CO2 Insufflation Research Articles

Logistics of safe and stress-free epicardial access in the electrophysiology lab: creative percutaneous subxiphoid pericardiostomy

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Professor Nanthakumar is a recipient of the mid-career investigator award from the Heart & Stroke Foundation of Ontario. Introduction Dry epicardial access (EA) into the virtual pericardial space carries a 6-25% risk of collateral damage to important adjacent structures including the right ventricle and the coronary and internal thoracic arteries.1 This renders conventional dry EA a potentially daunting and stressful undertaking. Separation of the parietal and visceral pericardial layers by CO2 insufflation has been described and may mitigate some risk , however even in experienced tertiary centres, injury to superior epigastric arteries, liver, stomach, and transverse colon, has been reported. Furthermore, insufflating the pericardial space may cause unwanted haemodynamic changes . There is thus the need for an approach that separates the pericardial layers and avoids injury to right ventricle and coronary arteries while also avoiding abdominal and thoracic structures by direct visualisation. Purpose We describe the logistics of a creative technique that combines percutaneous EA with a minimally-invasive subxiphoid pericardiostomy that can be done with a surgeon in the electrophysiology (EP) lab for the initial 20 minutes of the procedure. Methods We performed the procedure with a surgeon in 4 patients in a single tertiary centre. The procedure was done in the EP lab under general anaesthesia with standard surgical asepsis and IV cefazolin administered pre-operatively. The subxiphoid area is infiltrated with local anaesthesia. Following a limited 5cm midline incision, the linea alba is dissected exposing the preperitoneal fat but the peritoneal space is not entered. The lower sternum is retracted anteriorly to expose the diaphragm and cardiophrenic fat pad. The diaphragm is progressively sutured to the skin to bring the pericardium into view. A 0-silk suture is then used to tent the pericardium at which point an incision is made in the pericardium to create the window. The steerable sheath and pericardial drain are inserted in the standard over-the-wire percutaneous technique through separate adjacent punctures with direct pathway visualisation through the window. Following this, the surgical incision is closed, allowing the surgeon to leave, and mapping to ensue. Results The time from skin incision to pericardial drain insertion was 18±5 minutes. None of our patients had acute or delayed bleeding or adjacent organ injury peri-procedurally. The pericardial drain was removed within 12-24 hours. One patient had mild pericarditis that resolved after a short course of non-steroidal anti-inflammatory agents. The subxiphoid wound healed well in all patients. Conclusions Percutaneous EA with easy entry into the pericardial space under direct visualisation and realtime monitoring via a pericardiostomy can be readily attained with surgical collaboration. We propose this as an alternative approach to EA, particularly in situations in which the percutaneous access will be challenging (e.g. obesity, or in presence of adhesions).

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

PO-04-134 STAR MAPPING METHOD TO IDENTIFY ENDO-EPICARDIAL DISSOCIATION AND DRIVING SITES IN PERSISTENT ATRIAL FIBRILLATION

Recurrence rates following ablation for persistent AF (psAF) remain high with the underlying mechanisms complex and poorly understood. Asynchronous activation of the endocardial and epicardial surfaces during AF, defined as endo-epicardial dissociation (EED) may be a driver for AF. We aim to investigate whether using the novel vector mapping approach, Stochastic Trajectory Analysis of Ranked (STAR) signals, endo- epicardial dissociation and early sites of activation (ESA) can be identified. Six (6) patients underwent endo-epicardial AF ablation utilizing the pericardial percutaneous CO2 insufflation technique. Two AdvisorTM HD Grid mapping catheters were placed in corresponding endocardial and epicardial positions in the left atrium. During AF, 30 second segments were recorded at the base of the left atrial appendage, anterior, inferior, left lateral and posterior LA wall. Fifteen (15) corresponding endo-epicardial segments were analysed using STAR maps and assessed for ESA and variation in direction of activation wavefront between the endocardium and epicardium. Activation wavefront direction was defined as dissociated if there was >40-degree difference between activation direction of simultaneous endo-epicardial wavefronts on STAR mapping. For each 30 second recording if there was more than 1 dominant wavefront direction, the 2 most common were used and an average taken. The overall mean difference in angulation of wavefront between the endocardium and epicardium was 71 ± 55 degrees. Nine (9) of 15 STAR maps (53%) showed activation angulation difference of >40 degrees between the endocardial and epicardial wavefront activation. Of these 9, 3 were on the posterior wall, 3 were at the base of the appendage, 2 were on the left lateral wall and 1 was on the anterior wall. ESA was identified in 6 STAR mapped endo and epicardial segments of AF, with 4 of these 6 (67%) ESAs in the epicardium. STAR mapping identifies activation wavefront discrepancy showing EED in multiple sites of the atrium with the majority of ESAs in the epicardial atrial surface.

