Reverse Trendelenburg Research Articles

Impact of Either Trendelenburg or Reverse Trendelenburg Positioning for Ureteroscopy Lithotripsy Procedures: A Systematic Review and Meta-Analysis.

Urologists encounter multiple challenges in managing ureteral stones with ureteroscopic laser lithotripsy. This meta-analysis assesses the effectiveness of alternative surgical positioning, Reverse Trendelenburg (RevTren) and Trendelenburg (Tren), in reducing stone migration and enhancing outcomes compared with standard dorsal lithotomy positioning. A systematic review was conducted following PRISMA guidelines, searching Medline, Embase, Scopus, Cochrane, and WoS up to March 2024. This review focused on studies evaluating RevTren or Tren positioning during ureteroscopic lithotripsy compared with standard dorsal lithotomy, analyzing end points such as stone migration, conversion rates, success rates, complications, and operative time. Of 137 studies identified, 8 met the inclusion criteria, encompassing 1374 patients. RevTren significantly reduced ureteral stone migration (odds ratio [OR], 0.20; 95% CI, 0.08-0.47), lowered the need for conversion to a flexible ureteroscope (OR, 0.28; 95% CI, 0.12-0.67), and improved success rates (OR, 2.90; 95% CI, 1.88-4.48). Tren increased migration of ureteral and calyceal stones toward upper renal calyces (OR, 2.12; 95% CI, 1.48-3.04) and achieved a higher success rate (OR, 3.56; 95% CI, 2.15-5.92). Complications were comparable across all positions. Adjusting patient positioning during ureteroscopic laser lithotripsy can enhance procedure outcomes. RevTren effectively reduces ureteral stone migration and the necessity for flexible ureteroscopes, whereas Tren facilitates ureteral and calyceal stone migration toward upper calyces, increasing success rates. Both positioning techniques offer significant advantages over standard positioning and can be safely adopted in clinical practice without compromising patient safety.

Cardiac Output Directly Influences Intracardiac Air After Venous Air Embolism: An Echocardiographic Model Comparing Position Change on Intracardiac Air Bubble Clearance.

Venous air embolism (VAE) can cause significant morbidity and mortality. Prevention and management of VAE include cessation of air entrainment, positioning changes, and hemodynamic support. The degree to which position change and cardiac output (CO) moderate resolution of intracardiac air has not been rigorously studied using contemporary transesophageal echocardiography (TEE). This observational cohort-type study aimed to identify the effect of supine vs sitting positioning on the movement and resolution of intracardiac air. In 20 patients undergoing seated neurosurgery, central venous air aspiration catheters were placed through the median basilic vein. TEE was used to estimate the time required for clearance of agitated microbubbles from the right atrium and ventricle in both the supine and sitting position. Estimates of CO were also obtained echocardiographically in each position. Average clearance time was faster in the sitting vs the supine position with no significant difference in CO. A negative correlation between CO and right atrial clearance time across all patients was demonstrated with a Pearson coefficient of -0.4 (95% CI -0.07, -0.65) with P = .02. During VAE, both patient position and CO can significantly affect how bubbles move through intracardiac chambers. However, augmenting CO during VAE may be clinically more feasible, efficient, and productive than changing positioning-especially during crises unless the changing in position is intended to halt the entrainment of air. Further TEE studies of intravascular air movement affected by other position changes (lateral, reverse Trendelenburg) and vasopressors should be considered.

Fluid distribution during surgery in the flat recumbent, Trendelenburg, and the reverse Trendelenburg body positions.

