Trendelenburg Position Research Articles

Artificial lung ventilation in patients with morbid obesity during laparoscopic operations in the Trendelenburg position (literature review)

The literature review is devoted to the peculiarities of artificial lung ventilation (ALV) in patients with morbid obesity during laparoscopic oncosurgical interventions in the Trendelenburg position. At present, there are no consensus recommendations on the choice of the optimal ALV mode during anesthesia in this area of oncosurgery. When analyzing data obtained from other types of operations, there was no impression that there were significant advantages of any ALV modes, both with volume and pressure control. However, high values of positive end-expiratory pressure (PEEP) have the most evidence of benefit in this category of patients, and the inversion of the duration of the respiratory cycle phases without creating a high PEEP can help reduce the risk of lung damage when all other ALV techniques do not allow for adequate oxygenation.

Enterocele with Risk of Intestinal Incarceration: A Case Report

Purpose: To describe the diagnosis and management of enterocele with high risk of bowel ischemia in patients with pelvic organ prolapse. Methods: We describe the clinical case of an 81-year-old patient, hypertensive, obese, anticoagulated because of an atrial fibrillation and pelvic organ prolapse. Initially, conservative treatment was offered due to the high surgical risk, but sometime later the patient came to the emergency department with enterocele and risk of intestinal ischemia. Results: After placing the patient in the Trendelenburg position and applying ice to the perineum, the prolapse is reduced. Subsequently, urgent surgical intervention is performed with a total vaginal hysterectomy, anterior colporrhaphy, Ritcher's operation and colpoperineorrhaphy. This intervention solved the patient's clinical condition and also avoided the small bowel ischemia. Conclusion: The diagnosis of advanced enterocele with risk of intestinal obstruction is a very rare but potentially serious clinical case. The immediate recognition and management are very important because of the risk of vaginal rupture, intestinal necrosis, and also systemic infection.

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery.

We aimed to evaluate the effects of internal jugular vein (IJV) catheterization on intracranial pressure (ICP) and postoperative delirium (POD) during robot-assisted laparoscopic surgery by measuring the optic nerve sheath diameter (ONSD). Data from a prospective single-center cohort study, conducted from October 2021 to February 2022, were used. Forty out of 80 patients scheduled for laparoscopic radical hysterectomy or prostatectomy were assigned to the group receiving IJV catheterization (Group I), and the other 40 only received peripheral venous cannulation (Group C) according to clinical need of patients. Ultrasonography of ONSDs, the proportion of regurgitation time in a cardiac cycle, and hemodynamic parameters were measured at four time points: immediately after induction of anesthesia in the supine position (T0), 30 min (T1), 60 min (T2) after orienting to the Trendelenburg position, and before returning to the supine position at the end of surgery (T3). Time to eye opening and emergence stay, POD, and QoR-15 were compared. The ONSDs increase gradually as the surgery progressed. Group I showed a higher value of ONSD at T1 (4.72 ± 0.29 mm vs. 4.5 ± 0.33 mm, p = 0.0057) and T3 (5.65 ± 0.33 mm vs. 5.26 ± 0.31 mm, p < 0.0001). The proportions of the regurgitation time of IJVV were greater in Group I than those in Group C at T1 (14.95, 8.5%-18.9% vs. 9.6%, 0%-17.2%, p < 0.0001) and T3 (14.3, 10.6%-18.5% vs. 10.4%, 0%-16.5%, p = 0.0003). Group I had a delayed time to eye opening (10.7 ± 1.72 min vs. 13.3 ± 2.35 min, p < 0.0001) and emergence stay (32.2 ± 5.62 min vs. 39.9 ± 6.7 min, p < 0.0001). There were no significant differences in POD and QoR-15 between the two groups on day three. IJV cannulation may not be the preferred approach in robot-assisted laparoscopic surgery as it was risk factor for IJVV regurgitation, ICP elevation, emergence delayed.

