Trendelenburg Position Research Articles

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.

Mesial temporal atrophy in preoperative MRI rather than steep Trendelenburg position is associated with postoperative delirium in patients undergoing a major urologic surgery.

To investigate whether steep Trendelenburg in a major urologic surgery is associated with postoperative delirium, and to examine other potential clinical and radiologic factors predictive of postoperative delirium. 182 patients who received a major urologic surgery and underwent a 3.0-T brain MRI scan within 1year prior to the date of surgery were retrospectively enrolled. Preoperative brain MRIs were used to analyze features related to small vessel disease burden and mesial temporal atrophy. Presence of a significant mesial temporal atrophy was defined as Scheltens' scale ≥ 2. Patients' clinico-demographic data and MRI features were used to identify significant predictors of postoperative delirium using the logistic regression analysis. Independent predictors found significant in the univariate analysis were further evaluated in the multivariate analysis. Incidence of postoperative delirium was 6.0%. Patients with postoperative delirium had lower body mass index (21.3 vs. 25.0kg/m2, P = 0.003), prolonged duration of anesthesia (362.7 vs. 224.7min, P < 0.001) and surgery (302.2 vs. 174.5min, P < 0.001), and had more significant mesial temporal atrophy (64% vs. 30%, P = 0.046). In the univariate analysis, female sex, type of surgery (radical prostatectomy over cystectomy), prolonged duration of anesthesia (≥ 6h), and presence of a significant mesial temporal atrophy were significant predictors (all P-values < 0.050), but only the presence of significant mesial temporal atrophy was significant in the multivariate analysis [odds ratio (OR), 3.69; 95% CI 0.99-13.75; P = 0.046]. Steep Trendelenburg was not associated with postoperative delirium. Significant mesial temporal atrophy (Scheltens' scale ≥ 2) in preoperative brain MRI was predictive of postoperative delirium. Not applicable.

Measuring intraoperative anesthetic parameters during hepatectomy with inferior vena cava clamping.

Uncontrollable bleeding remained problematic in anatomical hepatectomy exposing hepatic veins. Based on the inferior vena cava (IVC) anatomy, we attempted to analyze the hemodynamic and surgical effects of the combined IVC-partial clamp (PC) accompanied with the Trendelenburg position (TP). We prospectively assessed 26 consecutive patients who underwent anatomical hepatectomies exposing HV trunks between 2020 and 2023. Patients were divided into three groups: use of IVC-PC (group 1), no use of IVC-PC (group 2), and use of IVC-PC accompanied with TP (group 3). In 10 of 26 patients (38%), hepatic venous pressure was examined using transhepatic catheter insertion. IVC-PC was performed in 15 patients (58%). Operating time and procedures did not significantly differ between groups. A direct hemostatic effect on hepatic veins was evaluated in 60% and 70% of patients in groups 1 and 3, respectively. Group 1 showed significantly more unstable vital status and vasopressor use (p < 0.01). Blood or fluid transfusion and urinary output were similar between groups. Group 2 had a significantly lower baseline central venous pressure (CVP), while group 3 showed a significant increase in CVP in TP. CVP under IVC-PC seemed lower than under TP; however, not significantly. Hepatic venous pressure did not significantly differ between groups. Systolic arterial blood pressure significantly decreased via IVC-PC in group 1 and to a similar extent in group 3. Heart rate significantly increased during IVC-PC (p < 0.05). IVC-PC combined with the TP may be an alternative procedure to control intrahepatic venous bleeding during anatomical hepatectomy exposing hepatic venous trunks.

A COMPARATIVE STUDY TO ASSESS EFFECTS OF PNEUMOPERITONEUM AND TRENDELENBURG POSITION ON HEMODYNAMICS AND VENTILATORY MECHANICS DURING TOTAL LAPAROSCOPIC HYSTERECTOMY IN OBESE AND NON-OBESE PATIENTS

