Insufflation Technique Research Articles

A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy.

Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO2 insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy. A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates. Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy. While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

COMPARISON OF ISOBARIC AND INSUFFLATED LAPAROSCOPY-ASSISTED OVARIOHYSTERECTOMY IN THE COMMON RABBIT (ORYCTOLAGUS CUNICULUS)

Surgical sterilization of female rabbits can be associated with a significant risk of postoperative morbidity. Laparoscopic ovariectomy has been reported previously to address this issue. The aim of the current study is to assess whether an isobaric (ISO) technique, utilizing an abdominal lifting technique, rather than insufflation (INS) technique, which involves pressurizing the abdomen, is feasible in this species. Four rabbit cadavers were used to subjectively compare the viability of the 2 techniques. Seven rabbit cadavers were used to assess the effects of ISO and insufflated pneumoperitoneum on the dimensions of the abdomen and the volume of the thorax at atmospheric and positive inspiratory pressures using CT imaging. There was a significantly higher (P = 0.006) difference between baseline and pneumoperitoneum thoracic volume in the ISO specimens versus the INS specimens. There was no significant difference in abdominal height in either technique and both afforded adequate working space. The implementation of ISO laparoscopy-assisted ovariohysterectomy was subjectively no more technically difficult than INS laparoscopy-assisted ovariohysterectomy in the rabbit. Based on this investigation, ISO laparoscopy is feasible and requires less specialized equipment compared with insufflated laparoscopy, making it more available in a general practice setting and for routine surgery. Use of ISO laparoscopy could potentially decrease ventilatory compromise compared with insufflated laparoscopy in rabbits.

No Difference in Pain Based on Insufflation Technique Used During Colonoscopy

No Difference in Pain Based on Insufflation Technique Used During Colonoscopy

Carbon Dioxide Insufflation of the Knee in the Treatment of Full-Thickness Chondral Defects With Micronized Human Articular Cartilage

BioCartilage (BC) is dehydrated, minced human hyaline articular cartilage that was developed as an adjunct to microfracture surgery to help stimulate the bone marrow and stem cells to form hyaline-like tissue in full-thickness chondral defects. The minced pieces of BC require a dry environment for application and can easily be disrupted by residual moisture of saline solution in the surrounding tissues. We present a technique of carbon dioxide insufflation during knee arthroscopy as a means of maintaining a dry environment for preparation of the bony bed during BC augmentation of microfracture surgery. This technique is safe and provides more than adequate visualization, as well as a dry environment, to make the arthroscopic application of BC significantly more efficient.

Repeated intranasal ketamine for treatment-resistant depression - the way to go? Results from a pilot randomised controlled trial.

Ketamine research in depression has mostly used intravenous, weight-based approaches, which are difficult to translate clinically. Intranasal (IN) ketamine is a promising alternative but no controlled data has been published on the feasibility, safety and potential efficacy of repeated IN ketamine treatments. This randomised, double-blind, placebo-controlled pilot study compared a 4-week course of eight treatments of 100 mg ketamine or 4.5 mg midazolam. Each treatment was given as 10 separate IN sprays, self-administered 5 min apart. The study was stopped early due to poor tolerability after five treatment-resistant depressed participants were included. Feasibility, safety (acute and cumulative), cognitive and efficacy outcomes were assessed. Plasma ketamine and norketamine concentrations were assayed after the first treatment. Significant acute cardiovascular, psychotomimetic and neurological side effects occurred at doses < 100 mg ketamine. No participants were able to self-administer all 10 ketamine sprays due to incoordination; treatment time occasionally had to be extended (>45 min) due to acute side effects. No hepatic, cognitive or urinary changes were observed after the treatment course in either group. There was an approximately two-fold variation in ketamine and norketamine plasma concentrations between ketamine participants. At course end, one participant had remitted in each of the ketamine and midazolam groups. IN ketamine, with the drug formulation and delivery device used, was not a useful treatment approach in this study. Absorption was variable between individuals and acute tolerability was poor, requiring prolonged treatment administration time in some individuals. The drug formulation, the delivery device, the insufflation technique and individual patient factors play an important role in tolerability and efficacy when using IN ketamine for TRD.

