CO2 Insufflation Research Articles

Flexible single port access in transoral endoscopic thyroidectomy vestibular approach

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is regarded the only no-scar technique which combines minimized surgical trauma with all advantages of endoscopy such as enhanced view, fluorescent parathyroid imaging (FPI) and optimum cosmesis. Addressing TOETVA specific local risk profiles like mental nerve injury, the potential of skin lesions or difficult specimen retrieval we modified the three trocar based TOETVA towards a soft single port platform. Single port-TOETVA (SP-TOETVA) was established and retrospectively analysed in five patients using a soft handmade single port housing multiple trocar valves. Standard laparoscopic instruments, one articulating instrument and a vessel-sealing device were utilized. CO2 insufflation was maintained at 6-8 mmHg. In all patients SP-TOETVA was completed successfully. Hemigland and total thyroid volumes ranged from 5-40 and 55 mL, respectively. Neither additional trocars nor conversion to open was required. Operation time yielded 102-214 min. Neuromonitoring and FPI were applied. The soft wound protection foil served for convenient specimen harvest. No intra- or postoperative complication occurred. In particular, no functional impairment on mental nerve was seen. SP-TOETVA with the soft and flexible handmade single port system is feasible and ensures wound protection. It allows for easy instrument application and benefits of minimally invasive surgery without the specific risk of lateral vestibular incisions.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

A prospective randomized, controlled study comparing low pressure versus standard pressure CO2 pneumoperitoneum during laparoscopic cholecystectomy

A prospective randomized controlled study was conducted to evaluate the feasibility and safety of low pressure co2 pneumoperitoneum versus standard pressure co2 pneumoperitoneum during laparoscopic cholecystectomy after receiving approval from ethical committee. Patients undergoing laparoscopic cholecystectomy were enrolled in the study after fulfilling eligibility criteria. According to surgical approach patients were randomly divided into two groups of 50 patients each, group A and group B respectively. Group a Patients underwent laparoscopic cholecystectomy with low pressure co2 pneumoperitoneum [less than 8 mmHg] while group B patients underwent laparoscopic cholecystectomy under standard pressure co2 pneumoperitoneum [12 to 15 mmHg]. The following parameters were assessed primarily in terms of incidence of pain in post-operative period, changes in cardiorespiratory, changes in the organ system functions and length of the hospital stay. Results: Both groups were matched for the demographic parameters. We found that operative time was comparable in both groups whereas post-operative pain analgesic requirement, changes in cardiorespiratory, changes in organ system function and length of the hospital were flavouring low pressure co2 pneumoperitoneum in a statistically significant manner. (p< 0.01). Conclusion: Low pressure co2 pneumoperitoneum is ideal for laparoscopic cholecystectomy in terms of post-operative pain, use of analgesics, and length of hospitals stay and minimizes the adverse hemodynamic effect of co2 insufflation.

METABOLIC EFFECTS OF CARBON DIOXIDE INSUFFLATION DURING LAPAROSCOPIC SURGERY: CHANGES IN PH, ARTERIAL PARTIAL PRESSURE OF CARBON DIOXIDE (PACO2) AND END TIDAL CARBON DIOXIDE (ETCO2)

Background: Laparoscopy involves inspecting the abdomen and pelvis using an endoscope. Carbon dioxide (CO2) is the gas that is commonly used to insufflate the abdomen so as to facilitate the surgical view.&#x0D; Aim: The present study was under taken to determine the Metabolic effects of carbon dioxide insufflation during laparoscopic surgery.&#x0D; Methods: An observational study on 50 patients above 18 years of age with physical status of American Society of Anaesthesiologists (ASA) Class I and II after obtaining approval from institutional ethical committee and consent of the patient was conducted in the Postgraduate Department of Anaesthesiology and Critical Care, Government Medical College Srinagar.&#x0D; Results: There was a progressive decrease in the pH during pneumoperitoneum in keeping with the hypercarbia. An increase towards baseline was observed during recovery but pH was still significantly lower than baseline 15 minutes into recovery (p&lt;0.118). The Pco2 increased after 15 mins Co2 insufflation &amp; peaked at 30 mins with mean &amp; SD 42.82,2.775 &amp; 46.16,2.909 respectively which was statically significant. Etco2 also increased after 15 mins of Co2 insufflation &amp; peaked at 30 mins with mean 41.56 &amp; 44.50 respectively which was statically significant. Similarly, Hco3 decreased over period of time with peak decrease at 30 mins of Co2 insufflation with mean 23.70, SD 1.919 &amp; range 19-27.&#x0D; Conclusion: Co2 insufflation does bring metabolic changes in Ph, Pco2, Etco2 &amp; HCO3 but with proper monitoring &amp; management laparoscopic procedure can be safely performed.&#x0D;