Background:Hysterectomy is a common gynaecological surgical procedure, with Laparoscopic hysterectomy (LH) emerging as a favorable approach due to its benefits such as shorter recovery periods and reduced complications. However, the creation of pneumoperitoneum and the Trendelenburg position required for total laparoscopic hysterectomy (TLH) can induce significant hemodynamic and ventilatory changes. Methodology: Our study included 60 patients who were categorized into two groups of 30 each based on their BMI: non-obese (BMI &lt; 30) and obese (BMI ≥ 30). All patients underwent routine pre-anaesthesia check-up followed by general anaesthesia. Diastolic blood pressure (DBP), systolic blood pressure (SBP), peripheral oxygen saturation (SpO2), heart rate (HR), mean arterial pressure (MAP), plateau pressure (PPLAT), peak pressure (PPEAK),and driving pressure (PDRIVING), end-tidal carbon dioxide (EtCO2) as well as static (CST) and dynamic (CDYN) lung compliance were measured at different time intervals including baseline, following induction of anaesthesia, insufflation, changing to Trendelenburg position, desufflation and after extubation. Results:The heart rate decreased on induction of anesthesia in both the groups and remained lower throughout the procedure but was statistically non-significant (p&gt;0.05). There was a rise in SBP, DBP, and MAP on insufflation and further with head-down positioning in both obese and non-obese patients, however, was statistically non-significant (p&gt;0.05). The PPEAK, PPLAT, and PDRIVING were increased on induction, following the creation of pneumoperitoneum as well as Trendelenburg position (p&lt;0.05). The values were higher in obese as compared to the non-obese. The static and dynamic compliance were lower at all time intervals in obese patients when compared to the non-obese group. Conclusion: Obese patients exhibit higher plateau pressure, peak inspiratory pressure, and driving pressure values, indicating increased airway resistance and potential ventilation challenges during surgery. Additionally, the reduced static and dynamic lung compliance values in obese patients suggest decreased lung elasticity and difficult ventilation.

Effect of the Duration of Restrictive Fluid Therapy on Acute Kidney Injury in Robot-Assisted Laparoscopic Prostatectomy.

In robot-assisted laparoscopic prostatectomy (RALP), restrictive fluid therapy (RFT) is often utilized until the vesicourethral anastomosis (console period) is completed. RFT can cause acute kidney injury (AKI). Thus, RFT prolongation in surgeries that utilize the Trendelenburg position and pneumoperitoneum may increase the risk of postoperative AKI. We aimed to evaluate the effect of RFT duration on postoperative AKI. Forty-four patients who underwent RALP were included in this prospective observational study. Patients were divided into two groups according to the RFT duration (Group I, RFT duration ≤ 3 h, and Group II, RFT duration >3 h). AKI was diagnosed and staged according to the Kidney Disease Improving Global Outcomes criteria (KDIGO) using patients' serum creatinine levels after the first 24 h postoperatively. Hemodynamic parameters were monitored using the pressure recording analytical method. The AKI incidence was significantly higher in Group II than in Group I (45.5% vs. 9.1%; p = 0.016). In both groups, all patients who developed AKI were KDIGO stage 1 and all recovered on the second postoperative day. At the end of the console period, the heart rate and arterial elastance were significantly higher, whereas the stroke volume index was significantly lower in Group II than in Group I (p = 0.041, p = 0.016, and p < 0.001, respectively). Although the amounts of fluid administered before and after the anastomosis were similar between the groups, the total amount of fluid administered was significantly different (p < 0.001). There was a significant negative correlation between RFT duration and the total amount of fluid administered (r2 = 0.43, p < 0.001). RFT duration of >3 h, total fluid administration of ≤3.3 mL/kg/h, and stroke volume index (SVI) at the end of the console period of ≤32 mL/m2 increased the risk of AKI by 12.0 times (1.7-85.2) (p = 0.013). RFT prolongation in RALP may increase the risk of developing AKI.

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.