The distribution and elimination of infused crystalloid fluid is known to be affected by general anesthesia, but it is unclear whether changes differ depending on whether the patient is operated in the flat recumbent position, the Trendelenburg ("legs up") position, or the reverse Trendelenburg ("head up") position. Retrospective data on hemodilution and urine output obtained during and after infusion of 1-2 L of Ringer's solution over 30-60 min were collected from 61 patients undergoing surgery under general anesthesia and 106 volunteers matched with respect to the infusion volume and infusion time. Parameters describing fluid distribution in the anesthetized and awake subjects were compared by population volume kinetic analysis. General anesthesia decreased the rate constant for urine output by 79% (flat recumbent), 91% (legs up) and 91% (head up), suggesting that laparoscopic surgery per se intensified the already strong anesthesia-induced fluid retention. General anesthesia also decreased the rate constant governing the return of the distributed fluid to the plasma by 32%, 15%, and 70%, respectively. These results agree with laboratory data showing a depressive effect of anesthetic drugs on lymphatic pumping, and further suggest that the "legs up" position facilitates lymphatic flow, whereas the "head up" position slows this flow. Both Trendelenburg positions increased swelling of the "third fluid space". General anesthesia caused retention of infused fluid with preferential distribution to the extravascular space. Both Trendelenburg positions had a modifying influence on the kinetic adaptations that agreed with the gravitational forces inflicted by tilting to body.

615. ROBOTIC REDO LAPAROSCOPIC HELLER’S CARDIOMYOTOMY

Abstract Introduction Robotic Heller’s cardiomyotomy is the preferred treatment option for achalasia cardia. However, following Heller’s cardiomyotomy up to 20% of patients experience dysphagia and regurgitation in the long term. The ideal management option for such patients needs to be determined. Surgical Steps The procedure is carried out with patient in supine position, legs abducted with the knees in slightly flexed position in reverse Trendelenburg position of approximately 30°.The pneumoperitoneum is created by closed Veress needle technique. After Relasing Adhesions, the gastrohepatic ligament is divided and the right crus is identified and retrocardiac window is formed; proximal short gastric vessels are divided for posterior wrap. The esophagus is separated by blunt dissection from the crus, the peritoneum and phrenoesophageal membrane are divided and the left crus is identified. If an anterior partial fundoplication is planned as antireflux procedure, the mobilization is limited to the lateral and anterior aspects. The anterior vagus nerve is identified and should be dissected and lifted away from the distal esophagus and proximal stomach in order to facilitate transhiatal dissection, myotomy and also to prevent injury to the esophagus and vagal trunks. Dissection is continued cranially around the esophagus for a distance of about 2–3 cm onto the dilated segment of the esophagus in the posterior mediastinum. If posterior partial wrap (Toupet) is planned, esophagogastric dissection is performed posteriorly from both crura and median arcuate ligament to get tension free wrap. Fundus of the stomach is dissected off the diaphragm and if needed two or three short gastric vessels are divided. Posterior vagal trunk is dissected along with esophagus. Conclusion Redo Robotic Heller’s cardiomyotomy can safely be performed with good symptomatic relief for patients who present with recurrent symptoms following Heller’s cardiomyotomy. Long term follow-up with larger sample size is needed to confirm these findings. https://drive.google.com/file/d/1uFgx0Aal92o5FE-Ndp-tAsCg01NJ6Crm/view?usp=sharing

The reverse Trendelenburg position in proximal ureteral stone management: A systematic review and meta-analysis

IntroductionUreteroscopy lithotripsy (URSL) presents a therapeutic option for patients with proximal ureteral calculi warranting active removal. This systematic review and meta-analysis aimed to assess the efficacy of the reverse Trendelenburg (RT) position during this procedure. MaterialsA comprehensive literature search was conducted across PubMed, Embase, and Cochrane databases to identify randomized controlled trials and observational studies comparing RT versus standard positioning (STD) in patients undergoing URSL for proximal ureteral stones. Heterogeneity was measured with the Cochran's Q test, I2 statistics, and prediction intervals (PI). A DerSimonian and Laird random-effects model was utilized for all outcomes. ResultsFour studies encompassing 505 patients undergoing URSL were analyzed. Among the studied participants, 293 (58%) underwent RT positioning. Overall, RT was associated with a lower average incidence of stone retropulsion (RR 0.42; 95% CI 0.27–0.65; I2=48%; PI 0.08–2.10) and a higher mean stone-free rate (RR 1.33; 95% CI 1.18–1.49; I2=0%). However, no significant difference between groups was found in the mean rate of overall complications (RR 0.76; 95% CI 0.40–1.43; I2=51%; PI 0.00–520.22) and operative time (MD –0.65; 95% CI –9.58–8.27; I2=94%; PI –111.95–110.65). In those with proximal ureteral stones undergoing RT positioning at only the 20° angle, there was a reduction in stone retropulsion without any measured heterogeneity (RR 0.35; 95% CI 0.23–0.52; I2=0%). ConclusionThese findings suggest that RT positioning is effective in improving outcomes for patients with proximal ureteral stones undergoing URSL, and its use should be considered during the procedure.

