Trendelenburg Position Research Articles

8066 5 Levels of Ureteric Dissection

<h3>Study Objective</h3> To delineate, describe, and proceed on different levels of ureteric involvement of endometriosis. <h3>Design</h3> Several years of surgeries on patients suffering from endometriosis leaves the authors with some distinct characteristics, and best understood management styles for involvements of the disease with the ureter. <h3>Setting</h3> The patient is positioned in the dorsal lithotomy in Trendelenburg position. Primary tracer is through the umbilicus, 3 operative ports are used, 2 at respective right and left flank and middle at supra pubic port. <h3>Patients or Participants</h3> This learning in this video has been compiled over several years with learnings from numerous surgeries to empirically categorize ureteric involvement of endometriosis and the best ways to manage each of them. <h3>Interventions</h3> All surgeries in this video presentation are laparoscopic surgeries <h3>Measurements and Main Results</h3> The study breaks down ureteric involvement into 5 primary categories namely (1) Tease and cut (2) Laminar dissection (3) The virgin gateway (4) The Wertheim Worry and finally (5) The Choke Hold. The list is non-exhaustive, and each level presents us with a more intense involvement of the disease than the last. <h3>Conclusion</h3> Endometriosis is an anatomy altering disease that presents itself in several ways. No patients have the exact same disease expression, and many more levels of involvement can be listed. However, for the purpose of this study, these involvement do enough to explain to us how the involvement can be managed in a majority of cases.

8509 Extracorporeal Knots in Laparoscopy: Modified Roeder's Knot

<h3>Study Objective</h3> Advancement in laparoscopic surgery led to the development of various extracorporeal knot tying techniques. In this video, we review types of extracorporeal knots and demonstrate the modified Roeder's knot (MRK) and its' application in total laparoscopic hysterectomy at the time of vaginal vault closure. This instructional video provides a step-by-step approach to the technique of the MRK. <h3>Design</h3> This video abstract uses still images, drawings, video footage and narration to demonstrate the MRK. <h3>Setting</h3> Operating Room, mid-laparoscopic procedure. The patient is in Trendelenburg position, three ancillary ports are used: 2 right-sided ipsilateral ports and a left lower quadrant port. <h3>Patients or Participants</h3> Patients undergoing laparoscopic gynecologic surgery. <h3>Interventions</h3> Application of MRK. <h3>Measurements and Main Results</h3> MRK is a sliding knot, that is formed entirely extracorporeally. The addition of an extra half-hitch to the classic Roeder's knot provides extra knot security. <h3>Conclusion</h3> MRK is safe and feasible for various minimally invasive endoscopic surgeries, especially for suturing tissues under tension. The technique is easy to learn and can be quickly mastered by surgeons and trainees.

Laser Assisted Appendectomy

<h3>Study Objective</h3> Appendiceal endometriosis is commonly encountered by gynecologists during laparoscopy for endometriosis or chronic pelvic pain. This video reviews appendiceal endometriosis, highlights important anatomical landmarks for appendectomy and demonstrates a novel technique for laparoscopic appendectomy using a CO2 Laser at the time of surgical management of endometriosis. <h3>Design</h3> This video uses still images, video footage and narration to review appendiceal endometriosis and laser-assisted appendectomy. The laser appendectomy approach is reviewed in four steps, addressing preoperative and intraoperative considerations. <h3>Setting</h3> Patient positioned in Trendelenburg position with left lateral tilt. <h3>Patients or Participants</h3> Patients undergoing gynecologic laser laparoscopic surgery for endometriosis or chronic pelvic pain. <h3>Interventions</h3> Laser assisted laparoscopic appendectomy. <h3>Measurements and Main Results</h3> When performing a laparoscopy for endometriosis or chronic pelvic pain assess the appendix for signs of endometriosis. The four key steps when planning a laser appendectomy are (1) patient preparation, (2) isolate the appendix, (3) secure blood supply, and (4) remove appendix. <h3>Conclusion</h3> Appendiceal endometriosis is common and pre-operative diagnosis is challenging. Appendectomy should be considered at the time of gynecologic surgery for endometriosis or chronic pelvic pain. This video can be used as a reference for gynecologists when performing appendectomy at the time of hysterectomy or laparoscopy for endometriosis or chronic pelvic pain.