Ultrasonographic Evaluation of Internal Jugular Vein for The Prediction of Post-Spinal Hypotension in Orthopedic Surgeries

Background: Relative hypovolemia may predispose to severe or prolonged hypotension after spinal anesthesia in patients undergoing orthopedic surgeries. Empirical administration of fluid preload is time consuming, costly and might lead to volume overload, especially in elderly patients. Therefore, predicting post spinal hypotension is of great importance to reserve fluid infusion for susceptible patients. Ultrasonographic evaluation of the internal jugular vein (IJV) diameter has been used to estimate intravascular volume in the ICU. Therefore, we investigated the efficacy of sonographic measurements of the internal jugular vein parameters for predicting post spinal hypotension in patients undergoing orthopedic surgeries. Methodology: The study was conducted on 62 patients scheduled for orthopedic surgeries. Sonographic measurements of IJV diameter and cross-sectional area were recorded at supine and Trendelenburg position before spinal anaesthesia. Blood pressure was monitored for 15 minutes for all patients and hypotension was documented. Results: Twenty-eight patients (45.2%) developed hypotension. The rate of increase in the diameter and cross-sectional area of the IJV with the change in patient’s posture was significantly higher in hypotensive patients. According to ROC curves analysis, a rate of increase of 12.36% in IJV diameter, and a rate of increase of 25.55% in IJV cross sectional area showed moderate specificity and sensitivity in the prediction of spinal hypotension. Conclusion: Preoperative sonographic measurements of the internal jugular vein diameter and crosssectional area at supine and Trendelenburg position can predict the occurrence of post-spinal hypotension.

Ultrasound evaluation of optic nerve sheath diameter in relation to propofol and inhalational anesthetics in patients having surgery in the Trendelenburg position.

Ultrasound evaluation of optic nerve sheath diameter in relation to propofol and inhalational anesthetics in patients having surgery in the Trendelenburg position.

Modes of mechanical ventilation and ultrasound scan technique for evaluating the optic nerve sheath diameter in patients undergoing surgery in the steep Trendelenburg position.

Modes of mechanical ventilation and ultrasound scan technique for evaluating the optic nerve sheath diameter in patients undergoing surgery in the steep Trendelenburg position.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update.

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Transient Left MCA Syndrome Triggered by a Diagnostic Lumbar Puncture in a Case of Atypical Moyamoya Syndrome (P12-5.017)

<h3>Objective:</h3> Case report <h3>Background:</h3> No reported cases of transient ischemia are triggered by diagnostic lumbar puncture (LP). Here we present a suspected moyamoya syndrome with reversible ischemic event shortly following LP. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> 48-year-old Asian woman presented to the emergency department after two weeks of gradually worsening left leg weakness &amp; numbness. She was diagnosed with subacute right MCA-ACA border-zone infarct on clinical assessment and MRI. Vessel imaging with CTA suggested widespread obstructive arteriopathy involving bilateral ACA and MCA while sparing the terminal ICA and posterior circulation, with extensive collateral development in lenticulostriate vasculature. Cerebral angiogram confirmed the CTA findings with no signs of diffuse atherosclerosis or inflammation, raising concern for Moyamoya syndrome despite the lack of ICA termini involvement. To rule out inflammatory etiology of arteriopathy, she underwent a diagnostic LP, and 24cc of clear fluid was collected, which was non-inflammatory. Towards the end of the procedure, she developed global aphasia, left-sided gaze deviation, right-sided hemiplegia &amp; homonymous hemianopsia, suggestive of left MCA syndrome, while being normotensive and in a supine position. CT perfusion map showed 131 mL of left MCA/ACA territory penumbra with no core infarct. She was placed in Trendelenburg position and resuscitated with fluids and phenylephrine to maintain high MAP goal. This was followed by rapid resolution of her left MCA syndrome within one hour. <h3>Conclusions:</h3> The proposed mechanism for transient left MCA syndrome during LP in our patient with likely atypical Moyamoya syndrome was likely due to a steal phenomenon characterized by shunting blood flow away from severely narrowed left MCA due to global intracranial vascular dilation secondary to ICP drop during LP. This is supported by complete resolution of symptoms within one hour, mainly due to repletion of drained CSF and position change, which restored ICP to exert resistance on other less stenosed intracranial vessels while supporting MAP. <b>Disclosure:</b> Dr. Bareja has nothing to disclose. Dr. Al Gburi has nothing to disclose. Dr. Shnawa has nothing to disclose.