Kontrollü Hipotansif Anestezi ile Yapılan Timpanoplastilerde Baş Pozisyonunun Serebral Oksijen Saturasyonu Üzerine Etkisi

Objective: Our goal was to examine the impact of head position, which had not been examined before, on cerebral oxygenation in tympanoplasties performed in the reverse Trendelenburg position during controlled hypotension. Methods: This prospective study was conducted in our clinic between July 2020 and November 2020. A total of 81 patients aged 18-59 years, who had an ASA physical condition classification score of 1-2 and were evaluated in two groups according to the type of surgery. In the tympanoplasty group, the head was turned to the contralateral ear and placed in minimal extension while in the septoplasty group, the head was kept in the neutral position. The regional cerebral oxygen saturation (c-rSO2) values of the right and left sides were recorded continuously with O3 regional oximetry probes on both sides throughout the operation. Results: When an overall examination was performed without separating the tympanoplasty group as right/left, the median oxygen saturation level was 69.50% (Q1:61.00-Q3:72.00) for the operated side and 74.00% (Q1:66.00-Q3:79.00) for the contralateral side. The oxygen saturation of the operated side was statistically significant lower (p<0.001). The median oxygen saturation of the operated side in the tympanoplasty group [69.50% (Q1: 61.00- Q3:72.00)] was statistically significantly lower than that of the septoplasty group [72.00% (Q1:65.25-Q3:77.75)] (p=0.004). Conclusion: This study showed that the rotation of the head 45° or above in the revers Trendelenburg supine position causes cerebral desaturation on the opposite side of rotation. Keywords: Anesthesia, blood pressure, ear, intracranial hypotension, otologic surgical procedures

Observational Analysis of Endotracheal Tube Cuff Pressure Changes during Laparoscopic Surgery in Trendelenburg and Reverse Trendelenburg Position

Observational Analysis of Endotracheal Tube Cuff Pressure Changes during Laparoscopic Surgery in Trendelenburg and Reverse Trendelenburg Position

The Effect of Intermittent Pneumatic Compression on Hemodynamics and Regional Cerebral Oxygen Saturation in Laparoscopic Bariatric Surgery with Mild Hypercapnia in the Steep Reverse Trendelenburg Position.

Obesity negatively affects hemodynamics and cerebral physiology. We investigated the effect of the utilization of an intermittent pneumatic compression (IPC) device on hemodynamics and cerebral physiology in patients undergoing laparoscopic bariatric surgery under general anesthesia with lung-protective ventilation. Sixty-four patients (body mass index > 30 kg/m2) were randomly assigned to groups that received an IPC device (IPC group, n = 32) and did not (control group, n = 32). The mean arterial pressure (MAP), heart rate (HR), need for vasopressors, cerebral oxygen saturation (rSO2), and cerebral desaturation events were recorded. The incidence of intraoperative hypotension was not significantly different between groups (p = 0.153). Changes in MAP and HR over time were similar between groups (p = 0.196 and p = 0.705, respectively). The incidence of intraoperative cerebral desaturation was not significantly different between groups (p = 0.488). Changes in rSO2 over time were similar between the two groups (p = 0.190) during pneumoperitoneum. Applying IPC to patients with obesity in the steep reverse Trendelenburg position may not improve hemodynamic parameters, vasopressor requirements, or rSO2 values during pneumoperitoneum under lung-protective ventilation. During laparoscopic bariatric surgery, IPC alone has limitations in improving hemodynamics and cerebral physiology.

The Effect of Pneumoperitoneum on the Ankle-brachial Index of the Patients Undergoing Laparoscopic Cholecystectomy: An Observational Study.