Effect of Postoperative Trendelenburg Positioning in Reducing Shoulder Pain after Laparoscopic Cholecystectomy

Background and Objective: Shoulder pain is one of the most common complaints of patients after laparoscopic cholecystectomy, which seems to be closely related to the residual volume of carbon dioxide gas used during surgery. Therefore, this study was conducted with the aim of investigating the effect of Trendelenburg positioning after surgery in reducing shoulder pain in patients. Materials and Methods: This study was conducted as a randomized clinical trial in 58 patients who were eligible for laparoscopic cholecystectomy. Patients were enrolled in the study by simple random sampling and randomly assigned to supine (control) and Trendelenburg (intervention) positions. After complete awakening in the recovery room, the patients in the intervention group were placed in the Trendelenburg position (30 degrees), while the patients in the control group were placed in the supine position for 30 minutes. The level of pain was measured 6, 12, 24and 48 hours after completion of the procedure using the NRS scale. Data analysis was performed using SPSS version 24 software. Results: The results of this study show that there is a significant difference between the pain intensity 6, 12, 24and 48 hours after the end of the intervention between the two intervention and control groups (P &gt;0.05). The pain in the intervention group is therefore lower than in the control group. Conclusion: As a simpleeffective, and inexpensive technique, the Trendelenburg position can reduce shoulder pain in patients undergoing laparoscopic cholecystectomy

Ultrasonographic evaluation of diaphragmatic excursion changes after major laparoscopic surgeries in the Trendelenburg position under general anaesthesia: A prospective observational study.

Laparoscopic surgeries result in increased intra abdominal pressure and cephalad displacement of the diaphragm. The Trendelenburg position can augment these respiratory changes. The primary objective of this study was to compare diaphragmatic excursions before and after a major laparoscopic pelvic surgery under general anaesthesia in the Trendelenburg position using ultrasonography (USG). This prospective observational study included 90 patients of either gender, aged 20-60 years, with American Society of Anesthesiologists physical status I/II. M-mode USG was used to assess diaphragm inspiratory amplitude (DIA) before induction of anaesthesia and 10 minutes after tracheal extubation. Factors such as age, gender, body mass index, positive end-expiratory pressure (PEEP), pain, peak airway pressures, duration of pneumoperitoneum, duration and degree of Trendelenburg position and duration of anaesthesia were recorded. Pearson's correlation and multiple linear regression were used to analyse the factors affecting change in DIA (ΔDIA). The mean difference (95% confidence interval (CI)) of measured DIA was 0.70 (0.598-0.809), P < 0.001. ΔDIA had a weak positive significant correlation with age, anaesthesia duration, pneumoperitoneum, and visual analogue scale (VAS) score 10 minutes after extubation. Multiple linear regression analysis showed 14.86% of the variance in DIA. Age (β = 0.008, P = 0.049), duration of anaesthesia (β = 0.002, P = 0.02) and VAS score 10 minutes after extubation (β = 0.128, P = 0.001) were significant independent predictors. DIA decreased significantly after pelvic laparoscopic surgeries performed in the Trendelenburg position. Age, duration of anaesthesia and pain after the procedure were significant independent predictors.

Retrospective analysis of perineal herniorrhaphy with cone-shaped polypropylene mesh in dogs: technique description and outcome.

This study aimed to describe the technique for the surgical repair of perineal hernia (PH) in dogs using a polypropylene mesh (PM) and to evaluate its outcomes. All dogs were placed in the Trendelenburg position. Castration and caudal celiotomy for cystopexy and colopexy were performed as needed. Ipsilateral perianal incision was performed in the affected hernia side. A PM was formed a cone-shape with suturing and placed in hernial foramen. The PH was repaired with suturing between PH and pelvic diaphragm including the sacrotuberous ligament, internal obturator muscle, and external anal sphincter muscle. The medical records of all dogs were reviewed to evaluate signalment, perioperative findings, postoperative complications, and prognosis. Of the 22 dogs, 15 were intact, and 7 were previously neutered. The median age and body weight were 10 years and 6.8 kg, respectively. The PH reconstruction using a cone-shaped PM was feasible in all dogs. The median operative time was 60.5 min for unilateral PH and 109 min for bilateral PH. Major postoperative complications occurred in seven dogs (32%), and three dogs (14%) had a recurrence of PH. In the long-term (> 2 weeks) follow-up period, 16 dogs (73%) had an excellent prognosis. Our study suggests that PH reconstruction surgery using a cone-shaped PM may be a viable treatment method for PH in dogs. Therefore, a cone-shaped PM could serve as an alternative treatment option for canine PH reconstruction.

Hypoxemia of the lower limbs during robot-assisted radical prostatectomy in Trendelenburg position.