V-NOTES technique in tubal pregnancy: a clinical case

Background. Ectopic are 3% of all pregnancies, with 4.1–10% of them entailing lethal consequences, which exposes the imperfection of current operative techniques. v-NOTES (vaginal— natural orifice transluminal endoscopic surgery) is an emerging surgical technique offering solutions to achieve a good aesthetic effect coupled with a minimally invasive intervention and fewer trocar-associated complications. This article presents our first clinical experience with v-NOTES in a patient with tubal pregnancy.Clinical case description. Patient V., 28 yo, a first-time pregnancy, admitted emergently with complaints of genital bloody discharge and abdominal pain. Beta-hCG 2,200 mU/mL on examination, with a 48-h increase by 400 U. In ultrasound (US): pregnancy not located in uterine cavity, an inclusion (gestational sac?) visualised extraovarially on the right from uterus. Progressive right tubal pregnancy in repeated US.The patient was advised with v-NOTES as a surgical procedure. An informed voluntary consent has been obtained.A posterior colpotomy with intra-abdominal port placement was performed under endotracheal anaesthesia in lithotomy position. CO2 insufflation to 14 mmHg. Laparoscopy revealed about 30 mL liquid blood in Douglas pouch of abdominal cavity; sanitated. Ampulla of right fallopian tube contained a 2.5 x 1.5 cm bluish-coloured gestational sac. Right antegrade tubectomy performed with ultrasonic scissors and a bipolar clamp for the specimen evacuation via port. Colporrhaphy. Blood loss 35 mL, surgery time 35 min. Pain visual analogue scale (VAS) score 2 in first postoperative 24 h. The patient was discharged on day 2.Conclusion. v-NOTES is an emerging surgical technique alternative to laparoscopic access, which combines the benefits of minimal invasiveness and good aesthetics. More surgical practice and multicentre trials are necessary to draw definitive conclusions.

Effect of insufflated CO2 during laparoscopic surgeries on end tidal CO2 concentration using capnography

Use of laparoscopic surgeries become a best alternate for laparotomy and is used for the diagnostic as well as therapeutic purposes in patients presented for gynecological surgeries. Advantages include; reduction in postoperative persistent obstruction of intestine, aches, hospitalization, health expenses and problems relating to surgical wounds. Its procedure includes a brief period of intraperitoneal carbon dioxide (CO2) insufflation. Although this insufflation of carbon dioxide (CO2) is continued for a very short period of time causes deleterious physiological changes in respiratory system, lung volumes and gas exchange through alveoli. Purpose of conducting the study to understand the determination of effect of blowing of CO2 to intraperitoneal cavity during laparoscopic surgeries on end tidal CO2. A prospective descriptive study was done after the ethical approval from the concerned departments. End tidal CO2 (EtCO2) concentration was recorded in intervals at pre-induction of anesthesia before insufflation and termed this as baseline concentration of the said gas, then recorded at 10-mmHg, between 10-15 mmHg, at 15-mmHg of intraperitoneal pressure and at the cessation of the surgery. End tidal CO2 (EtCO2) after CO2 insufflation during laparoscopic surgeries is compared with the baseline EtCO2. Upon assessing the data, EtCO2 increased slightly after CO2 insufflation and considerably after the surgical incision. After completion of the laparoscopic surgery, the EtCO2 exhibited a trend to baseline value. This study concludes that the patients who were otherwise healthy and were just undergoing laparoscopic surgeries, EtCO2 surges slightly subsequent to CO2 insufflation and readily comes to baseline value.

Quantifying and Statistically Modeling Residual Pneumoperitoneum after Robotic-Assisted Laparoscopic Prostatectomy: A Prospective, Single-Center, Observational Study.