Effect of the reverse Trendelenburg position on the incidence of gastroesophageal reflux in dogs anesthetized for elective stifle surgery

ObjectiveTo determine if a 15° reverse Trendelenburg position decreases the incidence of gastroesophageal reflux (GER) compared with a horizontal position in dogs anesthetized for stifle surgery. Study designProspective, randomized parallel-arm study. AnimalsA total of 44 healthy client-owned dogs were enrolled and data from 36 dogs were analyzed. MethodsDogs requiring preoperative radiographs under anesthesia, or with a history of gastrointestinal signs or administered gastroprotectant therapy within 1 month of surgery were excluded. Anesthesia protocol was standardized to include hydromorphone, dexmedetomidine, ketamine, propofol and isoflurane. Dogs were randomly assigned at enrollment to be positioned in a 15° reverse Trendelenburg or a horizontal position for surgery. Continuous pH monitoring was documented throughout the procedure with a 6.4 Fr (2.13 mm) esophageal pH probe positioned in the distal esophagus via the oral cavity. GER was defined as pH < 4.0 (acidic) or > 7.5 (alkaline) for more than 30 seconds. The proportions of dogs developing GER were compared between groups using Fisher’s exact test. Time to reflux was compared using survival curves and the Gehan–Breslow–Wilcoxon test. Statistical significance was set as p < 0.05. ResultsAn episode of GER occurred in 11/36 (30%) dogs. Reflux was alkaline in two dogs and acidic in nine dogs. The proportion of dogs with GER was 5/18 (28%) and 6/18 (33%) for dogs in the reverse Trendelenburg position and horizontal position, respectively, and was not statistically significant (p > 0.99). Median (range) time until reflux was 44 (23–135) and 44.5 (9–56) minutes when dogs were positioned in reverse Trendelenburg position and horizontal position, respectively (p = 0.66; two-tailed Mann–Whitney U test). Conclusions and clinical relevancePositioning the surgery table in a 15° rostral elevation for dogs anesthetized for elective stifle surgical procedures did not decrease the incidence of GER.

The use of a modified rescue cervical cerclage in a diamniotic dichorionic twin pregnancy that had cervical dilatation

AbstractObjectiveWe describe the successful utilization of a modified rescue cerclage in a 32‐year‐old G4 P1213 woman of Afro‐Caribbean descent with a Diamniotic Dichorionic twin gestation who presented at 20 weeks and 2 days for a routine anomaly scan and was found to have a dilated (1.7 cm) and short (0.49 cm) cervix.DesignA standard prophylactic cervical cerclage was done at 12 weeks' gestation using Mersilene™ tape. For the rescue cerclage, the client was placed in a steep Trendelenburg position, with back filling of the bladder. The cervix was grasped with ring forceps, and an inflated foley balloon catheter was introduced into the cervical opening to aid in reduction of membranes. In addition to the initial cerclage, two 1‐ Prolene™ sutures were inserted distally to the tape and a second Mersilene™ tape was inserted proximally at the vesicocervical junction (reinforcement cerclages). The first Prolene™ was to provide additional structural support to prevent prolapse of the membrane. The second Prolene™ was used to close the external cervical or to minimize the risk of an ascending infection. The procedure was uneventful and postoperatively she was treated with antibiotics, vaginal micronized progesterone and venous thromboembolism prophylaxis. The membranes remained intact.ResultThe twins were successfully delivered by a scheduled repeat caesarean section at 36 weeks with Twin 1 Apgar scores of 9 and 9 at 1 and 5 min, respectively, and Twin 2 Apgar scores of 8 and 10, respectively.ConclusionIn the context of a challenging obstetric history as in this case, a more aggressive approach inclusive of reinforcement cerclage may be considered. The successful outcomes in this case further reiterates the need for larger clinical trials with pregnant individuals with larger cervical dilations at entry.