Improvement in the perioperative care has led to increased use of minimally invasive surgeries. Multiple physiological changes during minimally invasive surgeries are attributed to the creation of pneumoperitoneum. One hundred and nine patients who underwent laparoscopic cholecystectomy at a tertiary care hospital in north India meeting the inclusion and exclusion criteria were enrolled. Out of the total 109 patients, 13 were males and 96 females (M:F = 1:7.3), the mean basal metabolic rate was 28.95 kg/m2. The mean systolic and diastolic blood pressure of the upper limb were 134.33 + 17.545 and 80.69 + 11.59 respectively. The mean systolic and diastolic blood pressure in lower limb (LL) were 142.32 + 21.552 and 79.44 + 11.94, respectively. Significant rise in the SBP was noticed in LL at the time of creation of Pneumoperitoneum and after changing the position for surgery (P < 0.05). The diastolic pressure in the LL rises significantly in the LL after creation of pneumoperitoneum, at induction, after reverse Trendelenburg position and extubation (P < 0.05). The mean arterial pressure increased significantly in the LL after the creation of pneumoperitoneum and persisted till the extubation (P < 0.05). A significant rise of ankle-brachial index (ABI) was observed in the patients after the creation of pneumoperitoneum and it remained significant till 15 min into surgery (P < 0.05). There was no correlation of ABI with weight and age of the patients on Pearson correlation. There is rise in ABI of the patients undergoing laparoscopic cholecystectomy at the time of creation of pneumoperitoneum, after Trendelenburg position and 15 min into surgery.

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

One of the common methods of anaesthesia for caesarean sections (CSs) involves the use of spinal anaesthesia in mothers. Various positions are utilized in this method. This study aims to compare the evaluation of two positions, Trendelenburg and reverse Trendelenburg, in candidates for CS to assess the duration of anaesthesia and changes in vital signs in women. This study was a randomized clinical trial in which 60 pregnant mothers who met the inclusion criteria entered the study. These mothers were randomly allocated into two equal groups using block randomization. One group of patients received spinal anaesthesia in the Trendelenburg position, while the other group received it in the Reverse Trendelenburg position. Vital signs (systolic and diastolic blood pressure, heart rate, Apgar score, and SPO2) of participants from both groups were evaluated for 1 h after the induction of anaesthesia. Additionally, sensory level and duration of anaesthesia were measured. Finally, the data from both groups were subjected to statistical analysis using SPSS version 26 software. The mean (SD) age of participating mothers in the Reverse Trendelenburg and Trendelenburg groups was 28.93 (5.82) and 30.97 (4.94), respectively. The two study groups did not significantly differ in baseline characteristics such as age, BMI, which could potentially impact vital sign outcomes or anaesthesia duration, and education (P>0.05). The mean (SD) duration of anaesthesia in the Trendelenburg position was significantly higher than in the Reverse Trendelenburg position [221.57(min) vs. 159.00(min)] (P<0.0001). There was no significant difference between the two positions, Trendelenburg and Reverse Trendelenburg, in terms of sensory level and its extent (P=0.08). The two study groups did not significantly differ in hemodynamic changes measured 13 times, including heart rate, systolic and diastolic blood pressure, and Apgar score (P>0.05). In spinal anaesthesia with the Trendelenburg position compared to the Reverse Trendelenburg position, there is a longer duration of anaesthesia. This is while the two positions did not differ in terms of hemodynamic changes and sensory level.

Abstract TP109: Quality Improvement Review and Practical Consideration of Hyperfine Portable Bedside Low-Field Magnetic Resonance Imaging in the Non-ICU Setting