The objective of this study is to assess frequency and risk factors for intraoperative hypoxemia of the lower limbs during robot-assisted radical prostatectomy (RARP). Trendelenburg position during RARP may contribute to hypoxemia and compartment syndrome (CS) of the lower limbs as a major but rare complication. This prospective study included patients undergoing RARP for prostate cancer. Preoperative calculation of the ankle-brachial-index (ABI) was performed. Peripheral oxygen saturation (SpO2) at the toes was routinely measured. Occurrence of SpO2 levels of <90% was defined as hypoxemic events and treated immediately. Blood pressure, intraabdominal pressure, SpO2 of the upper limb and surgery time were monitored in case of hypoxemia. A multivariable logistic regression model was performed with age, BMI, nicotine abuse, MAP, comorbidities as covariates and hypoxemia of the lower limbs as the outcome. A total of 207 patients were included. Among these, 126 patients had ABI measurements with 10.6% having an abnormal ABI value. One, two or at least three events of lower limb hypoxemia occurred intraoperatively in 19.7%, 14.8% and 16.9%, respectively. In 20 events, surgical instruments were affecting vascular perfusion by compression. None of the covariates were statistically significant associated with lower limb hypoxemia. No patient developed a compartment syndrome. Decrease in oxygen saturation of the lower extremities was observed frequently during RARP, without revealing any risk factors for its occurrence. Routine oximetry leads to an early detection of hypoxemia of the lower extremities, giving the anaesthesiologist and surgeon the opportunity to make adequate adjustments (increasing blood pressure and ending iliac vessel compression).

Individualized PEEP without Recruitment Maneuvers Improves Intraoperative Oxygenation: A Randomized Controlled Study.

Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEPIND, n = 28) or a control with a fixed PEEP of 5 cm H2O (Group PEEP5, n = 28). Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEPIND maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP5 maintained a PEEP of 5 cm H2O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEPIND was 16 cm H2O (ranging from 12 to 18 cm H2O). EIT-guided PEEPIND was associated with higher PaO2/FiO2 before extubation compared to PEEP5 (71.6 ± 10.7 vs. 56.8 ± 14.1 kPa, p = 0.003). Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia (3.8% vs. 26.9%, p = 0.021). Additionally, PEEPIND was associated with lower driving pressures (12.0 ± 3.0 vs. 15.0 ± 4.4 cm H2O, p = 0.044) and better compliance (44.5 ± 12.8 vs. 33.6 ± 9.1 mL/cm H2O, p = 0.017). Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021.

Optimal positive end-expiratory pressure titration of intraoperative mechanical ventilation in different operative positions of female patients under general anesthesia

ObjectiveThis study aimed to compare the effectiveness and safety of different titrated methods used to determine individual positive end-expiratory pressure (PEEP) for intraoperative mechanical ventilation in female patients undergoing general anesthesia in different operative positions, and provide reference ranges of optimal PEEP values based on the titration. MethodsA total of 123 female patients who underwent elective open abdominal surgery under general anesthesia were included in this study. After endotracheal intubation, patients' body position was adjusted to the supine position, Trendelenburg positions at 10° and 20° respectively. PEEP was titrated from 20 cmH2O to 4 cmH2O, decreasing by 2 cmH2O every 1 min. Electrical impedance tomography (EIT), hemodynamic and respiratory mechanics parameters were continuously monitored and recorded. Optimal PEEP values and reference ranges were respectively calculated based on optimal EIT parameters, mean arterial pressure (MAP), and lung dynamic compliance (Cdyn). ResultsEIT-guided optimal PEEP was found to have higher values than those of the MAP-guided and Cdyn-guided methods for all three body positions (P < 0.001), and it was observed to more significantly inhibit hemodynamics (P < 0.05). The variable coefficients of EIT-guided optimal PEEP values were smaller than those of the other two methods, and this technique could provide better ventilation uniformity for dorsal/ventral lung fields and better balance for pulmonary atelectasis/collapse. The 95% reference ranges of EIT-guided optimal PEEP values were 4.6–13.8 cmH2O, 7.0–15.0 cmH2O and 8.6–17.0 cmH2O for the supine position, Trendelenburg 10°, and Trendelenburg 20° positions, respectively. ConclusionEIT-guided optimal PEEP titration was found to be a superior method for lung protective ventilation in different operative positions under general anesthesia. The calculated reference ranges of PEEP values based on the EIT-guided method can be used as a reference for intraoperative mechanical ventilation.