8122 Butterfly Peritonectomy & Rectal Shaving in Deep Infiltrating Endometriosis Surgery

<h3>Study Objective</h3> Todescribe in detail the butterfly peritonectomy procedure developed by the author for effective dissection of the peritoneum in cases where deep infiltrating endometriosis has affected the peritoneum. <h3>Design</h3> The procedure has been developed over several years of the author performing laparoscopic surgeries on patients of DIE with involvement of the peritoneum; and has found this technique to be the most efficient, preserving, and effective for managing the involvement. <h3>Setting</h3> The patient is positioned in the dorsal lithotomy in Trendelenburg position. Primary tracer is through the umbilicus, 3 operative ports are used, 2 at respective right and left flank and middle at supra pubic port. <h3>Patients or Participants</h3> The procedure presented in this video has been compiled over several years with observations from numerous surgeries. For the purpose of simplicity, the author presents a single case of peritoneal involvement of endometriosis managed using butterfly peritonectomy. <h3>Interventions</h3> The surgery displayed in this video presentation is a laparoscopic surgery for a case of peritoneal involvement of endometriosis. <h3>Measurements and Main Results</h3> Adopting the Butterfly peritonectomy procedure for cases of peritoneal involvement see a reduced rate of recurrence in patients, reduced pelvic pain, and fertility preservation where applicable, along with effective safeguarding of the peripheral organs including lateral pelvic vessels, the ureter, the hypogastric nerve, and the rectum. <h3>Conclusion</h3> Butterfly peritonectomy enables surgeons to treat deep infiltrating endometriosis within the tricky folds of the peritoneum that engulfs some major vasculature, nerves, and organs. It provides the doctor with a fertility preserving approach to treating the disease thereby increasing adaptability within patients while also providing better surgical outcomes than before.

7547 Opioid-Sparing Versus Standard Postoperative Pain Regimen for Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

<h3>Study Objective</h3> This study investigated whether ICE-T, a multimodal opioid-sparing pain regimen using ice packs, acetaminophen (Tylenol), and ketorolac (Toradol) provided effective postoperative pain management compared with a standard pain regimen for total laparoscopic hysterectomy (TLH). <h3>Design</h3> This randomized controlled trial was designed to achieve over 90% power. Patients who underwent TLH were randomized to the ICE-T or standard pain regimen and outcomes were followed until postoperative day 4. <h3>Setting</h3> Intra-operatively patients were in dorsal lithotomy and Trendelenburg position. <h3>Patients or Participants</h3> Patients undergoing TLH for benign indications at the academic center from August 2019 until June 2021 were assessed for eligibility. Sixty-seven patients were enrolled preoperatively; 36 were randomized to the ICE-T regimen and 31 to the standard regimen. <h3>Interventions</h3> The ICE-T regimen prescribed around-the-clock ice-packs, acetaminophen and ketorolac. The standard protocol prescribed as needed ibuprofen and acetaminophen/oxycodone based on pain score. Both regimens included hydromorphone for breakthrough pain. These regimens were used inpatient and outpatient from post-anesthesia care unit discharge onwards. <h3>Measurements and Main Results</h3> Postoperative day 1 and 4 outcomes were evaluated using visual analog scales, validated Quality of Recovery Questionnaires, patient satisfaction scores, inpatient narcotic consumption and outpatient pain medication consumption. Patient and surgical demographics were evenly distributed. The median visual analog score and quality of recovery scores on postoperative day 1 were not significantly different; p=0.44 and p=0.85 respectively. However, the ICE-T arm median narcotic consumption on postoperative day 1 was significantly lower; 480.6 morphine milligram equivalents (MME) versus 619.2 MME, p=0.02. ICE-T arm postoperative day 4 median visual analog scores were also significantly lower in the per-protocol analysis (p=0.014). There were no significant differences in the postoperative day 4 median quality of recovery or satisfaction scores. <h3>Conclusion</h3> The ICE-T regimen is an effective multimodal opioid-sparing postoperative pain regimen for TLH. ICE-T has comparable pain control and patient satisfaction to the standard regimen while significantly decreasing narcotic consumption.