Introduction: The Hyperfine portable low-field Magnetic Resonance Imaging (MRI) scanner (0.064 Tesla) was FDA approved in 2020. The use of portable low-field MRI (pMRI) has been best studied in ICU settings, although there has been interest in expanding this technology in floor level status stroke patients. Methods: We report our experience launching pMRI in our academic comprehensive stroke program in the non-ICU setting. From September 2021 to March 2022, 24 pMRI scans were performed (2 volunteers, 22 floor-status stroke patients). Our institutional pMRI protocol includes localizer, DWI, ADC, and FLAIR (24 minutes scan time). Good head position (GHP) was defined as the vertex of the head abutting the top of the helmet insert. Complete scans were defined as including all sequences and Partial scan included DWI/ADC. Results: Among 24 scans, most 17/24 (70.8%) were Complete and 2 scans were aborted after only localizer images. Six scans were Partial, due to patient discomfort in 4 (“feeling hot” [2], neck/back pain [2]), and technical issues with machine in 2. Among 22 scans that were Partial or Complete, 6 scans had poor head positioning. We noted that although there was initial GHP, the head could shift out due to gravity or patient self-adjustment due to discomfort. To combat the shift issue, the bed was placed in slight reverse Trendelenburg. We also implemented wedge padding for the lower back that improved comfort. After scan # 11, re-training was performed to include GHP updates. Before re-training, 6/11 (45.5%) had GHP, and afterwards, 11/11 (100%) had GHP. Our quality review also noted that artifact on the DWI/ADC mimicking restricted diffusion could be seen in the internal capsule and corpus callosum, and clinical teams were educated on this. Conclusions: The use of low-field pMRI in non-ICU settings is feasible. Our institutional QI experience suggests that patient selection and technical skill in GHP is a consideration. After adjusting our protocol, the rate of GHP increased from 45% to 100%. Clinical teams also need to be aware of artifact mimicking restricted diffusion in areas of tightly bound white matter tracks. Further studies are warranted to better maximize pMRI and understand the logistical barriers to successful implementation.

OBEZ HASTALARDA LAPAROSKOPİK CERRAHİLERDE FARKLI PEEP UYGULAMALARININ OPTİK SİNİR KILIF ÇAPINA ETKİSİNİN DEĞERLENDİRİLMESİ

OBJECTIVE: Positive end-expiratory pressure (PEEP) application, which is used to improve oxygenation by keeping the alveoli open, may cause an additional increase in intracranial pressure (ICP) during pneumoperitoneum in obese patients. In this study, the effect of different PEEP applications on the optic nerve sheath diameter (ONSD) in obese patients undergoing laparoscopic surgery was evaluated. MATERIAL AND METHODS: The study included 26 patients with a Body Mass Index (BMI) of ≥ 30 and the American Society of Anesthesiologists (ASA) I-II status undergoing laparoscopic surgery in the reverse Trendelenburg position. After anesthesia induction, the patients were randomly allocated to either the PEEP 5 group or the PEEP 8 group. The patients were compared with respect to age, gender, BMI, ASA status, operations performed, and the hemodynamic data and ONSD values recorded intraoperatively at regular intervals. RESULTS: 22 patients completed the study. Except for gender (p=0.020), there was no difference in demographic and hemodynamic data between the groups. No difference was observed between the groups in respect of ONSD measurements at all times. In the intra-group comparisons, there was no difference in the ONSD values within the PEEP 5 group, whereas in the PEEP 8 group, the measurements at 5 minutes (T2) and 30 minutes (T3) after pneumoperitoneum, and at the end of surgery (T4) were significantly higher than the basal measurements (T1) (p=0.010, p=0.003, p=0.012). CONCLUSIONS: Although PEEP 8 and PEEP 5 applications have similar effects to ICP increase, we thought that it would be safer to apply PEEP increments by measuring ONSD via ultrasonography.

Effect of Carbon Dioxide Pneumo-peritoneum in Coagulation Profile of Patients undergoing Laparoscopic Cholecystectomy: A Prospective Cohort Study