To explore the feasibility and safety of feeding through a tube placed beyond pylorus by gastric insufflation technique at the bedside

To explore the feasibility and safety of feeding through a tube placed beyond pylorus by gastric insufflation technique at the bedside

Safe Protocol and Technique for 7 Minute Orbera Balloon Placement in an Ambulatory Endoscopy Center

Introduction: Orbera is an FDA approved endoscopically placed device for temporary weight loss in patients with BMI >27.FigureFigureFigureMethods: Between June 2016 to February 2017, 40 patients were evaluated and scheduled for balloon placement. The average BMI was 46.87 (37.2-60.97), mean age 46.62 (61-28 y/o). All patients were instructed to follow a non-vegetable diet for 1 week prior and liquid diet 2 days before the scheduled placement. All the procedures were performed in an accredited ambulatory endoscopy center by a single gastroenterologist with advanced therapeutic training and 25 years of experience, under propofol sedation. All patients were placed on a non-rebreathing mask at 100% oxygen while in the holding area until the patient was taken to the procedure room and sedation started, when it was switched to a nasal cannula set at 3 liters per minutes. The patients were also pre-medicated with 8 mg of ondasetron, glycopyrrolate 0.1 mg and hydrocortisone sodium 40 mg by intravenous route before the sedation with propofol. After the initial endoscopy to clear the stomach from pathology that can preclude the Orbera placement and to aspirate any remaining fluid, an over insuffl ation technique was used in the stomach and continued until the removal of the scope in order to create a good intra gastric pressure gradient to facilitate the passage of the balloon catheter through the EGJ and avoid coiling in the esophagus. Once the balloon is placed in the body of the stomach it is crucial to gently and slowly pull on catheter a bit under endoscopic surveillance until the catheter is in a straight position (not coiling in the stomach). That will allow the easy passage of water to fill the balloon in a faster and more efficient fashion. The balloons were filled up to 600 ml, a careful inspection is performed to see if there are any leaks. Complete aspiration of the air in the stomach is also preformed until we could see the stomach around the balloon. Results: In all cases the Orbera balloon was successfully placed in 7 minutes from scope in, to scope out without any complications or any episodes of oxygen desaturation, or the need for endotracheal intubation in an ambulatory setting. Conclusion: Orbera balloon can be safely and quickly placed in an ambulatory basis following this technique in an appropriate and controlled environment.

Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique.

Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique.

Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique.

To describe development of a two-port fetoscopic technique for spina bifida repair in the exteriorized, carbon dioxide-filled uterus and report early results of two cohorts of patients: the first 15 treated with an iterative technique and the latter 13 with a standardized technique. This was a retrospective cohort study (2014-2016). All patients met Management of Myelomeningocele Study selection criteria. The intraoperative approach was iterative in the first 15 patients and was then standardized. Obstetric, maternal, fetal, and early neonatal outcomes were compared. Standard parametric and nonparametric tests were used as appropriate. Data for 28 patients (22 endoscopic only, four hybrid, two abandoned) are reported, but only those with a complete fetoscopic repair were analyzed (iterative technique [n=10] compared with standardized technique [n=12]). Maternal demographics and gestational age (median [range]) at fetal surgery (25.4 [22.9-25.9] compared with 24.8 [24-25.6] weeks) were similar, but delivery occurred at 35.9 (26-39) weeks of gestation with the iterative technique compared with 39 (35.9-40) weeks of gestation with the standardized technique (P<.01). Duration of surgery (267 [107-434] compared with 246 [206-333] minutes), complication rates, preterm prelabor rupture of membranes rates (4/12 [33%] compared with 1/10 [10%]), and vaginal delivery rates (5/12 [42%] compared with 6/10 [60%]) were not statistically different in the iterative and standardized techniques, respectively. In 6 of 12 (50%) compared with 1 of 10 (10%), respectively (P=.07), there was leakage of cerebrospinal fluid from the repair site at birth. Management of Myelomeningocele Study criteria for hydrocephalus-death at discharge were met in 9 of 12 (75%) and 3 of 10 (30%), respectively, and 7 of 12 (58%) compared with 2 of 10 (20%) have been treated for hydrocephalus to date. These latter differences were not statistically significant. Fetoscopic open neural tube defect repair does not appear to increase maternal-fetal complications as compared with repair by hysterotomy, allows for vaginal delivery, and may reduce long-term maternal risks. ClinicalTrials.gov, https://clinicaltrials.gov, NCT02230072.