Background: Laparoscopic surgery (LS) requires CO2 insufflation to establish the operative field. Patients with worsening pain post-operatively often undergo computed tomography (CT). CT is highly sensitive in detecting free air—the hallmark sign of a bowel injury. Yet, the clinical significance of free air is often confounded by residual CO2 and is not usually due to a visceral injury. The aim of this study was to attempt to quantify the residual pneumoperitoneum (RPP) after a robotic-assisted laparoscopic prostatectomy (RALP). Methods: We prospectively enrolled patients who underwent RALP between August 2018 and January 2020. CT scans were performed on postoperative days (POD) 3, 5, and 7. To investigate potential factors influencing the quantity of RPP, correlation plots were made against common variables. Results: In total, 31 patients with a mean age of 66 years (median 67, IQR 62–70.5) and mean BMI 26.59 (median 25.99, IQR: 24.06–29.24) underwent RALP during the study period. All patients had a relatively unremarkable post-operative course (30/31 with Clavien–Dindo class 0; 1/31 with class 2). After 3, 5, and 7 days, 3.2%, 6.4%, and 32.3% were completely without RPP, respectively. The mean RPP at 3 days was 37.6 mL (median 9.58 mL, max 247 mL, IQR 3.92–31.82 mL), whereas the mean RPP at 5 days was 19.85 mL (median 1.36 mL, max 220.77 mL, IQR 0.19–5.61 mL), and 7 days was 10.08 mL (median 0.09 mL, max 112.42 mL, IQR 0–1.5 mL). There was a significant correlation between RPP and obesity (p = 0.04665), in which higher BMIs resulted in lower initial insufflation volumes and lower RPP. Conclusions: This is the first study to systematically assess RPP after a standardized laparoscopic procedure using CT. Larger patients tend to have smaller residuals. Our data may help surgeons interpreting post-operative CTs in similar patient populations.

Cerebral Oximetry after Low Pressure versus Standard Pressure Pneumoperitoneum in Laparoscopic Nephrectomy.

To evaluate whether pneumoperitoneum pressure lower than the standard pressure would allow higher cerebral oxygen saturation (rSO2) during laparoscopic nephrectomy (LN). Randomised controlled trial. Ondokuz Mayis University Hospital, Samsun, Turkey, from January to November 2020. Sixty-two patients (aged 18-65 years; ASA I-III) scheduled for LN were equally divided into a low-pressure (LP; 8 mmHg) and standard-pressure (SP; 14 mmHg) group. Mechanical ventilator settings were adjusted to maintain 32-37 mmHg ETCO2 and >96% SpO2 throughout the surgery. The rSO2 was evaluated by near-infrared spectroscopy before and one minute after induction and then every five minutes until patient transfer to the recovery unit. Oxygen and carbon dioxide partial pressures, pH, and haemoglobin, recorded at five minutes after induction, five and 30 minutes after insufflation, and 10 minutes after desufflation, were examined for correlations with rSO2. Both groups had similar rSo2, arterial blood gas, and haemoglobin values at all measurement times. The LP group showed no differences between the preoperative values and the values obtained at the different time points. In contrast, the SP group showed significant differences between the preoperative and the measured values (except at 25, 30, and 35 minutes) (p = 0.001). Four patients (12.9%) in both groups showed cerebral desaturation. The rSO2 values were moderately correlated with the CO2 and haemoglobin values. Low insufflation pressure offered no advantages over standard pressure in terms of haemodynamics, arterial blood gases, cerebral oxygen saturation during LN, and CO2 insufflation did not change rSO2 levels. Key Words: Pneumoperitoneum, Spectroscopy, Oximetry, Nephrectomy, Surgery, Laparoscopic nephrectomy.

Warm humidified CO2 insufflation improves pericardial integrity for cardiac surgery: a randomized control study.

