Prolonged Laparoscopic Surgery Research Articles

Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.

Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery. Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO2), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO2), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared. The values of ETCO2, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO2 at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar. During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.

Effect of posture and prolonged pneumoperitoneum on intraoperative and postoperative outcomes during gynecological laparoscopic surgery: an observational clinical study

Introduction Laparoscopic surgery is a common daily performed procedure. It has the advantages of small incision, better cosmetic aspects, less postoperative pain, and rapid recovery to daily activities. Pneumoperitoneum and increased intraabdominal pressure can induce many pathophysiologic disturbances, requiring the anesthesiologist to be well alert during the operation for necessary management. Patients and methods This is a prospective, observational clinical study. A total of 60 consecutive patients scheduled for gynecological laparoscopic surgery were recruited from the Gynecological and Obstetrics Department. Selected patients were divided into two groups according to the duration in Trendelenburg positioning: group I ( 1 h). A preoperative anesthetic assessment was carried out, and a standardized general anesthesia technique and monitoring were followed for all patients of the two groups. Pneumoperitoneum was generated by the insufflation of gas (CO2) into the peritoneal cavity. Results On the evaluation of the effect of prolonged pneumoperitoneum and position of patents on intraoperative hemodynamics, mean arterial blood pressure was significantly decreased (in group II) at time M3 (average mean blood pressure during Trendelenburg position till recovery). Heart rate also significantly decreased (in group II) at time heart rate 3 (average heart rate during Trendelenburg position till recovery). Intraabdominal pressure significantly decreased in group II at time intraabdominal pressure 4 (average time during positioning), and pulmonary function test parameters were significantly decreased after recovery. Conclusion Prolonged laparoscopic gynecological surgery can markedly affect intraoperative hemodynamics and postoperative respiratory function.

Results of hepatic and renal function tests to different CO2 pneumoperitoneum conditions: An experimental capnoperitoneum study in dogs

Carbon dioxide (CO2) is the most commonly used insufflation gas to provide exposure in the abdominal cavity during laparoscopic surgery. This study investigated the results of hepatic and renal function tests after different capnoperitoneum intraabdominal pressures in dogs. Twenty-four beagle dogs (12 males and 12 females) were used (n = 6 dogs). The intraabdominal pressure was maintained for 60 minutes, and urinalysis, hepatic and renal function tests were carried out at designed times. No surgery was performed on any of the dogs during the capnoperitoneum. In this study, whether low or high pressure, significant increases of gamma-glutamyltransferase, alkaline phosphatase, aspartate aminotransferase and creatinine levels were observed after pneumoperitoneum. However, our results showed a trend toward higher serum concentrations of some enzymes in dogs at an insufflation pressure of 15 mmHg compared to that of the other groups, although these differences did not reach statistical significance. Therefore, low pressure capnoperitoneum should be considered for dogs with compromised splanchnic function, particularly those undergoing prolonged laparoscopic surgery.

Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse

The benefits of laparoscopic surgery to the patient are well recognised, however it is more physically demanding on the surgeon. A survey was sent to members of the British Society of Gynaecological Endoscopy to ascertain musculoskeletal symptoms and vertebral disc prolapse thought to occur as a result of undertaking laparoscopic surgery. A total of 19 (15%) participants were diagnosed with a vertebral disc prolapse, for which one-third needed definitive treatment. There was a statistically significant association with length of practice and numbers of hours worked per week, with the risk of disc prolapse. There was a multitude of other musculoskeletal symptoms reported. These findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon, which is likely to increase as the capability and superiority of laparoscopic techniques develop. There is an urgent need to explore further the ergonomic impact of laparoscopic work to enable improvements to be made.

Postoperative delayed hypercapnia and respiratory failure after robot-assisted lower anterior resection

Postoperative delayed hypercapnia and respiratory failure after robot-assisted lower anterior resection

The safety and efficacy of minimal-flow desflurane anesthesia during prolonged laparoscopic surgery