Effect of retropneumoperitoneum on cerebral and renal oxygen saturation during retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP) in a pediatric population: Preliminary results of a prospective observational study using a dedicated anesthetic protocol and Near-InfraRed Spectroscopy

BackgroundRetroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP) for ureteropelvic junction obstruction (UPJO) has gained growing acceptance among pediatric urologists, and is increasingly performed as day-case surgery, involving smaller children and infants. However, retroperitoneal CO2 insufflation may cause hemodynamic derangements, respiratory changes, and hypercapnia, whose consequences are poorly investigated. We, therefore, decided to prospectively study its effect on regional tissue perfusion and oxygenation in a cohort of pediatric patients undergoing R-RALP, using a dedicated anesthetic protocol and cerebral and renal Near InfraRed Spectroscopy (NIRS). Material and methodsBetween January 2021 and September 2022, a cohort of 21 consecutive children [12 males (9 females), mean age of 7.1 ± 3.8 years and mean body weight of 25.7 ± 12.3 kg] underwent their first elective pyeloplasty for UPJO by R-RALP. The surgical procedure followed a previously described standardized technique and a dedicated anesthetic protocol. In conjunction with the minimal expected standard monitoring, cerebral and renal NIRS were added. Standard monitoring parameters and NIRS values were recorded at preset points throughout the procedures. ResultsStandard monitoring and NIRS measurements during R-RALP were not adversely affected by CO2 insufflation, pending a significant increase in respiratory rate, aimed to avoid hypercapnia, while keeping the ventilation pressure within the safety range, preventing lung injury. ConclusionsR-RALP, using a constant retroperitoneal CO2 insufflation pressure of 12 mmHg with a 5 L.min−1 flow, does not adversely affect respiratory and hemodynamics parameters, pending the implementation of a specifically designed anesthetic protocol aimed to prevent hypercapnia, the most threatening effect of retroperitoneal CO2 insufflation. Clinical Trial Registration NumberNCT03274050.

MP63-14 PRELIMINARY RESULTS OF FIRST-IN-HUMAN CRYOTHERAPY FOR NON MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023MP63-14 PRELIMINARY RESULTS OF FIRST-IN-HUMAN CRYOTHERAPY FOR NON MUSCLE INVASIVE BLADDER CANCER Gilad Amiel, Omri Falik-Nativ, Kamil Malshy, Omer Sadeh, Michael Mullerad, Eyal Kochavi, and Azik Hoffman Gilad AmielGilad Amiel More articles by this author , Omri Falik-NativOmri Falik-Nativ More articles by this author , Kamil MalshyKamil Malshy More articles by this author , Omer SadehOmer Sadeh More articles by this author , Michael MulleradMichael Mullerad More articles by this author , Eyal KochaviEyal Kochavi More articles by this author , and Azik HoffmanAzik Hoffman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003321.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Initial treatment for Non-Muscle Invasive Bladder Cancer (NMIBC) mostly remains unchanged in recent decades. Utilizing cryotherapy with CO2 is commonly used to treat superficial papillary lesions of the skin for many years. Recently, we have proven its potential in treating urinary epithelial lesions in an animal model. In this study we present our preliminary phase 1 clinical experience and results in treating low grade papillary lesions of the bladder with cryoablation. METHODS: Following local IRB and Ministry of Health approval, 10 patients with up to 3 papillary lesions and a maximum of 10 mm in size were recruited. Exclusion criteria included previous high-grade disease and/or positive cytology. Following an initial routine cystoscopy, the bladder irrigation medium was replaced with CO2 insufflation, and each lesion was treated with 2 cycles of direct spraying of liquid CO2. Each cycle lasted 15 seconds, with 10 seconds of thawing between the treatment cycles. Follow-up cystoscopy and mandatory treatment site biopsy were performed 4-6 weeks after treatment. Routine surveillance with office cystoscopy was performed every 3 months for 1 year thereafter. RESULTS: 8 men and 2 women were included (age 57—89 years). Overall, 14 lesions were treated. No complications were noted during treatment or during follow-up (range 2-14 months). Pathological analysis of the treatment site 4-6 weeks after treatment detected residual low grade TCC only in the very first patient, attributed to suboptimal lesion freezing due to our initial learning curve. The other 13/14 biopsy sites were negative for cancer (93%). CONCLUSIONS: Initial results of cryotherapy utilizing CO2 spraying for small low grade NMIBC is safe and feasible. Pathological analysis confirms efficacy in tumor eradication. This novel treatment may be used as an office procedure and therefore, after further validation studies, offers a potential paradigm shift in the treatment of NMIBC. Source of Funding: Biotechnological Incubator Trendlines, Misgav, Israel © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e876 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gilad Amiel More articles by this author Omri Falik-Nativ More articles by this author Kamil Malshy More articles by this author Omer Sadeh More articles by this author Michael Mullerad More articles by this author Eyal Kochavi More articles by this author Azik Hoffman More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION

You have accessJournal of UrologyCME1 Apr 2023V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION Marco Oderda, Serena Grimaldi, Giorgio Calleris, Daniele D'Agate, Federico Lavagno, Alessandro Marquis, Giancarlo Marra, Desireé Deandreis, and Paolo Gontero Marco OderdaMarco Oderda More articles by this author , Serena GrimaldiSerena Grimaldi More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Daniele D'AgateDaniele D'Agate More articles by this author , Federico LavagnoFederico Lavagno More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Desireé DeandreisDesireé Deandreis More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Today, PSMA is the most accurate radiopharmaceutical in PCa and it can be used as a tracer to identify PCa foci in resected specimens. To do so, a small, high-resolution PET/CT-imaging device (XEOS AURA®) was developed, with near five-fold optimization in spatial resolution as opposed to the standard clinical PET/CT devices. Aim of this feasibility study was to test the intraoperative use of this brand-new PET/CT specimen imager to guide robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND). METHODS: To date, we performed three cases of RARP and PLND with intraoperative use of XEOS AURA® specimen imager. All patients underwent preoperative staging with MRI and PSMA PET/CT. Surgeries were performed with Da Vinci Xi robot. During trocar placement, an intravenous injection of 68-Ga PSMA, 2 mBq/kg, was performed. Lymph nodes were immediately removed through the 12-mm assistant trocar and inserted into the specimen imager for analysis. After complete excision, the prostate was removed through a short Pfannestiel incision while maintaining CO2 insufflation, and analysed with the specimen imager to check for positive margins (PSM) before doing the urethra-vesical anastomosis. RESULTS: On average, the time required by XEOS AURA® to analyse each specimen was 12 minutes (SD 3). Total and positive nodal yield were 17.3 (5.8) and 0.3 (0.5 SD), respectively. PET/CT specimen imager showed a marked uptake for the only positive node retrieved, and a diffuse, weak uptake in several negative nodes. There was a good correspondence between marked uptake and node positivity, reflecting also preoperative PET/CT findings (Table 1). XEOS AURA® was useful to predict negative surgical margins, although in one locally advanced case this evaluation was uncertain. CONCLUSIONS: The use of PET/CT specimen imager is safe and feasible. The intraoperative knowledge of prostate cancer (PCa) location within lymph nodes or inside the prostate is essential to improve the oncological radicality of the procedure while safely pushing the boundaries of a hyper-conservative surgery. Source of Funding: University of Turin © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Oderda More articles by this author Serena Grimaldi More articles by this author Giorgio Calleris More articles by this author Daniele D'Agate More articles by this author Federico Lavagno More articles by this author Alessandro Marquis More articles by this author Giancarlo Marra More articles by this author Desireé Deandreis More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

Lateral Route Endoscopic Thyroidectomy with gas Insufflation: Proposed Critical View of Safety

BackgroundThe extra-cervical lateral route endoscopic thyroidectomy (LRET) approaches such as the trans-axillary, breast and axillo-breast approaches are proved to be safe, feasible, esthetic, highly effective. The inherent difficulty and long learning curve of these techniques prevents its widespread application.MethodsBenefiting from the experience of more than 5 years in LRET approaches with CO2 insufflation, the authors developed ten surgical key steps and a critical view of safety (CVS) for performing thyroid lobectomy via LRET approaches. A detailed description and a video of the surgical technique is provided.ResultsApplication of these structured key steps and CVS was feasible and effective in achieving thyroid lobectomy in all selected cases with unilateral goiter up to 8 cm, even in cases with thyroiditis or controlled toxic adenoma, without any adverse events and with shorter operative time than the non-structured surgical technique.ConclusionThe described ten key steps and CVS are conclusive, applicable, easy to learn. Our video could act as a guide for promoting the standardized, safe, and wide application of LRET techniques.