Flooding the surgical field with dry cold CO<inf>2</inf> during open-chamber cardiac surgery has been used to mitigate air entrainment into the systemic circulation. However, exposing epithelial surfaces to cold, dry gas causes tissue desiccation. This randomized controlled study was designed to investigate whether the use of humidified warm CO<inf>2</inf> insufflation into the cardiac cavity could reduce pericardial tissue damage and the incidence of micro-emboli when compared to dry cold CO<inf>2</inf> insufflation. Forty adult patients requiring elective open-chamber cardiac surgery were randomized to have either dry cold CO<inf>2</inf> insufflation via a standard catheter or humidified warm CO<inf>2</inf> insufflation via the HumiGard device (Fisher & Paykel Healthcare, Panmure, Auckland, New Zealand). The primary endpoint was biopsied pericardial tissue damage, assessed using electron microscopy. We assessed the percentage of microvilli and mesothelial damage, using a damage severity score (DSS) system. We compared the proportion of patients who had less damage, defined as DSS<2. Secondary endpoints included the severity of micro-emboli, by visual assessment of bubble load on transesophageal echocardiogram; lowest near infrared spectroscopy; total de-airing time; highest cardio-pulmonary bypass sweep speed; hospital length of stay and complications. A higher proportion of patients in the humidified warm CO<inf>2</inf> group displayed conserved microvilli (47% vs. 11%, P=0.03) and preserved mesothelium (42% vs. 5%, P=0.02) compared to the control group. There were no differences in the secondary outcomes. Humidified warm CO<inf>2</inf> insufflation significantly reduced pericardial epithelial damage when compared to dry cold CO<inf>2</inf> insufflation in open-chamber cardiac surgery. Further studies are warranted to investigate its potential clinical benefits.

Relief Effect of Carbon Dioxide Insufflation in Transnasal Endoscopy for Health Checks-A Prospective, Double-Blind, Case-Control Trial.

CO2 insufflation has proven effective in reducing patients’ pain after colonoscopies but has not been examined in esophagogastroduodenoscopies. Therefore, we examined the effect of CO2 insufflation in examinees who underwent transnasal endoscopies without sedation. This study is a single-center, prospective, double-blind, case-control trial conducted between March 2017 and August 2018. Subjects were assigned weekly to receive insufflation with either CO2 or air. The primary outcome was improvement of abdominal pain and distension at 2 h and 1-day postprocedure. In total, 336 and 338 examinees were assigned to the CO2 and air groups, respectively. Visual analog scale (VAS) scores for abdominal distension (15.4 vs. 25.5; p < 0.001) and distress from flatus (16.0 vs. 28.8; p < 0.001) at 2 h postprocedure were significantly reduced in the CO2 group. VAS scores for pain during the procedure (33.5 vs. 37.1; p = 0.059) and abdominal pain after the procedure (3.9 vs. 5.7; p = 0.052) also tended to be lower at 2 h postprocedure, but all parameters showed no significant difference at 1-day postprocedure. All procedures were safely completed through the planned program, and no apparent adverse events requiring treatment or follow-up occurred. In conclusion, CO2 insufflation may reduce postprocedural abdominal discomfort from transnasal esophagogastroduodenoscopies. (UMIN000028543).

Effects of neuromuscular blockade on the surgical conditions of laparoscopic totally extraperitoneal inguinal hernia repair: a randomized clinical trial.

Unlike other laparoscopic techniques, the peritoneum is not incised in laparoscopic totally extraperitoneal inguinal hernia repair (TEP), and the preperitoneal space is developed as the surgical field by blunt dissection and CO2 insufflation. While many studies have investigated the effect of neuromuscular blockade (NMB) on the surgical conditions and postoperative pain of laparoscopic intraperitoneal surgery, few studies have investigated those of TEP. In the present study, we investigated the effect of NMB on the surgical conditions and postoperative pain of TEP. Forty-two adult patients scheduled for unilateral TEP under general anesthesia with remifentanil and desflurane were randomly assigned to paralyzed or non-paralyzed groups. In the paralyzed group, rocuronium doses were administered to maintain post-tetanic count at ≤ 5 during surgery. Non-paralyzed subjects were not given any rocuronium. Postoperatively, surgeon-evaluated surgical conditions, assessed using a 100-mm visual analogue scale ranging from 0mm (not acceptable) to 100mm (excellent), were compared between the two groups. For evaluation of postoperative pain, the time from the end of anesthesia to the initial requirement of postoperative analgesia was compared by the log-rank test. Median [interquartile range] score of surgical condition in the paralyzed and non-paralyzed groups were 84 [75-90] and 84 [78-87], respectively (P = 0.46). Significant differences in postoperative analgesic requirements between the two groups were not confirmed (P = 0.74). NMB did not improve the surgical conditions nor reduce postoperative pain. NMB is not routinely needed for TEP just because it is a laparoscopic procedure. The trial was registered in the UMIN clinical trials registry (UMIN000029683, October 24, 2017; Principal investigator: Masafumi Fujimoto, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033920 ) prior to patient enrolment.