The evaluation of cardiac functions in deep Trendelenburg position during robotic-assisted laparoscopic prostatectomy.

This study aimed to demonstrate the reliability of the cardiac cycle efficiency value through its correlation with longitudinal strain by observing the effect of the deep Trendelenburg position. A prospective, observational study. Single center. Between May and September 2022, the hemodynamic parameters of 30 patients who underwent robotic assisted laparoscopic prostatectomy under general anesthesia were prospectively evaluated. All invasive cardiac monitoring parameters and longitudinal strain achieved transesophageal echocardiography were recorded in pre-deep Trendelenburg position (T3) and 10th minute of deep Trendelenburg position (T4). Delta values were calculated for the cardiac cycle efficiency and longitudinal strain (values at T4 minus values at T3). The estimated power was calculated as 0.99 in accordance with the cardiac cycle efficiency values at T3 and T4 (effect size: 0.85 standard deviations of the mean difference: 0.22, alpha: 0.05). At T4, heart rate, pulse pressure variation, cardiac cycle efficiency, dP/dt and longitudinal strain were significantly lower than those at T3 (p = 0.009, p < 0.001, p < 0.001, and p < 0.001, respectively). There was a positive correlation between the delta-cardiac cycle efficiency and delta-longitudinal strain (R2 = 0.36, p < 0.001). Although the absence of significant changes in mean arterial pressure and cardiac index after Trendelenburg position suggests that cardiac workload has not changed, changes in cardiac cycle efficiency and longitudinal strain indicate increased cardiac workload due to increased ventriculo-arterial coupling.

A randomised, prospective, double blind study of intraperitoneal instillation of 0.25% bupivacaine with clonidine versus 0.25% bupivacaine with dexmedetomidine for post-operative analgesia in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the standard and most accepted technique for Cholecystectomies due to lesser postop pain and short recovery time.The origin of abdominal and shoulder pain after laparoscopic procedures has led to the use of intra peritoneal instillation of local anaesthetic agent to reduce postoperative pain. To assess the efficacy and quality of postoperative analgesia between the study groups using Visual Analogue Scale (VAS) score at various time intervals along with side effects if any.: 60 patients belonging to ASA 1 and 11 categories posted for Laparoscopic Cholecystectomy were given General Anaesthesia. After completion of surgery, before removing the trocar, anaesthetic study solution was sprayed on the surface of liver, gall bladder bed, right sub-diaphragmatic space, and port sites in Trendelenburg position. Volume and dilution of two drugs were same in both groups. Bupivacaine (0.25%) 50 mL; Dexmedetomidine (1 µg/kg) (BD) or Clonidine (1 µg/kg) (BC) was used. VAS score, Heart rate and BP measured at various time intervals and the time of first rescue analgesia noted.: VAS of BD group was 5.27 ± 0.64 to 3.70 ± 0.837 from 1 hour to 6 hour post extubation, when compared to BC group of 6.03 ± 0.669 in 1 hour reduced to 4.17 ± 0.699 at 6 hour post extubation. Dexmedetomidine combination significantly reduced the total dose of rescue analgesic required in 24 hours as compared to Clonidine combination.

Role of lung ultrasonography for diagnosing atelectasis in robotic pelvic surgeries