3D Transoral Endoscopic Thyroid.

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a feasible new surgical procedure that does not require visible incisions. We describe our experience with three-dimensional (3D) TOETVA. We recruited 98 patients who were willing to undergo 3D TOETVA. Inclusion criteria were: (a) patients with a neck ultrasound (US) with an estimated thyroid diameter of 10cm or less; (b) estimated US gland volume ≤45ml; (c) nodule size ≤50mm; (d) benign tumor, such as thyroid cyst, goiter with one nodule, or goiter with multiple nodules; (e) follicular neoplasia; and (f) papillary microcarcinoma without evidence of metastases. The procedure is performed using a three-port technique at the oral vestibule, a 10mm port for the 30° endoscope, and two additional 5mm ports for dissecting and coagulation instruments. The CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule to the sternal notch and laterally to the sternocleidomastoid muscle. Thyroidectomy is performed entirely 3D endoscopically with conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. Ninety-eight 3D TOETVA procedures were successfully performed without any conversions. The mean operative time was 87.6 minutes (59-118 minutes) for lobectomy and 107.6 minutes (99-135 minutes) for bilateral surgery. We observed one case of transient postoperative hypocalcemia. Paralysis of the recurrent laryngeal nerve did not occur. The cosmetic outcome was excellent in all patients. This is the first case series of 3D TOETVA.

ELEVATIONS IN END TIDAL CO2 WITH CO2 USE DURING PEDIATRIC ENDOSCOPY WITH AIRWAY PROTECTION: IS THIS PHYSIOLOGICALLY SIGNIFICANT?

Inflation of the gastrointestinal lumen is vital for proper visualization during endoscopy. Air, insufflated via the endoscope, is gradually being replaced with carbon dioxide (CO2) in many centers, with the intention of minimizing post-procedural discomfort due to retained gas. Recent studies suggest that the use of CO2 during pediatric esophagogastroduodenoscopy (EGD) with an unprotected airway is associated with transient elevations in exhaled CO2 (end-tidal CO2, EtCO2), raising safety concerns. One possible explanation for these events is eructation of insufflation gas from the stomach. To distinguish eructated vs absorbed CO2 by sampling EtCO2 from a protected airway with either laryngeal mask airway (LMA) or endotracheal tube (ETT), and to observe for changes in minute ventilation (MV) to exclude hypoventilation events. Double-blinded, randomized clinical trial of CO2 versus air insufflation for EGD with airway protection by either LMA or ETT. Tidal volume, respiratory rate, MV, and EtCO2 were automatically recorded every minute. Cohort demographics were described with descriptive characteristics. Variables including the percent of children with peak, transient EtCO2 ≥ 60mmHg were compared between groups. 195 patients were enrolled for 200 procedures. Transient elevations in EtCO2 of ≥ 60mmHg were more common in the CO2 group, compared to the air group (16% vs. 5%, p=0.02), but were mostly observed with LMA and less with ETT. Post-procedure pain was not different between groups, but flatulence was reported more with air insufflation. (p=0.004). Transient elevations in EtCO2 occur more often with CO2 than with air insufflation during pediatric EGD despite protecting the airway with an LMA or, to a lesser degree, with ETT. These elevations were not associated with changes in MV. Although no adverse clinical effects from CO2 absorption were observed, these findings suggest that caution should be exercised when considering the use of CO2 insufflation, especially since the observed benefits of using this gas were minimal.

Novel Epicardial Access Technique Facilitated by Carbon Dioxide Insufflation of the Pericardium for Ablation of Ventricular Arrhythmias: Lessons From the Early Experience From a Single Centre in Australia.

Epicardial access for mapping and ablation of the epicardial substrate may be required in catheter ablation of ventricular tachycardias (VT). However, high complication rates are associated with the standard epicardial access approach. Recently, a novel method of intentional coronary vein (CV) exit with pericardial CO2 insufflation to facilitate epicardial access has been described. This study describes our initial experience with this technique. Patients undergoing epicardial VT ablation between 1 February 2021 to 31 May 2022 at the Royal Prince Alfred Hospital, Sydney, NSW, were included in this study. Via femoral venous access, a branch of the coronary sinus was sub-selected and intentional CV exit was performed with a high tip load coronary angioplasty wire. A microcatheter was then advanced over the wire into the pericardial space, followed by pericardial CO2 insufflation, facilitating subxiphoid pericardial puncture. Five (5) patients underwent epicardial access for VT mapping and ablation. All patients had successful intentional CV exit and CO2 facilitated epicardial access. The mean time to successful epicardial access was 37.2±17.5 minutes. With increasing operator experience, there was improvement in epicardial access times, with the fifth case requiring only 13 minutes. There was one case of inadvertent right ventricular puncture (without haemodynamic or ventilatory compromise) due to inappropriate CO2 insufflation into the right ventricle. Epicardial access was successful on the second attempt. This is the first case series of epicardial access facilitated by CO2 insufflation in Australia. This technique enabled successful epicardial access in all patients in our early experience, with no adverse outcomes from epicardial access. With increasing operator experience, this technique may allow for more widespread adoption of up-front epicardial access for the treatment of VT.