BackgroundMinimal-flow anesthesia can meet the demands of a modern society that is more sensitive to environmental protection and economic burdens. This study compared the safety and efficacy of minimal-flow desflurane anesthesia with conventional high-flow desflurane anesthesia for prolonged laparoscopic surgery.MethodsForty-six male patients (ASA physical status II or III) undergoing laparoscopic urologic surgery for more than 6 hours were randomly divided into two groups: the high-flow (HF) group and the minimal-flow (MF) group. The HF group was continuously administered a fresh gas flow of 4 L/min. In the MF group, a fresh gas flow of 4 L/min was administered for the first 20 minutes and was thereafter lowered to 0.5 L/min. Inspiratory and expiratory desflurane concentrations, respiratory variables, and hemodynamic variables were continuously monitored during administration of anesthesia. Measurements of carboxyhemoglobin (COHb) concentration and arterial blood gas analysis were performed every 2 hours during anesthesia. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine were measured on the first and second day after the surgery.ResultsDemographic data and duration of anesthesia were not different between the two groups. Significant differences were not observed between the two groups in terms of hemodynamic variables, respiratory variables, and inspiratory and expiratory desflurane concentrations. Inspiratory O2 concentration was maintained lower in the MF group than in the HF group (43-53% vs. 53-59%; P < 0.05). Compared with the HF group, COHb concentrations was higher (P < 0.05), but not increased from the baseline value in the MF group. Serum AST, ALT, BUN, and creatinine were not significantly different between the two groups.ConclusionsIn prolonged laparoscopic surgery, no significant differences were found in safety and efficacy between minimal-flow and high-flow desflurane anesthesia.

Transcutaneous Carbon Dioxide Monitoring Accurately Predicts Arterial Carbon Dioxide Partial Pressure in Patients Undergoing Prolonged Laparoscopic Surgery

Transcutaneous Carbon Dioxide Monitoring Accurately Predicts Arterial Carbon Dioxide Partial Pressure in Patients Undergoing Prolonged Laparoscopic Surgery

Comparison of the effects of sevoflurane and propofol on core body temperature during laparoscopic abdominal surgery.

BackgroundA decrease in core body temperature caused by heat distribution depends on the anesthetic agent used. The purpose of this study is to investigate the effects of sevoflurane and propofol on core temperature during laparoscopic major abdominal surgery requiring pneumoperitoneum of more than 90 min.MethodsFifty adult patients undergoing laparoscopic major abdominal surgery were randomly assigned to either a sevoflurane group (n = 25) or a propofol group (n = 25). In the sevoflurane group, anesthesia was induced with propofol 2 mg/kg, remifentanil 1.0 µg/kg, and maintained with 0.8-2.0 vol% sevoflurane and 0.1-0.2 µg/kg/min remifentanil. In the propofol group, anesthesia was induced with the effect-site concentration of propofol of 5.0 µg/ml and remifentanil 4 ng/ml, and maintained with the effect-site concentration of propofol of 2-3.5 µg/ml and remifentanil 3-5 ng/ml. Core body temperature was measured with an esophageal stethoscope with a temperature sensor after the start of the pneumoperitoneum (baseline) and at 15-min intervals until completion of surgery.ResultsDuring the study period, core temperature was comparable between the two groups. When compared with baseline values, core temperatures in both groups were significantly decreased 45 min after pneumoperitoneum.ConclusionsThis study demonstrated that in patients undergoing prolonged laparoscopic surgery, a decrease in core body temperature during sevoflurane-remifentanil anesthesia was not different than propofol-remifentanil anesthesia, and the incidence of hypothermia of the two groups did not differ.

Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia

The acid, base and electrolyte changes are usually observed in the perioperative settings. We report a case of prolonged laparoscopic repair of left-sided diaphragmatic hernia which involved a lot of tissue handling and fluid replacement leading to acid, base and electrolyte imbalance. A 42-year-old male underwent prolonged laparoscopic repair under general anesthesia. Intraoperatively, surgeon reported that contents of hernia includes bowel along with mesentery, spleen and lot of fatty tissue The blood loss was about 2 L which was replaced with 1 L of colloid and 7.5 L of lactated ringer. Near the end of surgery arterial blood gas analysis revealed metabolic acidosis, hyperkalemia, and hypocalcemia leading to delayed recovery. We conclude prolonged laparoscopic surgery involving lot of tissue handling including gut and fat should be monitored for acid, base, electrolyte imbalance and corrected timely to have uneventful rapid recovery.

Bile duct injury and use of cholangiography during laparoscopic cholecystectomy

Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC). Data for patients from 114 Swiss institutions who underwent LC for acute or chronic cholecystitis between 1995 and 2005 were used in univariable and logistic regression analyses. In total 31 838 patients, mean(s.d.) age 54·4(15·9) years, were analysed. The incidence of BDI was 0·3 per cent (101 patients), which did not change over time (P = 0·560). Univariable analysis revealed that male patients had a higher risk of BDI (0·5 per cent versus 0·2 per cent in female patients; P = 0·001), as did patients whose operation lasted at least 150 min (1·1 per cent versus 0·1 per cent for operating time of less than 150 min; P < 0·001). Logistic regression confirmed male sex (odds ratio (OR) 1·89, 95 per cent confidence interval 1·27 to 2·81) and prolonged surgery (OR 12·60, 10·87 to 23·81) as independent risk factors. Comparison of groups with and without intraoperative cholangiography showed no difference in the incidence of BDI (both 0·3 per cent; P = 0·755) and BDIs missed during surgery (10 versus 8 per cent; P = 0·737). Male sex and prolonged laparoscopic surgery are independent risk factors for BDI during LC. Frequent use of IOC does not seem to reduce BDI or the number of injuries missed during surgery.