V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT Luca Antonelli, Adrian Duss, Leutrim Zahiti, Agostino Mattei, and Christian D. Fankhauser Luca AntonelliLuca Antonelli More articles by this author , Adrian DussAdrian Duss More articles by this author , Leutrim ZahitiLeutrim Zahiti More articles by this author , Agostino MatteiAgostino Mattei More articles by this author , and Christian D. FankhauserChristian D. Fankhauser More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal segmental glomerulosclerosis (FSGS) is a histologic pattern that is associated with nephrotic syndrome in children and adults and represents an important cause of end-stage renal disease worldwide. The underlying podocytopathy is a consequence of multiple pathways either individually or collectively. The associated heavy proteinuria represents a perioperative risk factor for complications after transplantation. Therefore, a bilateral nephrectomy before transplantation is recommended to stop protein loss by the kidneys. METHODS: A 19 years-old woman with therapy resistant FSGS had a persistently low serum albumin level requiring 70g human albumin supplementation each week. A bilateral kidney embolization or surgical removal before listing for a kidney transplantation was required. To improve perioperative outcomes and cosmesis in a young female patient, she was scheduled for a robotic subumbilical access to avoid scar tissue in the upper abdomen.The patient was positioned in a supine position with 30° head down. Four robotic 8mm trocars were placed in a subumbilical line and a 5mm and 12mm assistant trocar were positioned laterally of the medial umbilical ligaments. No repositioning of the patient during the whole case was required. The peritoneum was incised at the level of the ileocecal valve up to the ligament of Treitz. A hammock-like barrier is created by suturing both lateral edges of the parietal peritoneum to the anterior abdominal wall. Subsequently the renal hilus was dissected and the kidney mobilized. The renal vessels were clipped. A 18mm laparoscopic morcellator was introduced after extending the 12mm assistant trocar incision and the kidneys were removed through the morcellator. RESULTS: Blood loss was <50 mL and theatre time 325 minutes. After the surgery the patient had mild bruises on both shoulders because of the long-time period in the Trendelenburg position but resolved without further treatment. Postoperative length of stay was 4 days. After successful removal of both kidneys, the patient was listed for a kidney transplant with priority given her age < 20 years. CONCLUSIONS: Bilateral robotic nephrectomy using a subumbilical access and removal of the kidney using a morcellator is technically demanding but feasible. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luca Antonelli More articles by this author Adrian Duss More articles by this author Leutrim Zahiti More articles by this author Agostino Mattei More articles by this author Christian D. Fankhauser More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-05 EPIDURAL ANESTHESIA WITHOUT MECHANICAL VENTILATION IN SINGLE-PORT TRANSVESICAL RADICAL AND SIMPLE PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023V07-05 EPIDURAL ANESTHESIA WITHOUT MECHANICAL VENTILATION IN SINGLE-PORT TRANSVESICAL RADICAL AND SIMPLE PROSTATECTOMY Ethan Ferguson, Roxana Ramos, Albert Geskin, Jay Chavali, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Jay ChavaliJay Chavali More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003288.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Due to pneumoperitoneum and Trendelenburg positioning, epidural-only anesthesia has a limited role in modern robotic or laparoscopic prostate surgery. Transvesical access in single-port (SP) robotic simple and radical prostatectomy allows for flat patient positioning and avoids the peritoneal cavity by limiting the surgical working space and insufflation to the bladder lumen. We sought to determine if epidural anesthesia without the need for paralysis or mechanical ventilation were feasible in patients undergoing transvesical SP simple and radical prostatectomy. METHODS: Patients previously scheduled for transvesical SP robotic radical or simple prostatectomy were selected and offered epidural or traditional general anesthesia. Exclusions included underlying obstructive sleep apnea, severe pulmonary disease, prior lumbar spinal surgery, or BMI >35. Low thoracic or high lumbar epidural catheters were placed in the preoperative unit prior to transport to the operating room. The transvesical access technique and basic operative steps of SP transvesical radical and simple prostatectomy are demonstrated. RESULTS: A total of 11 patients underwent epidural placement prior to transvesical SP radical (N=6) and simple (N=5) prostatectomy. All cases were completed by a single surgeon without extra ports, open conversion, or conversion to general anesthesia. No surgical interruptions were noted in 8 of 11 cases and all movement-related interruptions were brief and transient. No anesthetic complications were noted. Intraoperative narcotics were completely avoided in 3 patients. No patients required narcotic medications after discharge and there were no unplanned admissions. CONCLUSIONS: Epidural anesthesia without requiring mechanical ventilation is safe and feasible in selected patients undergoing transvesical SP robotic radical and simple prostatectomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e597 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Albert Geskin More articles by this author Jay Chavali More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