8506 Surgical Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> A case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position with sponge on ring forceps placed in the vagina. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancythrough transvaginal ultrasound and discuss management options in the late 1^st trimester. We show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with low estimated blood loss during laparoscopic total gravid hysterectomy. Final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st TM ultrasound should be considered inpatients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

8883 Total Laparoscopic Bladder Resection in the Management of Deep Endometriosis: “Take It or Leave It.”

<h3>Study Objective</h3> To highlight laparoscopic surgical anatomy for bladder resection in deep endometriosis (DE). <h3>Design</h3> Video article. <h3>Setting</h3> Laparoscopic 4K OR in IRCCS Sacro Cuore Don Calabria Hospital, Trendelenburg position under general anesthesia. <h3>Patients or Participants</h3> 35 years old woman complaining chronic pelvic pain and urinary specific symptoms, looking for pregnancy for 4 years. <h3>Interventions</h3> Opening and development of paravescical spaces, Bogros and Retzius spaces, bladder nodule isolation and resection of the whole-thickness portion of the nodule. En-bloc posterior eradication of DE after opening and development of para-rectal space and recto-vaginal space. <h3>Measurements and Main Results</h3> Duration of the surgical procedure was 180 minutes, blood loss 50cc, inpatient stay 12 days, Foley catheter was removed after 7 days (cystography was performed to assess bladder closure). <h3>Conclusion</h3> Laparoscopic bladder resection might be less invasive and precise if anatomical spaces are properly prepared and the resection is limited to the infiltrating portion of the nodule.

8118 A Conservative Tailor-Made Approach on Treating Bowel Endometriosis

<h3>Study Objective</h3> To display how the surgical inclination to perform a sub-radicle shaving procedure in place of resection and Anastomosis in cases of non-mucosal colonic involvement of endometriosis can lead to significantly better outcomes for the patient's quality of life. <h3>Design</h3> Based on empirical understanding of the authors following 1000+ surgeries of colonic involvement of endometriosis, they have formed their opinions around radicalization of procedures in cases of DIE involving the colon. <h3>Setting</h3> The patient is positioned in the dorsal lithotomy in Trendelenburg position. Primary tracer is through the umbilicus, 3 operative ports are used, 2 at respective right and left flank and middle at supra pubic port. <h3>Patients or Participants</h3> The learnings presented in this video have been compiled over several years with observations from numerous surgeries following close observations of patient recovery curves and reports on quality of life. For the purpose of simplicity, the author presents a single case of colonic involvement to elucidate the argument. <h3>Interventions</h3> The surgery displayed in this video presentation is a laparoscopic surgery for a case of colonic involvement in deep infiltrating endometriosis <h3>Measurements and Main Results</h3> Surgical excellence and an inclination to perform sub-radical procedures can help with the same level of disease minimization while ensuring the patient a far better outcome and post-surgical quality of life <h3>Conclusion</h3> Recent trends in surgery have led to an increase in resection procedures even in candidates that could undergo rectal shaving. While it is easy to believe that resection is a more total procedure and reduces the risk of diseases recurrence, it comes at the cost of long recovery times and often longer lasting repercussions, both of which can be avoided with almost equal recurrence avoidance in some candidates that qualify for rectal shaving.