Comparison of Different Carbon Dioxide Insufflation Rates on Hemodynamic Changes in Laparoscopic Surgeries: A Randomized Controlled Trial.

Introduction The injury and detrimental effects of carbon dioxide (CO2) insufflation during laparoscopic surgeries may be due to the higher flow rates used during insufflation. The aim of our study was to study the effects of different CO2 insufflation flow rates on hemodynamic parameters in laparoscopic surgeries. The secondary objectives were to compare the patient and surgeon satisfaction scores, postoperative shoulder scores, and surgical site pain scores. Methods This prospective, randomized, double-blinded trial was commenced after institutional ethical committee approval and The Clinical TrialsRegistry- India (CTRI) registration (CTRI 2021/10/037595). Ninety patients scheduled for laparoscopic cholecystectomy were randomly divided into three groups based on CO2 insufflation flow rate by computer-generated random numbers and the sealed envelope method: Group-A: 5 L/min; Group-B: 10 L/min; and Group-C: 15 L/min. General anesthesia was standardized in all three groups. Mean arterial pressure (MAP) and heart rate were recorded at different timelines, which included the arrival in the operating room (T0), just before the induction of anesthesia (T1), at the beginning of pneumoperitoneum (T2), 10 minutes (T3), 20 minutes (T4), 30 minutes (T5), and 60 minutes (T6) after the pneumoperitoneum, at the end of the operation (T7), five minutes (T8), and 15 minutes (T9) after arriving at the recovery room. The patient and surgeon satisfaction scores were assessed on a 5-point Likert scale. The visual analog score (VAS) was used to assess the surgical site pain and shoulder pain every four hours for 24 hours. The continuous data were assessed by one-way analysis of variance (ANOVA), and the categorical data were assessed by the Chi-square test. The sample size was estimated based on a pilot study and using the G Power 3.1.9.2 Program (Universitat Kiel, Germany) calculator. Results There was an increase in the mean arterial pressure (MAP) between the groups 60 min after pneumoperitoneum creation with higher flow rates. The baseline MAP was 85.76± 10.11 in group A, 86.03± 9.79 in group B, and 88.13± 8.46 in group C. At 60 min from the creation of the pneumoperitoneum, the MAP increased significantly from 99.17 ± 9.35 in group A, 102.43 ± 8.24 in group B, to 106.83 ± 8.31 in group C. This was statistically significant with a p-value of 0.004. There was a statistically significant difference in heart rate between the groups 10 minutes after pneumoperitoneum creation. No complications were reported in any of the groups. The postoperative shoulder pain was more severe when higher flows were used at 20 and 24 hours. The surgical site pain was also significantly more for up to 12 hours following surgery with higher flows. Conclusion We conclude that low-flow CO2 insufflation during laparoscopic surgeries is associated with fewer hemodynamic changes, better patient satisfaction scores, and lower postoperative pain scores.

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Challenges for anaesthesia for robotic-assisted surgery in the elderly

Steep and reverse Trendelenburg positions are often used in robotic-assisted surgery (RAS) to improve surgical access. The elderly are particularly vulnerable to the cardiovascular effect of the combination of pneumoperitoneum and these extreme positions. Falls in both cardiac output (CO) and mean arterial pressure (MAP) caused by pneumoperitoneum are enhanced in reverse Trendelenburg. Hypotension with dangerous cerebral and myocardial hypoperfusion may occur. Caution should be exercised in patients with low cardiac reserve and the degree of peri-operative risk should dictate the level of haemodynamic monitoring employed. The effects of pneumoperitoneum on CO are less pronounced in the standard Trendelenburg position due to gravity, but head-down combined with pneumoperitoneum can increase both MAP and systemic cardiovascular resistance. However, in patients with impaired myocardial contractility, the head-down position may lead to cardiac failure. In addition, the adverse respiratory effects of pneumoperitoneum, which include reduction of pulmonary compliance and functional residual capacity, may be exacerbated by steep Trendelenburg. At the same time, hypercarbia resulting from CO2 insufflation can lead to an increase in stasis of brain blood flow and intracranial pressure with possible repercussions on cognitive functions in the elderly. Another problem is the increase in intra-ocular pressure during steep Trendelenburg, and injury to the optic nerve has been reported after robot-assisted prostatectomy. Finally, strategies to use the lowest possible pneumoperitoneum pressure are considered to reduce possible complications. Moreover, the extreme positions should be limited only to the time strictly necessary for surgery and should be avoided in high-risk patients.