V03-06 SINGLE PORT ROBOTIC-ASSISTED TRANSVESICAL EXCISION OF BILATERAL URETEROCELES WITH URETERAL RE-APPROXIMATION

You have accessJournal of UrologyCME1 Apr 2023V03-06 SINGLE PORT ROBOTIC-ASSISTED TRANSVESICAL EXCISION OF BILATERAL URETEROCELES WITH URETERAL RE-APPROXIMATION Labeeqa Khizir, Juliana E. Kim, Alain Kaldany, Sai Krishnaraya Doppalapudi, and Sammy E. Elsamra Labeeqa KhizirLabeeqa Khizir More articles by this author , Juliana E. KimJuliana E. Kim More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Sai Krishnaraya DoppalapudiSai Krishnaraya Doppalapudi More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The patient is a 35-year-old female with prior medical history of recurrent urinary tract infections (UTI), who presented to the emergency department for severe right abdominal pain with difficulty urinating. On physical exam, the patient was found to have a non-tender prolapsed ureterocele per urethra causing transient bladder outlet obstruction. Subsequent MRI of the pelvis showed severe right-sided hydroureter with ectopic insertion of the right ureter at the bladder neck and associated ureterocele, as well as moderate left-sided hydroureter with associated ureterocele. Here, we present a minimally invasive and definitive robotic repair of bilateral ureteroceles. METHODS: The patient was prepped and draped in the usual sterile fashion. An anterior cystotomy measuring approximately 5 cm was made, and the bladder was emptied. A single port robotic access device was then placed directly into the bladder. The patient was placed in a slight Trendelenburg position and the robot was docked. Surgical footage highlights include: bilateral ureterocele excision using electrocautery, creation of a urothelial defect on the right ureter due to excision of the large ureterocele, ureteral re-approximation, and affixation of the ureter. The cystotomy was closed and the bladder was noted to be watertight. RESULTS: Total operative time was 123 minutes. The patient recovered with unremarkable post-operative course and was discharged on same day of surgery. Post-operative imaging showed resolution of symptoms and bilateral hydronephrosis thereafter. CONCLUSIONS: Single-port transvesical approach provided a better vantage point for robotic repair compared to more traditional endoscopic approaches. This approach also allowed for the mucosa to be oversewn easily, mitigating risk of future stricture formation or ureterocele recurrence. In addition, higher insufflation pressure within bladder allowed ureteroceles to be collapsed, yet visible, and aided in excision. In summary, single-port robotic-assisted transvesical excision with ureteral re-approximation allowed for minimally invasive and definitive repair of bilateral ureteroceles. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e247 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Labeeqa Khizir More articles by this author Juliana E. Kim More articles by this author Alain Kaldany More articles by this author Sai Krishnaraya Doppalapudi More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