Fertility-Sparing Cornual Wedge Resection for Management of GTN

<h3>Study Objective</h3> To describe the case of a 30-year-old female with cornual ectopic pregnancy treated with methotrexate with normalization of beta-hCG who subsequently developed GTN at the prior ectopic site. The patient desired future fertility and was treated with actinomycin-D with optimal response and negative beta-hCG for four months, yet the mass was persistent. The patient desired future fertility, and with guidance from gynecologic oncology and reproductive endocrinology, decision was made to proceed with a conservative operation. We demonstrate the technique of cornual wedge resection for treatment of GTN. <h3>Design</h3> Case-report <h3>Setting</h3> The patient was placed in dorsal lithotomy position with lower extremities in Allen-type stirrups and was placed in steep Trendelenburg position. <h3>Patients or Participants</h3> N/A - single patient, case report <h3>Interventions</h3> Actinomycin-D administered until beta-hCG negative for 4 months, mass noted to be persistent at uterine cornu, laparoscopic cornual wedge resection for removal of GTN given patient's desire to maintain future fertility <h3>Measurements and Main Results</h3> Pathology of the mass demonstrated necrotic chorionic villi and placental remnants, negative for malignancy. Follow up transvaginal ultrasound 3 months postoperatively demonstrated no residual mass and no uterine defect. Checking beta-hCG monthly until 12 months with negative tests, then will attempt to conceive with support from reproductive endocrinology and planned cesarean delivery similar to the management of patient's post-myomectomy. <h3>Conclusion</h3> With subspecialty support from gynecologic oncology and reproductive endocrinology, cornual wedge resection should be considered a viable option for treatment of GTN in patients who desire future fertility.

Da Vinci Xi Port Set-up and Docking Made Easy: 6 Steps to Success

<h3>Study Objective</h3> To demonstrate a step-by-step laparoscopic port set-up and docking method for the da Vinci Xi Robotic-Assisted System that can be adapted to most gynecological surgeries. <h3>Design</h3> Video demonstration of an easy and replicable port set-up that can facilitate operating in both the pelvis and upper abdomen. <h3>Setting</h3> Gynecologic robotic procedure performed in the operating room. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Port set-up and docking can be completed by following six easy steps. First, the surgeon must gain access to the abdominal cavity via the surgeon's preferred approach. The patient is placed in a deep Trendelenburg position. The left lateral robotic port is then inserted. The port should be positioned just above where the bowel meets the abdominal wall. The next step is insertion of the left sided 5 mm assist port midway between the umbilicus and lateral port, but 3-4 cm superiorly. Right sided ports can then be inserted. One or 2 ports can be used depending on whether or not a fourth arm is required. If four robotic arms are being used for the procedure, an additional right sided port can be inserted midway between the umbilicus and right lateral port. The final step includes docking the robot with the robot coming in from the patient's left or right side. Alternatively, the same port orientation can be used to operate in the upper abdomen by rotating the robot boom 180 degrees and docking so that the robot is facing the head. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Although there are many possible methods for port set-up and robotic docking, it can be efficiently performed if the steps outlined in this video are followed.

Optimal Nozzle Position and Patient’s Posture to Enhance Drug Delivery into the Peritoneum during Rotational Intraperitoneal Pressurized Aerosol Chemotherapy in a Swine Model

Even though rotational intraperitoneal pressurized aerosol chemotherapy (RIPAC) has been developed to improve the distribution and penetration depth of anti-cancer agents by pressurized intraperitoneal aerosol chemotherapy (PIPAC), the optimal nozzle position and patient's posture have not been investigated. Thus, we used nine pigs weighing 50-60 kg, and sprayed 150 mL of 1% methylene blue as an aerosol through the nozzle, DreamPen® (Dreampac Corp., Wonju, Republic of Korea), with a flow rate of 0.6 ml/min under a pressure of 140 to 150 psi for RIPAC in six and three pigs with supine and Trendelenburg positions, respectively. When we evaluated its distribution and penetration depth, even distribution among 13 regions of the abdomen was observed in three pigs with Trendelenburg position regardless of the depth of the nozzle. Regarding penetration depth, the numbers of regions with maximal penetration depth were high in the 2 cm depth of the nozzle with supine position (n = 5) and the 4 cm depth with Trendelenburg position (n = 3). Conclusively, even distribution and maximal penetration of anti-cancer agents can be expected during RIPAC in the medium depth (4 cm) between the nozzle inlet and the visceral peritoneum located on the opposite side of it and the Trendelenburg position.