Introduction: Laparoscopic Cholecystectomy (LC) is done under general anaesthesia with the patient in a reverse Trendelenburg position and with pressurised carbon dioxide in the peritoneum. This can induce venous stasis in the lower extremities and may affect the balance in the coagulation and fibrinolysis system, thereby thrombo-embolic complications. Aim: To investigate the effects of carbon dioxide pneumoperitoneum on the coagulation system of patients undergoing LC. Materials and Methods: A prospective longitudinal study was carried out from January 2021 to June 2021 among patients aged 18 to 60 years who attended the Surgery Department at Regional Institute of Medical Sciences, Imphal, Manipur, India and were diagnosed with gallstone disease and subsequently underwent LC. Independent variables like age, sex, religion, pre-operative prothrombin time, platelet count, activated Partial Thromboplastin Time (aPTT), and International Normalised Ratio (INR). Outcome variables comprised complications, postoperative prothrombin time, platelet count, aPTT, and INR. Data collected were analysed using Statistical Package for Social Sciences(SPSS) version 21.0. Paired t-tests were employed to test the association between mean values of post-operative and pre-operative PT, aPTT, INR, etc. A p-value of less than 0.05 was considered statistically significant. Results: The study enrolled 71 patients who encountered LC with carbon dioxide pneumo-peritoneum, including 18 male and 54 female patients. Maximum number of patients (28, 38.9%) fell into the 41 to 50 years age group. There was no significant difference in the mean value of prothrombin time (p=0.150) and INR (p=0.437) measured between the pre-operative and postoperative periods. Conclusion: LC is a safe procedure without clinically significant changes in the coagulation profile.

Effect of Intravenous Aminophylline on Hemodynamics and Recovery of Patients Undergoing Functional Endoscopic Sinus Surgery Under Dexmedetomidine Hypotensive Anesthesia: A Randomized Controlled Study.

The sympatholytic property of dexmedetomidine (DEX) makes it suitable as a hypotensive drug during functional endoscopic sinus surgery (FESS); however, delayed emergence from anesthesia and high postoperative sedation have been reported. Delayed emergence from anesthesia and high postoperative sedation are associated with a prolonged length of stay in the operating room and the postanesthesia care unit (PACU), which increases health care costs. This study aimed to overcome the negative impact of DEX on recovery by using aminophylline. This randomized, double-blind, placebo-controlled study was conducted on 52 patients planned for elective FESS under general anesthesia with DEX infusion for controlled hypotension during surgery. Patients were equally divided into 2 groups. The aminophylline group received 4 mg/kg aminophylline diluted in 50 mL saline 0.9% over 30 minutes after positioning in a 20-degree reverse Trendelenburg position. The control group received 50 mL saline 0.9% with a similar volume and period as the aminophylline group. The extubation time was significantly shorter in the aminophylline group (6.5 (5.25 - 7.75) minutes) than in the control group (9 (7.25 - 10) minutes) (P-value < 0.001). The PACU discharge time was significantly shorter in the aminophylline group (15 (10 - 20) minutes) compared to the control group (20 (15 - 28.75) minutes) (P-value = 0.036). Intraoperative heart rate and mean arterial pressure were nonsignificantly different between the 2 groups. Ramsay sedation score measurements at 15 min, 30 min, and 60 min after extubation were significantly lower in the aminophylline than in the control group (P-value < 0.05). Complications were nonsignificantly different between the 2 groups. Intraoperative aminophylline infusion enhances the recovery of patients undergoing FESS under DEX hypotensive anesthesia without intraoperative hemodynamic alterations and decreases their postoperative sedation without significant postoperative side effects.

OGBN V03 Robotic choledochoduodenostomy for benign common bile duct stricture

Abstract Background A 54-year-old male patient was referred with benign distal common bile duct (CBD) stricture secondary to chronic pancreatitis. He had multiple admissions with recurrent cholangitis requiring numerous Endoscopic Retrograde CholangioPancreatographies (ERCPs) and stent exchanges including SpyGlass procedure which did not demonstrate evidence of malignancy. His quality of life was poor due to debilitating pain and recurrent hospital admissions so he was offered elective choldechoduodenostomy aiming to bypass the bile duct stricture, but also allowing continued endoscopic surveillance. Methods A robotic choledochoduodenostomy was performed using the DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15degrees) in reverse Trendelenburg position with a slight left tilt. Initially, robotic cholecystectomy was carried out following which the CBD was dissected and its anterior wall delineated. The duodenum was kocherised to allow sufficient mobility for anastomosis. Subsequently, a longitudinal choledochotomy was performed and a metal stent was extracted. Then, an enterotomy was made perpendicularly to the choledochotomy. A choledochoduodenostomy was performed using continuous 4-0-V-Loc sutures for posterior wall and 4-0-PDS continuous sutures for anterior wall. Results The post-operative period was uncomplicated. The patient experienced minimal pain after procedure and was discharged home on post-operative day 2. He was reviewed in outpatient clinic 6 weeks after, and reported he had successfully discontinued all regular opiates and benzodiazepines previously used for pain control. Conclusions A robotic choledochoduodenostomy is an excellent alternative for the treatment of benign bile duct strictures in patients with recurrent cholangitis requiring repeated stent exchanges. Moreover, it has the advantage of continued endoscopic surveillance which is not possible with traditional hepatico-jejunostomy.