MP67-17 PLACEMENT OF APPROPRIATE SURGICAL POSITION BY MEASURING LOWER LEG PRESSURE PREVENTS THE DEVELOPMENT OF CREATINE KINASE ELEVATION AND LEG COMPARTMENT SYNDROME AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP67-17 PLACEMENT OF APPROPRIATE SURGICAL POSITION BY MEASURING LOWER LEG PRESSURE PREVENTS THE DEVELOPMENT OF CREATINE KINASE ELEVATION AND LEG COMPARTMENT SYNDROME AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Hiroki Natsuya, Masao Katakoka, Yusuke Kirihana, Tomoyuki Kumekawa, Yuusuke Hakozaki, Shunsuke Yoshioka, Yu Endo, Yuki Harigane, Yuta Matsuoka, Yuki Yoshida, Hitomi Imai, and Yoshiyuki Kojima Hiroki NatsuyaHiroki Natsuya More articles by this author , Masao KatakokaMasao Katakoka More articles by this author , Yusuke KirihanaYusuke Kirihana More articles by this author , Tomoyuki KumekawaTomoyuki Kumekawa More articles by this author , Yuusuke HakozakiYuusuke Hakozaki More articles by this author , Shunsuke YoshiokaShunsuke Yoshioka More articles by this author , Yu EndoYu Endo More articles by this author , Yuki HariganeYuki Harigane More articles by this author , Yuta MatsuokaYuta Matsuoka More articles by this author , Yuki YoshidaYuki Yoshida More articles by this author , Hitomi ImaiHitomi Imai More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003330.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One of the serious complications of robot-assisted radical prostatectomy (RARP) is leg compartment syndrome (LCS), which can cause permanent nerve and muscle damage. In this study, we focused on lower leg pressure during a steep Trendelenburg position in RARP, and examined whether the placement of an appropriate surgical position by measuring lower leg pressure could prevent the development of creatine kinase (CK) elevation and LCS after RARP. METHODS: A total of 300 patients who underwent RARP at our institution were investigated between August 2018-August 2022. The patients were divided into two groups, pressure measurement and non-measurement groups. In the pressure measurement group, lower leg pressure was measured by Portable Interface Pressure Sensor (Palm Q®), and the surgical position was made so that the leg pressure was around 10∼15 mmHg. Postoperative CK values and LCS incidence were compared between the two groups using the Mann-Whitney's U test. RESULTS: The pressure measurement group showed significantly lower CK values (POD1) compared to the pressure non-measurement group (768±1,045 IU/L vs 1,665±3640 IU/L, respectively, p<0.05). There were no significant differences in console time and BMI between the two groups (234±61 min vs 240±57 min, 24.7±3.2 kg/m2 vs 24.6±3.2 kg/m2, p=0.427, p=0.577, respectively). Postoperative lower leg pain symptoms were observed in 0 patients in the measurement group but 4 patients in the non-measurement group, with a significant difference between the 2 groups (p<0.05). Two of them were diagnosed with LCS. CONCLUSIONS: The placement of an appropriate surgical position by measuring lower leg pressure is important. In particular, positioning the patient with a lower leg pressure of 10-15 mmHg may prevents the development of postoperative CK elevation and LCS. Source of Funding: Nothing © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e950 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiroki Natsuya More articles by this author Masao Katakoka More articles by this author Yusuke Kirihana More articles by this author Tomoyuki Kumekawa More articles by this author Yuusuke Hakozaki More articles by this author Shunsuke Yoshioka More articles by this author Yu Endo More articles by this author Yuki Harigane More articles by this author Yuta Matsuoka More articles by this author Yuki Yoshida More articles by this author Hitomi Imai More articles by this author Yoshiyuki Kojima More articles by this author Expand All Advertisement PDF downloadLoading ...

Changes in cerebral oxygen saturation with the Trendelenburg position and increased intraabdominal pressure in laparocopic rectal surgery.

Position changes and increased intra-abdominal pressure in laparoscopic interventions lead to some physiopathological changes. There is no definite information in the literature regarding cerebral oxygen saturation in patients undergoing colorectal surgery. Our aim was to investigate whether there is oxygen saturation change in the brain tissue in pneumoperitoneum and the Trendelenburg position during laparoscopic rectal surgery. Cerebral oxygen saturation was measured in 35 patients who underwent laparoscopic rectal surgery in the Trendelenburg position. Measurements were made under general anesthesia in the pneumoperitoneum and the Trendelenburg position. The values that are statistically affected by the position are systolic blood pressure, mean arterial blood pressure and cerebral oxygen saturation. The Trendelenburg position does not disturb the cerebral oxygen saturation and it causes an increase in saturation. After pneumoperitoneum occurred, changes in systolic blood pressure, mean arterial blood pressure and brain oxygen saturation were detected. Cerebral oxygen saturation increases with the formation of pneumoperitoneum. The Trendelenburg position and increased intraabdominal pressure during laparoscopic rectal surgery do not impair brain oxygen saturation.

EVALUATION OF CHANGE IN BLOOD PRESSURE IN REPOSITIONING FROM LITHOTOMY TO SUPINE POSITION IN PATIENTS UNDERGOING SURGERIES UNDER SUB-ARACHNOID BLOCK- AN OBSERVATIONAL STUDY