Patients undergoing robotic pelvic surgery were included in prospective observational study, they are at increased risk of atelectasis and postoperative pulmonary complications.Lung ultrasonography in basal six zones and arterial gas analysis was performed as baseline after induction of GA and on de-docking robotic arms to detect incidence and severity of atelectasis and its effect on arterial oxygenation.Total fifty patients were recruited in the study with age 61.88 ± 8.49 years, BMI 25.97±4.03, intraoperative with steep trendelenburg position, average duration of docking was 155.32 ± 47.44 minutes, VCV provided to 29 and PCV to 21 patients. [Lung aeration score 0] was noted for all patients in Right anterior basal –Zone I, 50-60% of patients developed mild atelectasis [Lung Aeration score1] in Posterior basal zones III and VI. Total 10% patients developed moderate atelectasis [Lung Aeration score 2] and 4% developed severe atelectasis [Lung Aeration score 3] in zones III and VI. The incidence and severity of atelectasis was not affected by duration of robotic arms docking and mode of ventilation. For both VCV and PCV group statistically significant (p&amp;#62;0.05) decrease in Arterial Oxygen Pressure (Pao2) and Alveolar-arterial (A-a)o gradient difference was detected after completion of robotic surgery compared to baselines values. Atelectasis was detected in 60% patients in bilateral basal posterior zones in patients undergoing robotic pelvic surgeries causing statistically significant decrease in PaO2 compared to baseline values. Early detection of atelectasis by Lung Ultrasonography in the OR and applying optimal PEEP is recommended.

Review of Risk Factors and Complications of Anterior Migration of Ozurdex Implant: Lessons Learnt from the Previous Reports.

Purpose: Ozurdex had shown promising anatomical and functional outcomes in managing refractory Irvine-Gass syndrome over the years. Burgeoning usage of Ozurdex has prompted the study of its related complications, particularly the anterior chamber migration of the implant. Methods: Literature reviews on the anterior chamber migration of the Ozurdex via PubMed, EBSCO, and TRIP databases were searched from 2012 to 2020. The predisposing factors, outcomes, and management of such cases were evaluated. Results: A total of 54 articles consisting of 105 cases of anterior migration of Ozurdex were included in this analysis. The vitrectomized eye and compromised posterior capsule were highly associated with this complication. About 81.9% of the cases had cornea edema upon presentation, with 31.4% of them ending up with cornea decompensation despite intervention. Although there was high intraocular pressure reported initially in 22 cases, only 2 cases required glaucoma filtration surgeries in which they had preexisting glaucoma. Numerous techniques of repositioning or surgical removal of the implant were described but they were challenging and the outcomes varied. Conclusions: A noninvasive method of manipulating the Ozurdex into the vitreous cavity via the "Trendelenburg position, external pressure with head positioning" maneuvers is safe yet achieves a favorable outcome. Precaution must be taken whenever offering Ozurdex to the high-risk eyes. Prompt repositioning or removal of the implant is crucial to deter cornea decompensation. Clinical Trial Registration number: NMRR-22-02092-S9X (from the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia).

A Case of Air Embolism during Transoral Vestibular Endoscopic Thyroidectomy

Background: Carbon dioxide (CO2) embolism is a rare but potentially life-threatening complication of endoscopic surgery. While endoscopic thyroidectomy is superior to traditional open thyroidectomy in terms of cosmetic results, it may lead to venous or fatal paradoxical CO2 embolism. CO2 embolism involves the inadvertent injection of carbon dioxide into a large vein, artery, or solid organ. The clinical manifestations of CO2 embolism can vary from asymptomatic to neurological damage, cardiac failure, and even death, depending on the rate and volume of CO2 entry and the patient’s general condition. This case can enhance our understanding of CO2 embolization during endoscopic surgery. Case Presentation: This case report describes an incident in which a gas embolism occurred during endoscopic right lobe and isthmus thyroidectomy, resulting in arrhythmia and dramatic fluctuations in circulation and oxygen levels. The operation was halted, and CO2 injection was stopped. The surgical wound was covered with saline gauze, and the patient inhaled 100% pure oxygen while undergoing aggressive repeated manual pulmonary recruitment maneuvers. Additionally, vasoactive drugs such as m-hydroxyamine and ephedrine were administered to aid in treating the condition. The patient’s position was adjusted using the Durant maneuver (partial left lateral and Trendelenburg position). Following the aforementioned treatments, the patient’s ventricular arrhythmia transitioned back to a normal and regular sinus rhythm, and both circulation and oxygen levels stabilized. Conclusions: Carbon dioxide embolism is an uncommon yet potentially severe complication of laparoscopic procedures. We anticipate that this particular case will enhance our comprehension of carbon dioxide embolism during endoscopic surgery.