Comparison of P6 Acupoint Stimulation, Ondansetron and Dexamethasone for Prevention of Postoperative Nausea and Vomiting after Laparoscopic Surgeries: A Randomised Clinical Study

Introduction: Non pharmacological techniques have an established role in treatment of chronic pain and related conditions. A few non pharmacological techniques have been employed to avoid the adverse effects of drugs. They have also proven to be cost-effective. Liberal fluid administration is the most common non pharmacological methodology used for the prevention of PONV. However, the associated volume overload can be detrimental. Aim: To compare the efficacy of P6 acupoint stimulation, ondansetron and dexamethasone in the prevention of PONV in laparoscopic surgeries. Materials and Methods: This was a randomised clinical study, conducted in the Department of Anaesthesiology at a Tertiary Care Medical College and Hospital, India. The duration of the study was five months, from June 2022 to October 2022. A total of 120 patients posted for laparoscopic surgeries were divided randomly into three groups, group A, group O and group D. Patients were allocated by computer-generated randomisation. Patients in group A received capsicum plaster at P6 point. Patients in group O received 4 mg of ondansetron and patients of group D received 8 mg of dexamethasone. They were given 30 minutes before induction. Postoperatively, patients were extubated and shifted to postanaesthesia care unit for further monitoring. The demographic data, baseline vitals, surgical procedure, duration of surgery and duration of Carbon Dioxide (CO2 ) insufflation were noted intraoperatively. Additional fentanyl requirement, total analgesic requirement, postoperative heart rate, Mean Arterial Pressure (MAP), the incidence of PONV, nausea and vomiting score, number of episodes the requirement of rescue antiemetic, postoperative complication, adverse reactions and patient satisfaction score were all recorded postoperatively and was compared between the three groups using one-way Analysis of Variance (ANOVA). The data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Results: The mean age of the study participants for group A was 40.42±11.05 years, group O was 40.92±10.49 years and group D was 40.30±10.01 years, respectively. The three groups were comparable with respect to the demographics, baseline vitals, surgical procedure, duration of surgery, duration of CO2 insufflation, additional fentanyl requirement, total analgesic requirement, postoperative heart rate, and MAP. The incidence of PONV was insignificant between the groups with p-value=0.866. The p-value of nausea and vomiting scores were insignificant. The number of episodes of nausea and vomiting was also comparable between the groups p-value=0.880 and 0.375, respectively. The requirement of rescue antiemetic vomiting was insignificant with p-value=0.810. Conclusion: Ondansetron, dexamethasone and P6 acupoint stimulation are equally effective as prophylaxis for the management of PONV. It can be concluded that, P6 acustimulation can be used as an alternative to pharmacological agents for the management of PONV.

Modeling and simulation of high flow medical CO2 insufflator using PID-P, PID-PQT, and MPC-PQT controllers

Modeling and simulation of high flow medical CO2 insufflator using PID-P, PID-PQT, and MPC-PQT controllers

Comparison of surgical smoke between two approaches for endoscopic thyroidectomy and open thyroidectomy.

Surgical smoke has been recognized as a potential health risk by an increasing number of researchers. Moreover, the counts of surgical smoke produced during different surgical approaches are different. This study aimed to measure and compare the particulate matter (PM) of surgical smoke generated during open thyroidectomy and two endoscopic approaches for thyroidectomy to provide guidance for safe clinical practices. Forty-eight patients with thyroid cancer admitted to our hospital from June 2020 to December 2021 and treated with different surgical approaches were enrolled in this study. The total and peak counts of PM, dynamic changes, and other characteristics of surgical smoke produced during surgery were recorded. PM was classified as PM2.5 (size ≤ 2.5μm) and PM10 (size ≤ 10μm). In a single cut, both the peak and total counts of PM2.5 and PM10 of surgical smoke in the open thyroidectomy group (n = 15) were significantly higher than those in the breast approach endoscopic thyroidectomy with CO2 insufflation group (n = 15) and the gasless transaxillary endoscopic thyroidectomy group (n = 18) (p < 0.001). Moreover, the latter two groups showed no significant differences in the peak and total counts of PM2.5 and PM10 (p > 0.05). In thyroid surgery, more surgical smoke is produced during open thyroidectomy than during endoscopic thyroidectomy, while different endoscopic approaches showed no significant difference in surgical smoke production. Thus, endoscopic approaches outperform the open thyroidectomy approach with regard to surgical smoke production.