Objective: Spinal anaesthesia is associated with variety of hemodynamic alterations, because of sympathetic blockade. Hemodynamics are also affected by a variety of surgical techniques. The lithotomy posture and the effects of autotransfusion increases the Systolic Arterial Pressure in the sub-extremities. Study was designed to evaluate the changes in blood pressure in repositioning from lithotomy position to supine position in patients undergoing surgeries under sub-arachnoid block. This Methods: observational study was performed in 41 patients who underwent for elective/ emergency surgeries under subarachnoid block requiring lithotomy position. Demographic information such as age, height, weight, BMI, ASA grade, height of sensory block, quality of motor block and hemodynamics such as Heart Rate (HR), Pulse Oximetry (SpO2), non invasive Blood Pressure (NIBP) during lithotomy position and repositioning to supine position were also recorded. In this study there is no signi Results: cant difference was observed in patients in repositioning from lithotomy position to supine position following sub-arachnoid block. There is slightly increased in Systolic blood pressure in patients in lithotomy position compared to supine position. This study was performe Conclusion: d on 41 patients who underwent surgeries under subarachnoid block requiring lithotomy position and this study concluded that there is no difference was observed in patients in repositioning from lithotomy position to supine position. The purpose of the study is to take necessary precautions will be taken to prevent blood pressure changes intraoperatively. Spinal anaesthesia is most commonly used neuro-axial anaesthesia technique, where the local anaesthesia is directly injected into the intrathecal space (sub-arachnoid block). The uid that surrounds the brain and spinal cord is called cerebro-spinal uid, is present in the sub-arachnoid region (1). Spinal Anaesthesia is usually given in patients in lateral position or sitting position, Trendelenburg position will produce higher level of block as compared to supine position (2). The spinal anaesthesia was rst performed in 1885 by Dr. James Corning of New York City. He used cocaine and the patient was a dog. However, August Bier performed the rst sub-arachnoid block surgery in Germany in 1898. Sub-arachnoid block is the type of regional anaesthetic that was most frequently used for obstetrics and caesarean sections after the 1950s (3). Spinal anaesthesia is used in patients undergoing procedures: femur, ankle orthopaedic hip, tibia and knee surgery, including haemorrhoidectomy and leg vascular surgery, Endovascular aortic aneurysm repair, joint replacement, arthroplasty, Hernia (inguinal or epigastric), Combined general anaesthesia and cystectomy, nephrectomy, transurethral resection of bladder tumours, Transurethral excision of the prostate and Caesarean sections, various hysterectomy methods, cases of urology. By using spinal anaesthesia, a patient can avoid the hazards of a difcult airway, consciousness, and aspiration that come with general anaesthesia in pregnant patients. By using spinal anaesthesia, a patient can avoid the hazards of a difcult airway, consciousness, and aspiration that come with general anaesthesia in pregnant patients. (4) . Hypotension is the most common complication of spinal anaesthesia, which is linked to a variety of haemodynamic abnormalities. The sympathetic blockade, which causes venous and arterial dilatation, are the primary mechanism (5). Total peripheral resistance reduces as a result of arterial dilatation, and cardiac output and venous return both decrease, which can result in severe hypotension (6). Hypotension do occur in almost all patients and signicant hypotension (systolic BP)

Comparative study of propofol and dexmedetomidine Infusion for hypotensive anesthesia in FESS surgeries: A randomized prospective double-blind controlled study

Background: Intra operative bleeding is most common factor that diminishes visibility resulting in an increased incidence of complications in patients undergoing functional endoscopic sinus surgery (FESS). Methods to reduce intra-operative bleeding include Trendelenburg position, maintenance of normothermia, and controlled hypotension by various anesthetic techniques. Many studies have shown that propofol and dexmedetomidine infusion reduces the amount of bleeding in different surgeries. Aims and Objectives: The aim of the study was to compare the effects of dexmedetomidine and propofol infusion over hemodynamic, quantity of blood loss, and quality of surgical field in patients undergoing FESS and to compare the side effects of dexmedetomidine and propofol infusion in cases undergoing FESS. Materials and Methods: This was a comparative study conducted in the department of anesthesiology of a tertiary care medical college. The duration of study was 2 years. 60 patients of ASA Grades I and II with age between 20 and 60 years, including both males and females posted for FESS were included in this study on the basis of a predefined inclusion and exclusion criteria. Patients were divided into two groups (on the basis of whether they received propofol or dexmedetomidine infusion) of 30 patients each. Hemodynamic parameters (Heart rate and mean arterial pressure [MAP]) quantity of blood loss, quality of surgical field, and side effects were recorded and compared in both the groups. For statistical purposes, P&lt;0.05 was taken as statistically significant. Results: Antrochoanal polyp and chronic sinusitis were the most common indication of FESS in studied cases. Intraoperatively, heart rate was lower in both the groups as compared to baseline. However, the heart rate was lower in the Group D at all times as compared to Group P and the difference was statistically significant from 20 min onward after induction. The mean arterial blood pressure in both the groups was comparable till up to 15 min post induction with no statistical difference. Thereafter, the mean arterial blood pressure was lower in Group D than in Group P throughout the procedure, the difference being statistically significant (P&lt;0.05). The isoflurane requirement in Group D was significantly lower starting from 5 min of induction to throughout the procedure as compared to Group P (P&lt; 0.05). Mean blood loss in Group D was 115.0±16.78 ml and in Group P was 140.47±29.42 ml, the difference in blood loss was statistically significant (P&lt;0.0001). Conclusion: Dexmedetomidine is comparatively better than propofol in controlling heart rate and MAP, reducing the blood loss, and isoflurane requirement in patients undergoing FESS.