Intra-abdominal insufflation as a diagnostic modality for penetrating anterior abdominal wall trauma in a busy urban center: a retrospective case-series

Background: The optimal algorithm for evaluating patients with anterior abdominal stab wounds (AASW) is not clear and has been a long standing controversy. Currently, the workup and management of penetrating anterior abdominal wall trauma may involve the decision to proceed immediately to surgery based on the presentation of the patient, or the work up may involve local wound exploration (LWE), focused abdominal sonography for trauma (FAST) exam, CT scan, or serial abdominal exams. Here we discuss an observational sign utilizing the Veress needle intra-abdominal insufflation test that can be used in conjunction with the current AASW algorithm, to rule in peritoneal violation. Methods: Eight patients admitted to our level 1 trauma center with penetrating AASW were evaluated using LWE, FAST, or CT scan followed by Veress needle insufflation and DL for suspected intra-abdominal injuries. These cases were retrospectively evaluated for the efficacy of Veress needle insufflation as an observational test for peritoneal violation. Results: Eight hemodynamically stable patients from December 2013 to June 2014 presented to our level one trauma center after sustaining penetrating AASW. All eight patients went to the operating room for Veress needle insufflation and DL. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mmHg, all patients with peritoneal violations [5] were found to have CO2 escape from their wounds. The remaining three patients with no violation to the peritoneum did not have any appreciable CO 2 escape. Conclusions: Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO 2 escape, we were able to successfully identify all patients with peritoneal violation and rule out violation in those without peritoneal injuries. With further research, our technique can be used to safely, accurately and in a timely manner stratify patients for the need of further diagnostic and interventional procedures.

‘Instead of popping pills, perhaps you should add frog breathing’: experiences of glossopharyngeal insufflation/breathing for people with cervical spinal cord injury

Background: People with cervical spinal cord injury have impaired function of the respiratory muscles, which results in reduced ventilation. Glossopharyngeal insufflation/breathing increases total lung capacity and improves cough function, however, knowledge of the experiences regarding learning and practicing glossopharyngeal insufflation in everyday life is missing.Purpose: To describe and explore the experiences of learning and practicing glossopharyngeal insufflation among people with cervical spinal cord injury.Methods: Twenty six individuals with cervical spinal cord injury, who had participated in a previous intervention study on glossopharyngeal insufflation, were interviewed. Semi-structured telephone interviews were analyzed with qualitative content analysis.Results: An overall theme and seven categories emerged. Glossopharyngeal insufflation was perceived as a possibility to make a difference in one’s life by improving respiratory function, both immediately and for time ahead and thereby ease everyday activities, and by increasing participation, independence, and overall health. The participants with cervical spinal cord injury described that they could learn glossopharyngeal insufflation, but it could be perceived as difficult. However, the use of glossopharyngeal insufflation could be experienced by the individual as being different, and there were sometimes doubts about its effectiveness.Conclusions: Use of glossopharyngeal insufflation can enable people with cervical spinal cord injury to increasingly participate in everyday activities. Increased autonomy might lead to improved self-esteem and provide well-being. However, ambivalence about the usefulness of glossopharyngeal insufflation may arise and the technique can be difficult to learn. Therefore, individualized information and instructions from health professionals are required.Implications for RehabilitationPracticing glossopharyngeal insufflation leads to increased participation in everyday activities for people with cervical spinal cord injuries and provides the individual hope to influence future life situation. People with cervical spinal cord injuries therefore need support from health care professionals in order to be motivated to learn and then use the glossopharyngeal insufflation technique also as health promotionGlossopharyngeal insufflation can improve respiratory function and also increase awareness of breathing; health professionals should therefore be able to assess which patients who can benefit from glossopharyngeal insufflation in order to make the technique become an important part of the rehabilitation.The technique can be difficult to perform perfectly and is sometimes perceived as uncomfortable. It may also cause unpleasant side effects and therefore individualized information and instructions regarding glossopharyngeal insufflation are required.