Peritoneal Transforming Growth Factor Beta-1 Expression During Prolonged Laparoscopic Procedures

Laparoscopic surgery may affect peritoneal physiology. Short-term laparoscopic surgery does not affect peritoneal transforming growth factor beta (TGF-b1) expression. The current study was conducted to evaluate the hypothesis that prolonged laparoscopic surgery may affect peritoneal TGF-b1 expression. In the first study, 24 patients scheduled for a right colonic resection were enrolled in the trial. Twelve underwent conventional surgery (CCR) and 12 were operated on laparoscopically (LCR). In the second study, 12 patients undergoing laparoscopic gastric bypass (LGB) surgery for morbid obesity were included. Biopsies of the parietal peritoneum were taken at standardized moments during the procedures. Tissue concentrations of active and total TGF-b1 were measured by using enzyme-linked immunosorbent assays. During the LCR, there was a significant increase in peritoneal active TGF-b1 levels (P < 0.05). A similar, but not significant, trend was observed during the CCR. A similar pattern was seen in the total TGF-b1 concentrations during both procedures. The LGB procedure did not affect peritoneal active or total TGF-b1 concentrations. During the procedure, both the active and total TGF-b1 levels were significantly higher in the LCR, when compared to the LGB, group (P < 0.05). Prolonged laparoscopic surgery may affect peritoneal TGF-b1 expression, depending on the procedure performed. Considering the role of TGF-b1 in various biologic processes, including adhesiogenesis and oncology, these results may have clinical consequences.

Transcutaneous Carbon Dioxide Monitoring Accurately Predicts Arterial Carbon Dioxide Partial Pressure in Patients Undergoing Prolonged Laparoscopic Surgery

There may be large differences between measurements of end-tidal carbon dioxide partial pressure (Petco(2)) and arterial carbon dioxide partial pressure (Paco(2)) during laparoscopic surgeries. Transcutaneous carbon dioxide (Ptcco(2)) monitoring can be used to noninvasively and continuously estimate Paco(2). In the present study we evaluated the accuracy of Ptcco(2) monitoring in predicting the Paco(2) during laparoscopic surgeries with prolonged pneumoperitoneum. Sixteen patients who underwent laparoscopic radical gastrectomy or radical proctectomy under general anesthesia were included in the study. Their Paco(2), Petco(2), and Ptcco(2) values were measured at 3 time points before and after pneumoperitoneum. Agreement among measures was assessed by the Bland-Altman method. Forty-eight sample sets were obtained. The average Paco(2)- Ptcco(2) difference was -0.9 + or - 6.4 mm Hg (mean + or - 2 SD). The average Paco(2) - Petco(2) difference was 7.5 + or - 7.0 mm Hg (mean + or - 2 SD). Paco(2) - Ptcco(2) was less than or equal to + or -5 mm Hg for 88% of the samples. Paco(2) - Petco(2) was less than or equal to + or -5 mm Hg for 17% of the samples (P < 0.05). While undergoing long-term pneumoperitoneum laparoscopic surgery, Ptcco(2) monitoring is more accurate than is PETCO(2) monitoring in predicting the patients' Paco(2).

The Risk Factors of Postoperative Respiratory Insufficiency after Prolonged Robotic Radical Prostatectomy

Background: Robotic radical prostatectomy is performed in elderly patients and requires extreme changes in the patient’s position and is often associated with a long surgery time. This study reviewed the pulmonary complications occurring after a robotic radical prostatectomy and analyzed the potential risk factors. Methods: The medical records of all patients who had undergone robotic radical prostatectomy at our institution were reviewed. Among the 80 total patients, 58 were capable of spontaneous respiration at the end of surgery (Group I), whereas 22 patients required assisted ventilation (Group II). A comparison between the two groups was made in terms of the demographic characteristics, coexisting diseases, anesthesia and operation time, amount of intraoperative blood loss and transfused blood products. Results: The mean age of the patients was 67.2 ± 7.3 years. The mean operation time was 384.1 ± 203.4 min (range, 195−1,180 min). The anesthesia and operation time, amount of intraoperative blood loss and number of transfused patients were all significantly higher in Group II. Univariate analysis revealed age, body mass index, intraoperative blood loss and transfusion, anesthesia and operation time to be related to postoperative respiratory insufficiency. Multivariate analysis revealed intraoperative transfusion and operation time to be predictive risk factors. Conclusions: Prolonged laparoscopic surgery in a steep Trendelenburg position has a high likelihood of postoperative respiratory insufficiency, with the intraoperative transfusion and a longer operation time being possible contributing factors.