Alteration in facial skin blood flow during acute exposure to -10 and -30° head-down tilt in young human volunteers.

What is the central question of this study? Facial skin blood flow (SBF) might increase during head-down tilt (HDT). However, the effect of HDT on facial SBF remains controversial. In addition, the changes in facial SBF in the cheek (cheek SBF) during a steeper angle of HDT (>-12° HDT) have not been investigated. What is the main finding and its importance? This study showed that cheek SBF decreased during -30° HDT, alongside increased vascular resistance. Furthermore, vascular impedance was suggested to be elevated, accompanied by an increased hydrostatic pressure gradient caused by HDT. Constriction of the facial skin vascular bed and congestion of venous return owing to the steep angle of HDT can decrease facial SBF. Head-down tilt (HDT) has been used to simulate microgravity in ground-based studies and clinical procedures including the Trendelenburg position or in certain surgical operations. Facial skin blood flow (SBF) might be altered by HDT, but the effect of a steeper angle of HDT (>-12° HDT) on facial SBF remains unclear. We examined alterations in facial SBF in the cheek (cheek SBF) using two different angles (-10 and -30°) of HDT and lying horizontal (0°) in a supine position for 10min, to test the hypothesis that cheek SBF would increase with a steeper angle of HDT. Cheek SBF was measured continuously by laser Doppler flowmetry. Cheek skin vascular resistance and the pulsatility index of cheek SBF were calculated to assess the circulatory effects on the facial skin vascular bed in the cheek. Cheek SBF decreased significantly during -30° HDT. In addition, the resistance in cheek SBF increased significantly during -30° HDT. The pulsatility index of cheek SBF increased during both -10 and -30° HDT. Contrary to our hypothesis, cheek SBF decreased during -30° HDT along with increased skin vascular resistance. Vascular impedance, estimated by the pulsatility index in the cheek SBF, was elevated during both -10 and -30° HDT, and elevated vascular impedance would be related to increased hydrostatic pressure induced by HDT. Skin vascular constriction and venous return congestion would be induced by -30° HDT, leading to deceased cheek SBF. The present study suggested that facial SBF in the cheek decreased during acute exposure to a steep angle of HDT (∼-30° HDT).

AVALIAÇÃO ULTRASSONOGRÁFICA DO DI METRO DA BAINHA DO NERVO ÓPTICO EM PROSTATECTOMIAS: REVISÃO DE LITERATURA

Introduction: Neuroimaging assessment and neuromonitoring are important in the treatment of patients at risk of severe acute brain injury. However, the neurological examination may be unreliable, either due to sedation or the patient's baseline status. Therefore, a non-invasive and easily accessible tool stands out, the measurement of the Optic Nerve Sheath Diameter (ONSD), which is related to Intracranial Pressure (ICP). Objective: To review the literature, summarizing the evidence related to the measurement of ONSD in prostatectomies for the analysis of intraoperative ICP. Method: The paper's search was performed in Pubmed/Medline, Lilacs and Google Scholar databases, using the descriptors: intracranial pressure AND ultrasound AND optic nerve AND prostatectomy. Results: 30 articles were selected, 20 of which were excluded because they did not adequately discuss the proposed theme. Conclusion: ONSD is a very useful method for determining ICP increase, especially during Robot-Assisted Laparoscopic Radical Prostatectomy (RALRP), which may be associated with inadequate emergence of anesthesia. Dexmedetomidine, administered during the course of surgery, attenuates the increase in ICP during pneumoperitoneum in the Trendelenburg position. Finally, propofol reduces ICP changes in patients undergoing robotic surgery in comparison to sevoflurane.