Incidence and patterns of surgical glove perforations: experience from Addis Ababa, Ethiopia

BackgroundSurgical glove perforation is a common event. The operating staff is not aware of the perforation until the procedure is complete, sometimes in as high as 70% of the incidences. Data from Ethiopia indicates that the surgical workforce suffers from a very surgery related accidents, however there is paucity of data regarding surgical glove perforation.The main objective is to describe the incidence and patterns of surgical glove perforation during surgical procedures and to compare the rates between emergency and elective surgeries at one of the main hospitals in Addis Ababa Ethiopia.MethodsThis is a prospective study, performed at the Minilik II referral hospital, Addis Ababa. All surgical gloves worn during all major surgical procedures (Emergency and Elective) from June 1-July 20, 2016 were collected and used for the study. Standardised visual and hydro insufflation techniques were used to test the gloves for perforations. Parameters recorded included type of procedure performed, number of perforations, localisation of perforation and the roles of the surgical team.ResultsA total of 2634 gloves were tested, 1588 from elective and 1026 from emergency procedures. The total rate of perforation in emergency procedures was 41.4%, while perforation in elective surgeries was 30.0%. A statistically significant difference (P < 0.05) was found in between emergency and elective surgeries.There were a very high rate of perforations of gloves among first surgeons 40.6% and scrub nurses 38.8% during elective procedures and among first surgeons (60.14%), and second assistants (53.0%) during emergency surgeries.Only 0.4% of inner gloves were perforated. The left hand, the left index finger and thumb were the most commonly perforated parts of the glove. Glove perforation rate was low among consultant surgeons than residents.ConclusionsOur reported perforation rate is higher than most publications, and this shows that the surgical workforce in Ethiopia is under a clear and present threat. Measures such as double gloving seems to have effectively prevented cutaneous blood exposure and thus should become a routine for all surgical procedures. Manufacturing related defects and faults in glove quality may also be contributing factors.

The clinical application of tracheal gas insufflation

Tracheal gas insufflation is a non conventional respiratory support technology.It might avoid severe CO2 retention in lung protective ventilation strategy, reduce ventilator-associated lung injury, which was recommented recently.In this article, we made a brief introduction of the principle, classification and clinical applications of tracheal gas insufflation technique. Key words: Tracheal gas insufflation; Mechanical ventilation; Lung protective ventilation strategy,

Retrospective analysis of computed tomographic colonography in a rural hospital.

The aims of this study were to investigate the diagnostic performance of computed tomography colonography (CTC) performed in a rural secondary hospital, and to describe the local pattern of CTC service provision. A single site, retrospective observational analysis was conducted for all patients undergoing CTC during the 12-month period from 1st of January to 31st of December 2014 with comparison to available colonoscopy. There were 639 CTCs performed during the 12-months period. The average time from referral to performance of CTC scan was 21.3days. The diagnostic yield of CTC for CRC was 5.8%; and for large polyps ≥10mm was 8.0%. The sensitivity and specificity of CTC for detecting CRC were 97.1% and 88.2% respectively. The most predictive symptoms for finding colorectal lesions were rectal bleeding and anaemia. The referral rate from CTC to colonoscopy was 16.9%. 63 patients (9.9%) had follow up recommendations made in their reports due to extracolonic findings. Computed tomography colonography performed in a rural secondary hospital provided sufficient sensitivity to detect large polyps or CRC. The specificity for CRC was lower than reported figures in the literature. Technical issue of CTC performance due to poor insufflation techniques was identified as a main contributing factor reducing CTC accuracy. CTCs were performed with acceptable waiting time and showed high overall diagnostic yield for colorectal neoplasm in a rural hospital.

Study of the Effect of the Rate of Flow of Carbon Dioxide Gas for Creation of Pneumoperitoneum on Cardiovascular System during Laparoscopic Surgeries

Laparoscopy has gained a worldwide acceptance due to its added advantages. Pneumoperitoneum required for this although aids in the surgical skill but invites a straight challenge to the attending anaesthesiologist for optimal control of haemodynamics .Reports of serious complication have been documented with abrupt and rough insufflation techniques of artificial creation of pneumoperitoneum ranging from mild bradycardia to frank cardiac arrest due to vagal mediated parasympathetic response due to rapid stretching of peritoneum. Gradual, gentle and slow rate of insufflation can prevent such complications. In this context, we have conducted a study on 40 patients of ASA I and ASA II, undergoing elective laparoscopic surgery requiring general anaesthesia with intubation. Patients were randomly allocated into study (A) and control (B) group. Group A (20 patients) comprises of the group where surgeon uses gradual and slow rate of insufflations of co2 whereas group B comprises of patients in which the surgeons uses abrupt and rapid insufflations of co2 at the rate of more than 4L/min and have found statistically significant hemodynamic changes in group B in comparison to Group A. Hence, we have concluded that insufflation with high flow rate while establishing artificial pneumoperitoneum increase IAP instantaneously and unexpected cardiovascular changes occurs such as hypotension, bradyarrhythmia whereas slow rate of insufflations prevents such complications. In patients with compromised cardio respiratory status, such vagal response with abrupt and rapid insufflations of co2 can prove to be detrimental .Therefore, not only maintaining IAP below 12-15 mmHg but also keeping slow insufflation rate (2-4lit/min) when establishing pneumoperitoneum is important and essential.