Effects of Retroperitoneal or Transperitoneal Pneumoperitoneum on Inferior Vena Cava Hemodynamics and Cardiopulmonary Function: A Prospective Real-Time Comparison.

Objective: To evaluate the effects of CO2 pneumoperitoneum on venous hemodynamics and cardiopulmonary function during transperitoneal or retroperitoneal laparoscopic surgery. Materials and Methods: A single-institution prospective study. Forty-three patients with renal-cell carcinoma undergoing retroperitoneal (22) or transperitoneal (21) laparoscopic partial nephrectomy were enrolled. Hemodynamic functions were monitored by minimally invasive FloTrac/Vigileo system. Transesophageal echocardiography was used to measure the diameter and blood flow of the inferior vena cava (IVC). Measured parameters were recorded at baseline, 10, 30, 60 minutes following insufflation to 14 mm Hg and 10 minutes following desufflation. Results: For hemodynamic changes in the transperitoneal laparoscopic surgery (TPL) and retroperitoneal laparoscopic surgery (RPL), transperitoneal CO2 insufflation resulted in a rapid parallel increase in central intravenous pressure (CVP), peak airway pressure (AWP), and IVC blood flow velocity after the first 30 minutes of pneumoperitoneum (p < 0.05). In contrast, CVP, AWP, and IVC blood flow velocity increased progressively in RPL. The variation of those parameters was significantly lower than that of TRL (p < 0.001; p = 0.002; p = 0.004). The mean maximum CVP in the two groups was 20 and 16 mm Hg, respectively. The IVC diameter at the cavoatrial junction was significantly reduced in TPL after 10 minutes of insufflation, but it remained unchanged in RPL throughout the surgery. For cardiopulmonary function changes, heart output decreased after a short period of pneumoperitoneum, but no statistical differences were observed between the two groups. The increments of partial pressure of arterial carbon dioxide and end-tidal carbon dioxide tension were significantly higher in RPL than TPL (p < 0.001; p < 0.001). Conclusions: Compared with retroperitoneal pneumoperitoneum, transperitoneal pneumoperitoneum has significant effects on IVC hemodynamics. Elevated intra-abdominal pressure (IAP) causes higher AWP and venous return resistance, which lead to the significant increase of CVP during transperitoneal approach. Adjusting the balance between IAP and CVP might be an effective way to control intravenous bleeding. Clinical Trial Registry: Registration number: ChiCTR2000038291.

Transoral Endoscopic Vestibular Approach Sistrunk Procedure: Surgery Video

Introduction: Thyroglossal duct cyst (TGDC) is a congenital malformation and it is usually found in children <10 years old (>90%).1–4 It is the most common neck cyst and congenital neck mass in the pediatric population and a smaller number of cases occur in adulthood.1–5 The diagnosis is confirmed with imaging and it can be done with a simple ultrasound scan, CT scan, or MRI. The definitive treatment is surgical removal and the gold standard surgery is called Sistrunk procedure,6 which involves excision of the whole cyst and the body of the hyoid bone, because of the embryologic origin of the malformation. This technique described in 19206 was a game changer in the treatment of TGDC as it reduced recurrence rates from 40% to <3%,7 however, it has not changed since then. More recently, the transoral vestibular approach technique for accessing the central neck made possible a total endoscopic safe technique for thyroid and parathyroid removal—TOETVA/TOEPVA.8,9 As TGDCs are located in the same field, the same technique has been shown to give good access for treating TGDC without leaving a neck scar.1–3 Other authors already published two case reports2,3 and a case series1 about effective excision of TGDC transorally. They named the technique transoral endoscopic vestibular approach Sistrunk (TEVAS) procedure.1 The aim of this video is to describe, step-by-step, a case of TEVAS. Materials and Methods: We recorded this video of TEVAS in a woman. The patient involved in the case gave written informed consent to participate in this study. Case: A 47-year-old woman with no medical history presented with a long-term midline neck mass with recent enlargement associated with neck discomfort and sensation of compression. Clinical examination showed a midline mass located on the level of the hyoid bone measuring ~5 cm. Sistrunk sign was positive. The patient underwent a CT scan that showed a 4.5 cm TGDC. Surgery was indicated and endoscopic approach was chosen. The surgery began with the confection of three endoscopic portals through the oral vestibule. After that, the working space was made with an ultrasonic scalpel while running CO2 insufflation. The midline was opened and TGDC was observed. The soft tissue around the cyst was dissected with an ultrasonic scalpel and the hyoid bone was exposed, cutting the insertions of the strep muscles. The bone was cut using the ultrasonic scalpel with an open jaw, touching it with the active blade and making some pressure. The thyroglossal duct was ligated with hemolocks and after that it was sectioned, releasing the specimen, which was removed through the central port using an endobag. Conclusion: This video illustrates the application of TEVAS for treating TGDC. Experience with TOETVA/TOEPVA made possible the execution of this surgery. The most important aspect to choose this novel approach was the patient's motivation to avoid a neck scar. Cutting the hyoid bone was the most challenging step. Using a harmonic scalpel to do the osteotomies was efficient and we recommend it. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. Runtime of video: 11 mins 58 secs

