BIS readings; systolic and diastolic blood pressure, heart rate were recorded in supine position. Patients were then shifted to desired TBG position either (>30°) or (<30°) as per group allotment. Data were recorded at 30 min intervals and all the patients were followed upto 24 h postoperatively for any recall.

RESULTS

A rise in BIS value was noticed, when position was changed from supine to head down in both groups. During comparison between two groups with different angulations, TBG >30° showed a higher BIS value than TBG <30°. This statistically significant (P < 0.05) trend was observed at all the 30, 60, 90, and 120(th) min interval. Interestingly, BIS values returned to preoperative levels following adopting final supine position. No incidence of awareness was reported in both the series throughout the study.

CONCLUSION

Though awareness remains unaltered BIS value gets increased with higher angle of inclination in TBG position during LAVH operation.

Secure patient positioning using Badillo/Trendelenburg restraint strap during robotic surgery

Steep Trendelenburg position is routine during robotic urologic and gynecologic surgery in order to optimize exposure of the pelvis. This position requires that the patient be properly secured as to avoid any movement during the procedure. We analyzed the safety and tolerability of a reusable strap with disposable cushions used during robotic assisted radical prostatectomy. The Badillo/Trendelenburg restraint is a harness which is placed on the table prior to patient transfer. The restraint is a Class I FDA-registered device (Pintler Medical, Seattle, WA). Patients were marked at the beginning and end of the case to determine if any movement had occurred. The Badillo/Trendelenburg restraint was employed in 1,200 consecutive RARP cases. The restraint was used by a single surgeon at two institutions. The operating table was marked from edge of the patients shoulder to the end of the head of table at the beginning and end of the case to determine if any movement had occurred. Maximum movement observed was 1 cm. All patients were questioned and a physical examination were done in the post operative period for any shoulder or nerve injury. No reports of shoulder or brachial injury. For patients undergoing robotic surgery with steep Trendelenburg position the Badillo/Trendelenburg restraint provides a secure, reliable and safe means of maintaining proper position without any patient movement.

Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability

OBJECTIVES

The objective of this study was to evaluate heart rate variability and hemodynamic parameters following steep Trendelenburg positioning during robotic sacrocolpopexy.

STUDY DESIGN

For 19 women, median age 57 (range: 45-72), blood pressure and ECG were recorded during surgery. From the ECG signals interbeat intervals were used to assess heart rate variability, analyzed in time and frequency domains using the Fast Fourier transform. The low frequency and high frequency spectral bands were used to assess sympathetic and parasympathetic pathways respectively.

RESULTS

All women underwent robotic supracervical hysterectomy and sacrocolpopexy. A statistically significant decrease in the mean values of the low-frequency and high-frequency spectral bands, representing sympathetic and parasympathetic activity, respectively were demonstrated 5min following Trendelenburg positioning of the patients (from 3.6±1.4 to 2.9±0.8ms(2)/Hz, and from 3.5±1.4 to 2.9±1ms(2)/Hz, P<0.05). These changes correlated with a mean 20% decrease in heart rate, which lasted for 30min, and with a second drop in sympathetic and parasympathetic activity and heart rate, commencing 2h from the start of surgery, and lasting until the end of the operation.

CONCLUSIONS

Steep Tredelenburg positioning during robotic urogynecology surgery results in significant changes in the autonomic nervous system modulation of heart rate variability and in other hemodynamic parameters.

Intraocular pressure and steep Trendelenburg during minimally invasive gynecologic surgery: is there a risk?

STUDY OBJECTIVE

Steep Trendelenburg position is frequently used during gynecologic minimally invasive surgery (MIS). However, little attention has been given to the potential impact of this nonphysiologic positioning on patients, specifically intraocular pressure (IOP). The purpose of our study was to evaluate IOP changes during laparoscopic or robotic hysterectomy conducted in the steep Trendelenburg position.

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

John Sealy Hospital at the University of Texas Medical Branch, Galveston, TX.

PATIENTS

Female patients with no history of ocular pathology who underwent elective robotic or laparoscopic hysterectomy.

INTERVENTIONS

The anesthesia protocol was standardized for all study patients. IOP and mean arterial pressure (MAP) were obtained before anesthesia, after general anesthesia and intubation were achieved, after 1 hour of steep Trendelenburg positioning, after 2 hours of steep Trendelenburg positioning, and after the patient was returned to the supine position. Ocular perfusion pressure (OPP) was calculated using the following equation: OPP = MAP - IOP.

MAIN RESULTS

A total of 10 patients were included in this prospective study. A significant increase in IOP from baseline was observed after 1 hour and 2 hours of steep Trendelenburg positioning (p = .005 and .002, respectively). There was a statistically significant trend of increasing the IOP from baseline to the second hour of steep Trendelenburg positioning (p < .001). The IOP remained significantly elevated once the patient was returned to the supine position when compared with the baseline IOP (p = .006). OPP significantly decreased from baseline after 2 hours of steep Trendelenburg positioning (p = .03).

CONCLUSIONS

IOP increases significantly when patients are placed in the steep Trendelenburg position. Although further studies are needed to better characterize this process, given the aging population of our MIS patients in whom risk for glaucoma is significant, preoperative ocular health assessment should be considered in certain cases.

Isometric gluteus medius muscle torque and frontal plane pelvic motion during running

The objective of this study was to investigate the relationship between isometric GM torque and the degree of frontal plane pelvic drop during running. Twenty-one healthy, recreational runners (9 males, 12 females) who ran 8.05 km or more per week were obtained from a sample of convenience. GM maximal isometric torque was collected prior to the run. Subjects then ran on a treadmill for 30 minutes while bilateral three-dimensional pelvic kinematic data were collected for 10 seconds at each 2 minute increment. Left side pelvic drop showed a slight increase (effect size = 0.61); while, the right side pelvic drop remained stable (effect size = 0.18). Pearson's Correlations showed no relationship between GM isometric torque and frontal plane pelvic drop for any of the data collection periods during the 30-minute run. These results suggest that isometric GM torque was a poor predictor of frontal plane pelvic drop. One should question whether a dynamic rather than static measure of GM strength would be more appropriate. Future research is needed to identify dynamic strength measures that would better predict biomechanical components of running gait. Key pointsThere is a lack of research linking static, clinical measures to dynamic running gait observations.Isometric gluteus medius muscle torque is a poor predictor of frontal plane pelvic drop in running.Future studies should identify dynamic strength measures that correlate with elements of running biomechanics.