Effect of the Trendelenburg position, Deep Breathing Exercise, and Warm Water Application on Shoulder Pain and Post-gynecologic Laparoscopic Recovery

Effect of the Trendelenburg position, Deep Breathing Exercise, and Warm Water Application on Shoulder Pain and Post-gynecologic Laparoscopic Recovery

Open reconstruction of severe superior vena cava syndrome with right internal jugular-Superior vena cava bypass using femoral vein.

Current treatment of chronic benign superior vena cava syndrome (SVCS) is endovascular with angioplasty/stenting1Rizvi A.Z. Kalra M. Bjarnason H. Bower T.C. Schleck C. Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment.J Vasc Surg. 2008; 47: 372-380Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar,2Wilson L.D. Detterbeck F.C. Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes.N Engl J Med. 2007; 356: 1862-1869Crossref PubMed Scopus (355) Google Scholar. Open surgical bypass is typically considered for patients who fail endovascular therapy3Picquet J. Blin V. Dussaussoy C. Jousset Y. Papon X. Enon B. Surgical reconstruction of the superior vena cava system: Indications and results.Surgery. 2009; 145: 93-99Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,4Kalra M. Sen I. Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome.Surg Clin North Am. 2018; 98: 321-335Abstract Full Text Full Text PDF Scopus (20) Google Scholar. This report illustrates the surgical treatment of symptomatic SVCS. The patient consented to the publication. A 31-year-old male patient presented with recurrent edema and dilated veins of the upper extremities, head, neck, and chest, with concomitant severe headache. His history was significant for previous left lower extremity osteomyelitis six years before, being treated with antibiotics through a left upper extremity peripherally inserted central catheter (PICC). Symptoms of SVCS developed three years later. He was treated with bilateral subclavian and innominate vein stenting extending into the superior vena cava (SVC). Despite oral anticoagulation since the first intervention, the patient had multiple in-stent reocclusions and seven reinterventions with only temporary symptom improvement. Physical examination evidenced facial edema, plethoric facies, and dilated veins in the chest and abdomen. Computed tomography venogram (CTV) demonstrated occlusion of all stents. The right internal jugular vein (RIJV) was patent at the upper-neck level, close to the carotid bifurcation and the SVC was also patent caudally to the azygos vein. A left upper extremity and central venogram were performed and attempts were made to cross the occluded stents, without success. The patient then agreed to proceed with an open reconstruction. A RIJV to SVC bypass was performed using the patient´s right femoral vein, which had 8 mm in diameter, via a median sternotomy and a right neck incision (01:39). The suitable diameter of the vein-graft relies upon the main vessels’ diameter and patient´s anatomy, although a minimum dimeter of 6 mm is generally accepted. After the SVC anastomosis, a Valsalva maneuver was performed, and the clamp was opened with the patient in Trendelenburg position to minimize the risk of air embolism. At the two-year follow-up, a patent bypass was demonstrated with symptoms resolution. Annual follow-up with duplex ultrasound will be pursued. Open surgical treatment of SVC syndrome is associated with long-term symptoms relief and is an excellent option for patients who fail endovascular treatment. The femoral vein-graft was an excellent conduit with a good size-match to the RIJV, durable results and symptoms resolution. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTBmNTRkMDM4ODYxZjBkNTkxYTBlMWZlNDc5OGU3NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTk5NzY2fQ.cmFN_OFbjDH4lOiwl1zKkjrgnyVQ2yXQnj_hVfumqU1CX0DvODIdqDnFjP8WKhsd08e_hL8cEQf62356emnlqTr0YQ3Taf7QzqEzXDSXdshLabCLWCJSBJImuFBTwhSNEbChKp9VtQEQaGgQFyoxmim8ywtDZOp91FbZKEyqSzPRGpQZ1TaQTnYdofXOPWy6HWHwpA7L72nUSdtDa6DKZAo-7fV2qqKuAhpR-b2_-TYFZ5QDsM4894KbXMoSfpiuH1MyYN3E2RcS1dja_5IiR_wUucRBjC65wTnhE2xRmiUL_0CZXxMNdfGKpq8bBaTg1GNl69QgdXWvXJkmViQ8Mw Download .mp4 (86.14 MB) Help with .mp4 files