Heated and Humidified CO 2 Prevents Hypothermia, Peritoneal Injury, and Intra-Abdominal Adhesions During Prolonged Laparoscopic Insufflations

Insufflation with standard cold-dry CO(2) during laparoscopic surgery has been shown to predispose patients to hypothermia and peritoneal injury. This study aimed to compare the effect of prolonged cold-dry CO(2) insufflation with heated-humidified CO(2) insufflation (3-5 h) on hypothermia, peritoneal damage, and intra-abdominal adhesion formation in a rat model. A total of 160 Wistar rats were randomized to undergo no insufflation or insufflation with cold-dry CO(2) (21 degrees C, <1% relative humidity) or heated-humidified CO(2) (37 degrees C, 95% relative humidity) for 3, 4, or 5 h. Core body temperature was measured via rectum before and during insufflations. Peritoneal samples were taken at 6, 24, 48, and 96 h after treatments and analyzed with light microscopy and scanning electron microscopy. Intra-abdominal adhesions were evaluated 2 weeks later. Core body temperature significantly decreased in the cold-dry group, whereas it was maintained and increased in the heated-humidified group. Scanning electron microscopy and light microscopy studies showed intense peritoneal injury in the cold-dry CO(2) group but significantly less damages in the heated-humidified group. Increased intra-abdominal adhesion formation was observed in the cold-dry CO(2) group, while no adhesions were found in the rats insufflated with heated-humidified CO(2). Heated-humidified CO(2) insufflation results in significantly less hypothermia, less peritoneal damage, and decreased adhesion formation as compared with cold-dry CO(2) insufflation. Heated-humidified CO(2) may be more suitable for insufflation application in prolonged laparoscopic surgery.

Decreased Peritoneal Tissue Plasminogen Activator During Prolonged Laparoscopic Surgery

Peritoneal fibrinolysis is crucial in the peritoneal healing processes and subsequent adhesion formation. During conventional surgery, the peritoneal fibrinolytic system is rapidly disturbed. Short-term laparoscopy does not seem to affect peritoneal fibrinolysis. The aim of the present study was to assess the effect of prolonged laparoscopic surgery on peritoneal fibrinolysis. Twelve consecutive patients undergoing laparoscopic gastric bypass surgery for morbid obesity were included in the study. During the procedure, biopsies of the parietal peritoneum were taken at the start of the procedure and each 45 min afterward. Tissue samples were homogenized and tissue-type plasminogen activator (tPA) antigen, tPA activity, urokinase-type PA antigen, and plasminogen activating inhibitors type 1 antigen were measured using commercial assay techniques. Both tPA antigen and its activity progressively decreased during the procedure, reaching significant levels after 90 min of surgery. The levels of uPA antigen and plasminogen activating inhibitors antigen did not significantly change throughout the procedure. As for conventional surgery, prolonged laparoscopic surgery causes a decreased fibrinolytic activity in the peritoneum due to decreased tPA levels.

Comparison of Core Temperature Changes during Prolonged Laparoscopic and Open Surgery

Background: As the insufflation of dry gas into the peritoneal cavity has been suggested to induce heat loss, the long lasting pneumoperitoneum for laparoscopic procedures may cause hypothermia. This study is aimed to investigate the effect of gas insufflation on the hypothermia during laparoscopic surgery. Methods: Forty male patients scheduled for abdominal surgery (20 patients for open laparotomy, and 20 patients for laparoscopic surgery) were included in the study. The changes of esophageal temperature were measured for 3 hours of operations and compared between the groups. The amount of insufflated CO2 gas was measured and the relationship between the amount of gas and the occurrence of hypothermia was analysed. Results: The esophageal temperature of open laparotomy patients were significantly lower after 120 min of operation time (P ＜ 0.05). There was no relationship between the amount of gas and the occurrence of hypothermia (P = 0.21). Conclusions: With longer operations, laparoscopic surgery has the advantage less core temperature loss, but there was no relationship between the amount of gas and the occurrence of hypothermia. (Korean J Anesthesiol 2007; 52: 150～5)

The impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery

Meininger, D.1; Zwissler, B.1; Byhahn, C.1; Westphal, K.2; Bremerich, D. H.1 Author Information

Impact of Overweight and Pneumoperitoneum on Hemodynamics and Oxygenation during Prolonged Laparoscopic Surgery

Anesthesia adversely affects respiratory function and hemodynamics in obese patients. Although many studies have been performed in morbidly obese patients, data are limited concerning overweight patients [BMI 25-29.9 kg m(-2)]. The aim of this study was to evaluate the effects of prolonged pneumoperitoneum in Trendelenburg position on hemodynamics and gas exchange in normal and overweight patients. We studied 15 overweight and 15 non-obese [BMI 18.5-24.9 kg m(-2)] patients who underwent totally endoscopic robot-assisted radical prostatectomy under general anesthesia with an inspired oxygen fraction of 0.5. A standardized anesthetic regimen was used, and patients were examined at standard times: after induction of anesthesia and Trendelenburg posture, every 30 minutes after establishing pneumoperitoneum, and after the release of the pneumoperitoneum with the patient still in Trendelenburg position. After induction of anesthesia and Trendelenburg positioning arterial oxygen pressure [P(a)O2] and alveolar-arterial difference in oxygen tension [A(a)DO2] differed significantly between both groups with lower P(a)O2 [235 +/- 27 versus 164 +/- 51 mmHg] and higher A(a)DO2 [149 +/- 48 versus 76 +/- 28 mmHg] values in overweight patients. During pneumoperitoneum, P(a)O2 transient increased above baseline values in overweight patients, whereas A(a)DO2 decreased. Hemodynamic parameters [HR, MAP, and CVP] did not differ significantly between groups. Arterial oxygenation and A(a)DO2 are significantly impaired in overweight patients under general anesthesia in Trendelenburg posture. In overweight patients pneumoperitoneum transient reduced the impairment of arterial oxygenation and lead to a decrease in A(a)DO2. Hemodynamic parameters were not affected by body weight.

Postoperative changes in liver function tests: randomized comparison of low- and high-pressure laparoscopiccholecystectomy

Pneumporeitoneum at 14 mmHg causes dangerous hemodynamic disturbances in some patients, leading to splanchnic ischemia. Laparoscopic cholecystectomy (LC) using low-pressure pneumoperitoneum (7 mmHg) minimizes adverse hemodynamic effects on hepatic portal blood flow and hepatic function. This study evaluated the changes in liver function tests after high-pressure LC (HPLC; 14 mmHg) and low-pressure LC (LPLC; 7 mmHg). For this study, 50 patients were randomly assigned to undergo either HPLC (n = 25) or LPLC (n = 25) Liver function tests including total bilirubin, gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were obtained preoperatively, then 24 and 48 h postoperatively. All patients had normal values on the preoperative liver function tests. The anesthesiologic protocol was uniform. The findings showed that ALT after 24 h (LPLC: 1473.72 +/- 654.85; HPLC: 2233.74 +/- 1247.33; p = 0.0096) and 48 h (LPLC: 1322.99 +/- 601.51; HPLC 2007.80 +/- 747.55; p = 0.0008) and AST after 24 h (LPLC: 1189.96 +/- 404.79 i.j.; HPLC: 1679.40 +/- 766.13; p = 0.0069) were increased in the patients who underwent HPLC. The AST levels after 48 h were statistically unchanged from baseline in both groups. Total bilirubin, ALP, and GGT levels remained unchanged from baseline in both groups, without a significant difference between the two groups. Because LPLC minimizes adverse hemodynamic effects on hepatic function, a low-pressure pneumoperitoneum should be considered for patients with compromised liver function, particularly those undergoing prolonged laparoscopic surgery.

Severe Hypercarbia after Prolonged Laparoscopic Surgery: A case report

Laparoscopic surgery is replacing conventional surgical techniques for many common operation. absorption is a problem associated with laparoscopic surgery. However, hypercarbia have been proved clinically safe with appropriate ventilatory changes. But most of the studies have been conducted during laparoscopic cholecystectomy, laparosopic gynecological surgery, and animal studies. Therefore, studies on the effects of prolonged pneumoperitoneun are lack. We experienced a case of severe hypercarbia after prolonged pneumoperitoneum. It is important that repeated arterial blood gas analysis during and especially after prolonged pneumoperitoneum to find hypercarbia.