OGBN V02 Robotic common bile duct clearance

Abstract Background A 44-yar old male patient presented with painful obstructive jaundice and bilirubin of 127 μmol/L. A Contrast Enhanced Computed Tomography (CECT) revealed dilated biliary tree as a result of obstructing stone in the proximal common bile duct (CBD). The patient underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and sphincterotomy which demonstrated pus in the bile duct, but also a stone impacted in the common hepatic duct which could not be extracted endoscopically. Therefore, a 7Fr pigtail stent was inserted. Subsequently, he was discharged home and re-admitted for an elective robotic cholecystectomy and bile duct clearance 6 weeks later. Methods Robotic CBD clearance was performed using DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15 degrees), in reverse Trendelenburg position and left tilt. The CBD was dissected out, the anterior duct wall was delineated and longitudinal choledochotomy was carried out. A large stone was extracted through the choledochotomy site followed by removal of stent. Subsequently, a cholangioscopy was performed using a single-use flexible ureteroscope and no further stone disease was identified proximally or distally. Following this, a bile duct closure was performed using 4-0 Polydioxanone interrupted sutures and SutureCut Needle Driver. Results There were no intra- or post-operative complications. The patient made an excellent recovery from robotic common bile duct clearance and was discharged home less than 24 hours post procedure. Conclusions This video presentation highlights the technical aspects of robotic common bile duct clearance and demonstrates that the robotic system allows for accurate dissection and precise suturing which could reduce the risk of bile duct stricture.

551 Admissible or Overkill - Get It Right First Time (GIRFT) operative documentation for Laparoscopic Cholecystectomy

Abstract Aim Get It Right First Time (GIRFT) Laparoscopic Cholecystectomy (LC) documentation best practice was updated in September 2022. This was a combined incentive by NHS &amp; Royal College of Surgeons with the aim to improve poor operative documentation leading to medico-legal claims and preventing defence of good medical practice. We aim was to assess how we locally adhere to these. Method Retrospective 2-cycle, 2-month review of all LC (August 2022 (pre GIRFT) and September 2022 (post GIRFT)). Operation notes were scrutinised and compared to the newly set national standards. 60 operation notes were sampled (33 pre, 27 post), completed by 8 surgeons. We defined the recommendations into 24 essential and 8 non-essential elements. Results N = 0 operative notes contained 100% of the required information recommended by GIFRT. Of the pre GIRFT, 33% (n = 11) had ≥75% of the essential criteria (p = 0.162). Post GIRFT, 44% (n = 12) had ≥75% of the essential criteria (p = 0.097). Notable deviation from standards were poor documentation on patient position &amp; skin preparation (23%), intra-abdominal pressure setting (7%) and histology sent (3%). 0% stated the table position (reverse Trendelenburg or right side up). Conclusions Although the GIFRT guidelines for documentation in LC are lengthy, without them it is difficult to defend good medical practice when exposed to medico-legal claims. Despite GIFRT release, locally we only had minor improvements in documentation standards. This indicates that a set operation notes proforma and further dissemination of these recommendations may be needed to improve documentation standards.

Laparoscopic ultrasonography of the liver is feasible and safe in dogs.