Electric impedance tomography and protective mechanical ventilation in elective robotic-assisted laparoscopy surgery with steep Trendelenburg position: a randomized controlled study

Electrical impedance tomography (EIT) reconstructs functional lung images and evaluates the variations of impedance during the breathing cycle. The aim of this study was to evaluate the effect of protective mechanical ventilation on ventilation distributions recorded by the EIT during elective robotic-assisted laparoscopy surgery with steep Trendelenburg position. This prospective, randomized single center study included patients with healthy lungs undergoing elective robot-assisted laparoscopic urological surgery in general anesthesia. Patients were randomly assigned to either protective lung ventilation or conventional ventilation. In the protective ventilation group, tidal volume (TV) was set at 6 ml/Kg predicted body weight (PBW), with PEEP 6 cmH2O, and recruitment maneuvers (RM) as needed. In the conventional ventilation group, TV was set at 9 ml/Kg PBW, with PEEP 2 cmH2O and RM only as needed. Ventilation distribution was assessed using an EIT device. This study included 40 patients in the functional image analysis. Significant differences were found in ventilation distribution in the region of interest (p < 0.05). Driving pressure was significantly lower in protective ventilation group (p < 0.05). Peak and plateau pressures were not different between the groups while statical significance was found in tidal volume and respiratory rate. EIT may be a valuable tool for monitoring lung function during general anesthesia. During elective robotic-assisted laparoscopy surgery with steep Trendelenburg position, protective mechanical ventilation may have a more homogenous distribution of intraoperative and postoperative ventilation. Larger sample size and long-term evaluation are needed in future studies to assess the benefit of EIT monitoring in operation room.Clinical trial registration ClinicalTrials.gov Identifier: NCT04194177 registered at 11th December 2019.

Effects of Individualised High Positive End-Expiratory Pressure and Crystalloid Administration on Postoperative Pulmonary Function in Patients Undergoing Robotic-Assisted Radical Prostatectomy: A Prospective Randomised Single-Blinded Pilot Study

Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). The aim of the study was to evaluate whether crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and post-operative pulmonary function in patients undergoing RALP. Prospective randomised single-centre single-blinded explorative study. Patients were either allocated to a standard PEEP (5 cmH2O) group or an individualised high PEEP group. Furthermore, each group was divided into a liberal and a restrictive crystalloid group (8 vs. 4 mL/kg/h predicted body weight). Individualised PEEP levels were determined by means of preoperative recruitment manoeuvre and PEEP titration in STP. Informed consent was obtained from 98 patients scheduled for elective RALP. The following intraoperative parameters were analysed in each of the four study groups: ventilation setting (peak inspiratory pressure [PIP], plateau pressure, driving pressure [Pdriv], lung compliance [LC] and mechanical power [MP]) and postoperative pulmonary function (bed-side spirometry). The spirometric parameters Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25-75) were measured pre- and post-operatively. Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A p-value of <0.05 was considered significant. The two individualised high PEEP groups (mean PEEP 15.5 [±1.71 cmH2O]) showed intraoperative significantly higher PIP, plateau pressure and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualised high PEEP levels had a significantly higher mean Tiffeneau index and FEF25-75. Perioperative oxygenation and ventilation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two respective PEEP groups. Individualised high PEEP levels (≥14 cmH2O) during RALP improved intraoperative blood oxygenation and resulted in more lung-protective ventilation. Furthermore, postoperative pulmonary function was improved for up to 48 h after surgery in the sum of the two individualised high PEEP groups. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and post-operative oxygenation and pulmonary function.

Effect of expiratory flow limitation on ventilation/perfusion mismatch and perioperative lung function during pneumoperitoneum and Trendelenburg position.

Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch. This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until seven days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs). Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; P<0.001). Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.