Fetoscopic insufflation of heated-humidified carbon dioxide during simulated spina bifida repair is safe under controlled anesthesia in the fetal lamb.

To assess the safety of Partial-Amniotic-Insufflation-of-heated-humidified-CO2 (hPACI) during fetoscopic spina bifida repair (fSB-repair). A simulated fSB-repair through an exteriorized uterus under hPACI was performed in 100-day fetal lambs (term=145days) under a laboratory anesthesia protocol (n=5; group 1) which is known to induce maternal-fetal acidosis and hypercapnia. Since these may not occur clinically, we applied a clinical anesthesia protocol (n=5; group 2), keeping maternal parameters within physiological conditions, that is, controlled maternal arterial carbon dioxide (CO2) pressure (pCO2 =30mmHg), blood pressure (≥67mmHg), and temperature (37.1-39.8°C). Our superiority study used fetal pH as the primary outcome. Compared to group 1, controlled anesthesia normalized fetal pH (7.23±0.02 vs. 7.36±0.02, p<0.001), pCO2 (70.0±9.1 vs. 43.0±1.0mmHg, p=0.011) and bicarbonate (27.8±1.1 vs. 24.0±0.9mmol/L, p=0.071) at baseline. It kept them within clinically acceptable limits (pH≥7.23, pCO2 ≤70mmHg, bicarbonate≤30mm/L) for ≥120min of hPACI as opposed to ≤30min in group one. Fetal pO2 and lactate were comparable between groups and generally within normal range. Fetal brain histology demonstrated fewer apoptotic cells and higher neuronal density in the prefrontal cortex in group two. There was no difference in fetal membrane inflammation, which was mild. Fetoscopic insufflation of heated-humidified CO2 during simulated fSB-repair through an exteriorized uterus can be done safely under controlled anesthesia.

Development of a Gastight Thoracotomy Model for Investigation of Carbon Dioxide Field-Flooding Efficacy.

Carbon dioxide (CO2) field-flooding during cardiac surgery is a prevention technique to avoid blood-air contact and subsequent embolization. Although it was first used more than 60 years ago, there is still some perplexity around its efficacy, mainly because the gas is invisible and air embolization is difficult to quantify.An accurate assessment of field-flooding can, therefore, best be performed in models where various methods can be tried in a controlled environment and evaluated with industrial-grade sensors. Multiple options are available for anatomically correct models that reproduce a sternotomy situation, but models for minimally invasive cardiac surgery are expensive and normally meant for training of surgical techniques where only the top side of the model is important.We created a low-cost and “home-made” gastight mini-thoracotomy model with internal organs and left atrial incision to investigate CO2 insufflation in a simulated minimally invasive mitral valve surgery. The model was validated with CO2 field-flooding tests with a commercial diffuser, while three sensors continuously registered the local concentration of CO2 gas.

Cardiac Arrest due to Carbon Dioxide Embolism During Laparoscopic Gynecologic Surgery of a Patient with Previous Abdominal Surgery: A Case Report

Catastrophic carbon dioxide (CO2) embolism is a rare, but potentially life-threatening, the complication of laparoscopic gynecologic surgery. We report the case of a healthy 53-year-old woman who developed CO2 embolism and cardiac arrest during laparoscopic surgery. She had a history of two cesarean sections and had extensive peritoneal adhesions. After placement of the trocar and insufflation of CO2, end-tidal CO2 dropped from 35 to 15 mm Hg, and the patient had a cardiovascular collapse. In this patient, CO2 embolism was diagnosed on the basis of a sudden decrease in end-tidal CO2, hypotension, and hypoxemia. The patient was managed quickly and aggressively. The patient recovered completely following the treatment for CO2 embolism, with no cardiopulmonary or neurological sequelae. There is an increased risk of catastrophic CO2 embolism during laparoscopic gynecologic surgery in patients with previous abdominal surgery. Therefore, the surgeon and anesthesiologist should remain vigilant to promote early detection of CO2 embolism.