To describe the feasibility and technique for performing laparoscopic ultrasound (LUS) of the liver in dogs. 12 client-owned dogs presenting for elective laparoscopic surgery from January 1, 2022, to October 31, 2022. Laparoscopic exploration and LUS of the liver were performed in all dogs. Dogs were positioned in reverse Trendelenburg and laterally rotated to facilitate access to all liver lobes. Time to perform laparoscopic exploration and LUS, ability to visualize and access each liver lobe entirely, and any complications were recorded. Each dog underwent an elective laparoscopic procedure. The surgeon completed a National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire after surgery. Mean body weight was 25.9 kg (SD, ± 4.1 kg; range, 5.7 to 62 kg). All liver lobes were scanned to the level of the hilus in 10/12 dogs. In 2 dogs, the caudate lobe could not be completely imaged. Median time to perform LUS was 9 minutes (IQR, 5 to 16.5 minutes), and median NASA-TLX score was 9/100 (IQR, 6.3 to 20). There was a significantly strong negative correlation between time to perform LUS (r = -0.77; P = .0037) and NASA-TLX score (r = -0.84; P = .0006) with trial number. Minor complications occurred in 2 dogs during laparoscopic exploration. No complications occurred during LUS. LUS was feasible and safe in all dogs. The right lateral and caudate lobes were occasionally challenging to access. Technical demand and time to perform LUS improved with experience, suggesting a learning curve. Evaluation of LUS in dogs with clinical disease is warranted.

Effect of reverse Trendelenburg position and positive pressure ventilation on safe non-hypoxic apnea period in obese, a randomized-control trial

PurposeThere is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP).MethodsFifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH2O and an additional 10 cmH2O of PEEP while breathing spontaneously (RT/PPV group) according to randomization.ResultsThe SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO2) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p < 0.0001), a higher proportion of patients that reached the satisfactory FEtO2 of 0.90 (21/24, 88% vs. 13/24, 54%, p = 0.024), a higher FEtO2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p = 0.038).ConclusionIn the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population.Trial registrationNCT02590406, 29/10/2015.

Changes in Bispectral Index with different positions during general anaesthesia.

Background &amp; Objective: Bispectral index (BIS) is used for intraoperative anesthesia depth assessment during general anesthesia (GA). This monitoring modality has been used routinely at many centers during GA, but especially during susceptible patients, in which precise depth of anesthesia is required. We aimed to compare changes of BIS in different head positions under GA, but without surgical stimulation. Methodology: Thirty ASA physical status I patients aged 18−60 y were recruited for this prospective, observational study after ethical approval by the institutional ethical review committee. After administration of GA, patients were kept in supine position for 15 min and the BIS, signal quality index (SQI), electromyography (EMG), mean arterial pressure (MAP) and heart rate (HR) were recorded. Patients were then sequentially placed in: reverse Trendelenburg (45°), supine, Trendelenburg (45°) positions, each for 15-min duration and 3 readings were taken in each position at 5 min interval. Lastly patient was positioned back to supine position for the surgery to begin. Results: There was a statistically significant decrease of BIS value with a change from supine position to reverse Trendelenburg position (P = 0.02) and increase in BIS value from supine to Trendelenburg position (P = 0.01). Changing of position from supine to reverse Trendelenburg was found to have a statistically significant decrease in MAP (P = 0.005), whereas changing to Trendelenburg position significantly increased MAP compared to supine position (P &lt; 0.001). There was a positive moderate linear correlation between BIS and MAP (r = 0.513, P = 0.004). Conclusion: A change of position from supine to reverse Trendelenburg decreases and from supine to Trendelenburg position transiently increases the BIS values. Abbreviations: BIS - Bispectral Index; SQI - Signal Quality Index; EMG – Electromyography; MAP - Mean Arterial Pressure Key words: Anesthesia; Anesthesia, General; Bispectral Index; Electroencephalography; Electromyography; Monitoring; Positioning Citation: Kamaruzaman K, Izaham A, Rahman RA, Mokhtar MN. Changes in bispectral index (BIS) with different positions during general anesthesia. Anaesth. pain intensive care 2023;27(3):325−331. DOI: 10.35975/apic.v27i3.1922 Received: June 24, 2022; Reviewed: April 10, 2023; Accepted: April 10, 2023