Gas Analysis Using Raman Spectroscopy Demonstrates the Presence of Intraperitoneal Air (Nitrogen and Oxygen) in a Cohort of Children Undergoing Pediatric Laparoscopic Surgery

Clinically significant gas embolism during laparoscopy is a rare but potentially catastrophic event. Case reports suggest that air, in addition to the insufflation gas, may be present. We studied the effects of equipment design and flushing techniques on the composition of gas present under experimental and routine pediatric surgical conditions. Concentrations of nitrogen (N2), oxygen (O2), and carbon dioxide (CO2) were measured by Raman spectroscopy in gas delivered to and retrieved from a mock peritoneum during simulated laparoscopy. We then analyzed the composition of insufflated and recovered gases during elective laparoscopic procedures conducted with CO2-preflushed and unflushed tubing to determine the presence of significant (10%) quantities of air. In vitro, CO2 was not detected at the distal end of insufflator tubing until after delivery of approximately 0.2 L of gas, and N2 persisted until >0.4 L was delivered, with 40% ± 8% (mean ± SD, range 33%-49%) recovered from the mock peritoneum at the termination of initial insufflation. In clinical studies, preflushing reduced the initial concentration of N2 from 78% ± 0.5% to 23% ± 15%, but >10% air was detected in all subsequent samples, regardless of insufflation technique. Laparoscopic equipment and practice routinely permit delivery of air to the insufflated cavity. Purging the equipment with CO2 reduces but does not eliminate air (N2, O2) within the peritoneal cavity during laparoscopy. Thus, when vascular injury occurs, embolized gases will contain variable quantities of N2, O2, and CO2. As the initial insufflation volume diminishes and approaches the volume of the insufflation tubing, which occurs in infants and young pediatric patients, the concentration of N2 will approximate that of room air in an unflushed system. Small insufflation volumes containing high N2 concentrations can contribute to catastrophic air emboli in neonates and small pediatric patients.

Thoracic block technique associated with positive end-expiratory pressure in reversing atelectasis.

A preschool four-year-old male patient had been admitted to the Mandaqui Hospital with a diagnosis of lobar pneumonia, pleural effusion, and right lung atelectasis. Treatment consisted of antibiotics and physiotherapy sessions, using a technique described in the literature as Insufflation Technique to Reverse Atelectasis (ITRA), which consists of a thoracic block of healthy lung tissue, leaving only the atelectasis area free, associated with the use of invasive or noninvasive mechanical ventilation with positive airway pressure for reversal of atelectasis. Two physiotherapy sessions were conducted daily. The sessions lasted 20 minutes and were fractionated into four series of five minutes each. Each series bilateral thoracic block was performed for 20 seconds with a pause lasting for the same time. Associated with the thoracic block, a continuous positive airways pressure was used using a facial mask and 7 cm H2O PEEP provided via CPAP. Conclusion. ITRA technique was effective in reversing atelectasis in this patient.

Laparoscopic entry techniques in obese patient: veress needle, direct trocar insertion or open entry technique?

Laparoscopy is a common procedure in bariatric surgery. Serious complications can occur during laparoscopic entry as reported by Ahmad et al. (Cochrane Database Syst Rev 15:2, 2012). Several techniques, instruments, and approaches to minimize the risk of injury (the bowel, bladder, major abdominal vessels, and an anterior abdominal wall vessel) have been introduced. These methods include the standard technique of insufflation after insertion of the Veress needle, the open (Hasson technique), the direct trocar insertion, and optical trocar insertion. Furthermore, it is more difficult to perform in the obese patient, especially if the first trocar is not umbilical. This is because obese patients have a very thick abdominal wall (particularly in women) as well as a thick peritoneum. The aim of this article was to demonstrate the safety of various laparoscopic entry techniques in obese patient.