Anesthesia for Per-oral endoscopic myotomy (POEM) - not so poetic!

Peroral endoscopic myotomy (POEM) is a promising natural orifice transluminal endoscopic procedure for the treatment of esophageal motility disorders, with similar effectiveness as of Heller myotomy. It is performed under general anesthesia in endoscopy suite. Creation of submucosal tunnel in the esophageal wall is a key component. The continuous insufflation of CO2 inadvertently tracks into surrounding tissues and leads to capno mediastinum, capno thorax, capno peritoneum, and subcutaneous emphysema. Thus, the challenges, for an anesthesiologist are not only providing remote location anesthesia, increased risk of aspiration during induction, but also early detection of these complications and specific emergency management. Though a therapeutic innovation, POEM remains an interdisciplinary challenge with no specific anesthesia care algorithms and evidence-based recommendations. The purpose of this review is to outline the anesthesia and periprocedural practices based on existing evidence.

Port-Site Metastasis (PSM): Definition, clinical contexts and possible preventive actions to reduce risk

The "port-site metastasis" represents a tumor recurrence that develops in the abdominal wall within the scar tissue of the insertion site of one or more trocars, after laparoscopic surgery, not associated with peritoneal carcinomatosis. This last aspect is central because in the literature some isolated cases are reported, but most cases are associated with peritoneal carcinomatosis. The first case in the literature dates back to 1978 and in the literature, the incidence varies from 1% to 21%, although most published research reports a very small number of patients. Currently, the incidence in a specialized cancer center is consistent with the incidence of recurrence on a laparotomy scar. Possible mechanisms for cell implantation at the port site are direct implantation into the wound during forced, unprotected tissue retrieval or from contaminated instruments during tumor dissection; the effect of gas turbulence in lengthy laparoscopic procedures, and embolization of exfoliated cells during tumor dissection or hematogenous spread. Probably, however, the triggering mechanism is necessarily multifactorial. To date, the only significant prognostic factor in patients diagnosed with port-site metastasis is the interval between laparoscopy and the diagnosis of the port site: in fact, patients who develop the port site within 7 months after surgery have a generally worse prognosis, as well as port-site metastasis are more frequent in advanced cancers and the presence of ascites. To reduce the risk, the following measures are proposed in the literature: 1) Select the patient who does not have a metastatic oncologic condition or friable cancerous masses or lymph node spread or attached external or intracystic vegetations, preferring well-localized, benign or low-malignant or otherwise intact tumors; 2) Use wound protectors and use of protective bags (or endo bag) for tissue retrieval; 3) Peritoneal washing with heparin, to prevent free cell adhesion, or washing with cytocidal solutions. Evaluate the utility of using Povidone-iodine, Taurolidine (which has anti-adhesion activity and decreases proangiogenic factors), and chemotherapy products; 4) Avoid removing pneumoperitoneum with trocars in place; 5) Avoiding direct contact between the solid tumor and the port site; 6) Prefer laparoscopy to laparotomy, if possible; 7) Avoid the use of gas or direct CO2 insufflation, although in literature the point is controversial and deserves more attention and study, as the initial hypothesis that CO2 increased the invasion capacity of tumor cells (in vitro and in vivo) has been refuted several times. Insufflation of hyperthermic CO2 and humidified CO2 leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO2 pneumoperitoneum; 8) Comply with surgical protocols and techniques by updating one's surgical skills, as it has been demonstrated, as already reported here, the presence of cancerous cells on instruments, washing systems and trocars (in particular, on the trocars of the first operator). Suturing all layers of the abdominal wall decreases the risk of the port site; 9) Avoid excessive manipulation of the tumor mass during the surgical/operative procedure.

Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia?

Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children. To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels. Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device. Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration. This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.