A Case of Umbilical Cord Prolapse With Intact Membranes Managed Successfully With Conservative Measures

Umbilical cord prolapse with ruptured membranes is an obstetric emergency with management consisting of delivery via emergent cesarean delivery. If the umbilical cord prolapses beyond the internal os with intact membranes, there is an opportunity to intervene and reduce the risk of fetal morbidity and mortality. A healthy 30-year-old, gravida 1 para 0 was incidentally found to have a short cervical length at 25 weeks five days on routine anatomy ultrasound evaluation. On evaluation via ultrasound by the maternal-fetal medicine service, the umbilical cord was noted to be prolapsing through the cervix with membranes intact. The cord prolapse with intact membranes resolved after placing the patient in the Trendelenburg position and nifedipine was administered for tocolysis given the uterus was noted to be contracting. For the remainder of the pregnancy, the patient underwent close follow-up and serial ultrasound scans with confirmation of the fetal head as the presenting part. The patient ultimately delivered vaginally at term. Cord prolapse with intact membranes, when identified via ultrasound, can be managed conservatively via Trendelenburg positioning and tocolysis to avoid premature cesarean delivery.

ABDOMINAL COMPRESSION IN END-STAGE FIBROTIC INTERSTITIAL LUNG DISEASE (ILD) IMPROVES RESPIRATORY COMPLIANCE

ABDOMINAL COMPRESSION IN END-STAGE FIBROTIC INTERSTITIAL LUNG DISEASE (ILD) IMPROVES RESPIRATORY COMPLIANCE

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

The effect of Trendelenburg position on outcomes of retrograde intrarenal surgery for medium sized renal pelvis stones

Aim: To compare safety and efficiency between Trendelenburg position retrograde intrarenal surgery (tRIRS) and conventional position retrograde intrarenal surgery (cRIRS) in the management of renal pelvis stones 10-20 mm in size. &#x0D; Material and Method: From September 2018 to September 2019, the patients undergoing RIRS for single renal stones between 10-20 mm were included in the study prospectively. Patients were divided into two groups randomly. First group of patients were positioned completely parallel to the ground (cRIRS), second group were positioned with Trendelenburg (tRIRS). Success was evaluated at end of 3rd months by non-contrast enhanced tomography. Stones that smaller than 4 mm were accepted as clinical insignificant residual fragment. Complications was classified according to Clavien, class 2 or more complications were recorded. &#x0D; Results: Totally 100 patients were included to final analyze. Patients’ age, gender, stone side and mean stone surface area were similar between groups. Success rate was higher in tRIRS group (90% vs 72% p=0.022). Mean operation time was lower (41.8 vs 58.2 min. p

Effect of Change of Position (Supine vs. Steep Trendelenburg) on Bispectral Index Value During Robotic Surgery.

Background: Bispectral Index (BIS) is used to monitor anesthetic depth and is a useful instrument to keep a check on intraoperative awareness. But there are various situations in which it shows false readings. Our aim of the study was to observe the changes in BIS value with steep Trendelenburg position, which is usually done, in robotic pelvic surgeries.Methods: We included 100 patients in our study who underwent robotic prostatectomies and hysterectomies. After anesthetizing the patient, the patient's heart rate, systolic blood pressure, mean arterial pressure, end-tidal desflurane, end-tidal CO2, and BISwere recorded at three min. intervals, for 15 minutes before and 15 minutes after the Trendelenburg position without surgical stimulus.Results: We found a significant increase in BIS values (p <0.05) after the change of position from supine to steep Trendelenburg. Heart rate, systolic blood pressure, and mean arterial pressure were almost constant.Conclusion: Our study concluded that the BIS value increases when patients were shifted from the supine to Trendelenburg position, which might raise the concern of a decrease in anesthetic depth.