Robotic assited perineal prostatectomy (RAPP) as a new era for anesthesiology: It's effects on hemodynamic parameters and respiratory mechanics.

Robotic-assisted perineal prostatactomy(RAPP) is a new alternative surgical technique, in prostate cancer patients especially with a history of intra-abdominal surgery. The aim of this study is to examine the effects of the challenging patient position and CO2 insufflation in perineal space during RAPP on both hemodynamic parameters and respiratory mechanics. Hemodynamic and respiratory parameters of 30 patients who underwent RAPP and 31 patients who underwent Robotic-assisted laparoscopic prostatectomy (RALP) for prostate cancer between 2017 and 2019 were retrospectively evaluated. Comparison between RAPP and RALP patients showed that anesthesia, surgery and insufflation times were shorter in RAPP patients (p < 0.05). Blood pCO2 level was higher, and the pH decrease was more prominent in the RAPP patients 30 and 60min after perineal CO2 insufflation (p < 0.05). The mean arterial pressures, driving pressure, Ppeak and Pplato values were statistically higher in the RALP patients and 60min after insufflation while static and dynamic lung compliance values were found to be lower. Our results showed that blood pCO2 level may severely increaseafter perineal CO2 insufflation. The fact that respiratory mechanics are less affected despite the difficult patient position for lungs in RAPP patients, the presence of higher CO2 level supports that the perineal CO2 insufflation plays a more important role in increased CO2 level. Considering these changes, especially the sudden increase in the risk of CO2 level, close follow-up and timely intervention by anesthesiology can ensure all changes remain in a clinically safe range.

The Usefulness of AirSeal™ Intelligent Flow System in Gas Insufflation Total Endoscopic Thyroidectomy

Total endoscopic thyroidectomy (TET) using low CO2 insufflation provides cosmetic advantage, excellent working space and visibility. On the contrary, suctioning blood or mist/smoke produced by energy device application causes narrowing of working space especially in neck surgery. In this regard, AirSeal intelligent flow system would be particularly suitable in TET. However, the benefit of AirSeal is unknown in TET unlike abdominal surgery. Therefore, the impact of AirSeal was evaluated in TET in this study. Twenty patients who underwent total endoscopic hemithyroidectomy were retrospectively analyzed. Insufflation was conducted by either conventional or AirSeal system according to the surgeon’s preference. Short-term surgical outcomes including operation time, bleeding, frequency of scope cleaning, and disappearance of subcutaneous emphysema were compared as well as actual visibility. AirSeal application dramatically reduced obstacle smoke/mist and prevented narrowing working space by suctioning. Frequency of scope cleaning was significantly less in AirSeal group than that in conventional group (p = 0.016). In patients with nodule < 5 cm, intraoperative hemorrhage was less in AirSeal group than that in the counterpart (p = 0.077) regardless of larger nodule size in AirSeal group (p = 0.058). Notably, subcutaneous emphysema around surgical cavity disappeared significantly earlier in AirSeal group than in the counter parts (p = 0.019). On the contrary, AirSeal application did not shorten operation time in the current study. AirSeal provided excellent visibility and seamless operation. AirSeal has great potential to decrease not only surgeon’s stress but surgical invasion on patients. The results in this study give rational to AirSeal application to TET.