Direct Trocar Insertion: an Efficient Access Technique for Laparoscopic Cholecystectomy

Aim: To evaluate the feasibility and safety of direct trocar insertion for gaining access to peritoneal cavity in laparoscopic cholecystectomy. Methods: An Observational study was conducted at Surgical unit II Ghulam Mohammad Mahar Medical College Hospital Sukkur from January 2016 to December 2020. Two thousand one hundred twenty (n=2120) patients were included in the study. All the patients who underwent laparoscopic cholecystectomy were included in the study. Informed and written consent was obtained from every patient to participate as study subject. Data was analyzed on SPSS version 16. Mean +/- standard deviation was calculated for age, first port access time and time to establish pneumoperitoneum. Results: Under general anesthesia with patient in supine posture, abdominal access gained by first making small incision of 10mm in skin and subcutaneous fat at sub umbilical region with No. 11 scalpel and then by direct trocar insertion followed by creation of pneumoperitoneum. Cholecystectomy performed. Study variables included first port access time, no. of attempts for DTI, extraperitoneal CO2 insufflation, port site bleeding, visceral injury, port site infection and port site hernia and were recorded on predesigned proforma. Variables like extraperitoneal CO2 insufflation, port site bleeding and visceral injury were expressed as percentage. Conclusion: We conclude that direct trocar insertion is the safe, quick and effective method for creation of pneumoperitoneum and should be employed routinely in all laparoscopic procedures. Keywords: Laparoscpy, Cholecystectomy, Trocars

A prospective randomized controlled trial of the safety and efficacy of carbon dioxide insufflation compared with room air insufflation during gastric endoscopic submucosal dissection.

Carbon dioxide (CO2 ) insufflation during gastric endoscopic submucosal dissection (GESD) under sedation can be used instead of room air insufflation. Appropriate monitoring of the partial pressure of CO2 during GESD is necessary due to the impaired respiration. The aim of this study was to assess the safety and efficacy of CO2 insufflation during GESD compared with conventional room air insufflation. Patients with a gastric epithelial neoplasm or early gastric cancer were enrolled. A total of 76 consecutive patients were randomly assigned to the CO2 insufflation group (CO2 group) or the room air insufflation group (air group). The primary outcome was the mean difference of end-tidal CO2 (EtCO2 ) between two groups. The upper bound of the 95% CI for the mean EtCO2 difference between the two groups before the procedure and at 15, 30 and 45 min after insufflation met the criteria for noninferiority. In a subgroup analysis of patients 70years and older, the mean difference of EtCO2 was not significantly different between two groups. However, the air group received more analgesics than the CO2 group after the procedure (67.6% vs 35.1%, P=0.005). In addition, in terms of improvement of abdominal pain or bowel gas after 24h of GESD, CO2 group showed better results than air group (both P<0.05). CO2 insufflation during GESD is as safe as using room air, and patients, including elderly patients, receiving CO2 achieve more rapid relief of abdominal pain and intra-abdominal residual gas during and after the procedure.

Effects of Dexmedetomidine on Intraoperative Hemodynamic Responses in Patients Undergoing Laparoscopic Cholecystectomy: A Randomised Double Blind Trial

Background: Dexmedetomidine is selective alpha 2 agonist with sedative sympatholytic, analgesic properties and is used as an anaesthetic adjuvant. We have evaluated the effect of dexmedetomidine on various hemodynamic responses to incidences such as laryngoscopy, endotracheal intubation, exubation and pneumoperitoneum in patients who were undergoing surgeries like laparoscopic cholecystectomy. We have used loading dose of 0.5mcg/kg of inj. Dexmedetomidine given over 10 minutes followed by infusion of a dose of 0.3mcg/kg/hour for the control of hemodynamic response to laparoscopy. Methods: Patient of either sex aged between 18-50 yrs, belongs to ASA I and II (AMERICAN SOCIETY OF ANAESTHESIOLOGY) posted for laparoscopic cholecystectomy were included. Institutional ethical committee clearance was obtained prior to study. After enrolment and valid written consent was taken. 60 patients were enrolled written valid informed consent was taken. Patients were divided into two groups 30 each with computerized randomization. Base line parameters were noted. Observer and patient was blinded for the content of syringe. Group A received injection dexmedetomidine and group B received bolus and infusion of normal saline at same rate. Routine general anaesthesia was instituted. Parameters were noted after induction, after intubation, after co2 insufflation, after 20 min, after 40 min, after co2 deflation, after extubation, after 1 and 2 hrs post-extubation. Results: Group A showed significantly less rise in HR and MAP than Group B. Requirement of intraoperative propofol was more in Group B. There was no significant difference for time taken to awakening in both groups. Conclusion: We found Injection Dexmedetomidine in given doses gave good hemodynamic control with minimal undesired effects during laparoscopy.