The Effect of Patient Positioning on Ureteral Efflux During Intraoperative Cystoscopy: A Randomized Controlled Trial

To identify the relationship between patient position during surgery and time to confirmation of ureteral patency on cystoscopy. Randomized controlled trial. Academic tertiary care medical center. A total of 91 adult women undergoing laparoscopic (either conventional or robotic) hysterectomy between February 2021 and February 2022 were randomized to intervention (n=45) or control (n=46). Exclusion criteria included known kidney disease or urinary tract anomaly, current ureteral stent, pregnancy, malignancy, and recognized intraoperative urinary tract injury. Subjects in the control group were placed in a 0° supine position during cystoscopy. Subjects in the intervention group were placed in a 20° angle in reverse Trendelenburg (RT) during cystoscopy. The primary outcome, time to confirmation of bilateral ureteral patency, was measured at the time the second ureteral jet was viewed during intraoperative cystoscopy. There was no significant difference in mean time to confirmation (66.5 seconds in supine vs 67 seconds in RT, p=.2), nor in total cystoscopy time (111 seconds in supine vs 104.5 seconds in RT, p=.39). There were no significant differences in need for alternative modalities to aid in ureteral efflux visualization, delayed diagnosis of ureteric injury, and operative time. RT position seemed to have reduced the time to confirmation for the small group of patients with longer confirmation time (>120 seconds). Reverse Trendelenburg position does not change time to confirmation of bilateral ureteral patency compared to supine position. However, there may be a benefit in position change if time to confirmation is >120 seconds. 'Ureteral Jets and Patient Positioning Study', NCT04732403, Feb 1, 2021, clinicaltrials.gov/ct2/show/NCT04732403, https://data.mendeley.com/datasets/pssg5tf4ws.

Anesthetic Challenges and Perioperative Factors Affecting Delayed Graft Function in Robotic-Assisted Kidney Transplant: A Review of a Single-Center Experience of 100 Cases.

Background and objectiveThe advent of robot-assisted kidney transplant (RAKT) has ushered in a new set of challenges. In this single-center retrospective observational study, we aimed to highlight the anesthetic challenges and analyze perioperative parameters to identify the risk factors for delayed graft function (DGF) in RAKT.MethodsA descriptive analysis of perioperative factors of the first 100 cases of RAKT at our center was performed. Data were retrieved from the hospital's electronic medical records (EMR) of donors and adult patients who underwent RAKT between July 2015 and December 2020. The data analyzed included demographics, preoperative optimization, intraoperative and postoperative management, and complications. DGF was defined as a requirement of dialysis within one week of transplant. The Fisher’s exact test, independent sample t-test, and the Mann-Whitney test were used to analyze data.ResultsAmong a total of 193 renal transplants performed during the study period, 100 patients underwent RAKT, which included 27 females and 73 males. Of these, 91 were live while the remaining involved deceased-donor transplants. Pneumoperitoneum and steep Trendelenburg position required various “anesthetic maneuvers” to maintain hemodynamics and respiratory parameters. Optimal fluid management, with frusemide and mannitol, ensured good urine output (UOP) (93%). Post-reperfusion, the release of pneumoperitoneum, maintenance of adequate perfusion pressures, immunosuppression, and regional hypothermia helped in ensuring adequate graft function (93%). The incidence of DGF in our series was 7% and the mortality rate was 3%. Recipient age (p=0.045), dyslipidemia (p=0.021), and diabetes mellitus (p=0.023) were identified as significant risk factors for DGF.ConclusionAdvanced recipient age, diabetes, and dyslipidemia were factors significantly associated with DGF in RAKT in our series of 100 cases. However, the duration of the steep Trendelenburg position, docking of robot/pneumoperitoneum (console time), fluid management, warm and cold ischemia times, rewarming time, and type of graft did not influence DGF. Awareness of the systemic involvement in RAKT, proper preoperative optimization, and knowledge of potential problems are essential for the efficient anesthetic management of RAKT.