Search

The aim of this study was to compare different end-tidal carbon dioxide (EtCO 2 ) levels to prevent postoperative nausea and vomiting (PONV) caused by increased intracranial pressure due to pneumoperitoneum and Trendelenburg position in gynaecological laparoscopic surgery. A total of 60 female patients aged 25-50 years who would undergo laparoscopic gynaecological surgery under general anaesthesia were randomised into two groups: group A (EtCO 2 : 26 - 35 mmHg, n  = 30) and group B (EtCO 2 : 36 - 45 mmHg, n  = 30). In both groups, ONSD and EtCO 2 of the patients were measured at baseline after anaesthesia induction ( T b ), at 5 min after pneumoperitoneum ( T PP5 ), and at 10 min intervals after Trendelenburg position ( T PP10 , T PP20 , T PP30 ). At 5 ( T D5 ) and 10 min ( T D10 ) after deflation, ONSD measurements were repeated. The incidence and severity of PONV of the patients, and antiemetic drugs used in both groups were assessed in the postoperative period. In the intraoperative follow-up periods, T PP5 and subsequent EtCO 2 values, as well as T PP10 and subsequent ONSD values, were significantly higher in group B and the incidence of nausea, the PONV scores and the incidence of rescue antiemetic use significantly lower in group A than in group B ( p <.001 for all). This result indicates that low EtCO 2 levels have beneficial effects on ICP and PONV in laparoscopic gynaecological operations.Impact statement What is already known on this subject? Laparoscopic gynaecologic surgery has been a more preferred technique. The incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynaecologic surgery is remarkably high. In the prevention of PONV after gynaecologic laparoscopic surgery, single and multiple drug therapies and methods have been used. What the results of this study add? Postoperative nausea and vomiting caused by intracranial pressure (ICP) increase due to carbon dioxide pneumoperitoneum and Trendelenburg position in gynaecologic laparoscopic surgeries were decreased in the early postoperative period by low end-tidal carbon dioxide levels in the intraoperative period. It was shown that low end-tidal carbon dioxide levels have beneficial effects on ICP and PONV in laparoscopic gynaecologic operations. What the implications are of these findings for clinical practice and/or further research? This result indicates that low end-tidal carbon dioxide levels have beneficial effects on ICP and PONV in laparoscopic gynaecologic operations.

Background: Robot-assisted laparoscopic prostatectomy (RALP) frequently entails postoperative pulmonary complications (PPCs) due to the Trendelenburg position and pneumoperitoneum. Diaphragm thickening fraction (TF) as an imaging marker can offer the advantage of predicting respiratory outcomes. Therefore, we evaluated the effect of diaphragm TF on the occurrence of PPCs in RALP., Methods: We measured the preoperative thickness of the diaphragm at peak inspiration ( T pi ) and end expiration ( T ee ) using ultrasonography. Diaphragm TF was calculated as TF = ( T pi - T ee )/ T ee . A receiver operating characteristic (ROC) curve analysis of TF was performed. After dividing patients into two groups according to the optimal TF cut-off value, we compared the occurrence of PPCs between the groups. The predictivity of diaphragm TF for the occurrence of PPCs was evaluated., Results: Of 145 patients, 40 patients (27.6%) developed PPCs. Patients with PPCs had a significantly lower TF than those without PPCs (0.31 ± 0.09 vs. 0.39 ± 0.11, P < 0.001). In the ROC curve analysis, the optimal TF cut-off value was 0.28. The patients were divided into TF ≥ 0.28 group ( n = 114) and TF < 0.28 group ( n = 31). The incidence of PPCs was significantly higher in the TF < 0.28 group than in the TF ≥ 0.28 group (51.6% vs. 21.1%, P = 0.001). Diaphragm TF < 0.28 was associated with a higher incidence of PPCs than diaphragm TF ≥ 0.28 (odds ratio = 4.534, 95% confidence interval [1.763-11.658], P = 0.002)., Conclusion: Preoperative diaphragm TF < 0.28 was associated with an increased incidence of PPCs, suggesting that diaphragm TF as a prognostic imaging marker provides useful information on PPCs in RALP requiring the Trendelenburg position and pneumoperitoneum. Trial Registry Number . This trial is registered with KCT0005028., Competing Interests: All authors declared no competing interests., (Copyright © 2021 Jihion Yu et al.)

Background: Optic nerve sheath diameter (ONSD) measurement with ultrasound has emerged as a simple, non-invasive and reliable surrogate of invasive intracranial pressure (ICP) measurement. Increase in ICP might lead to postoperative nausea and vomiting (PONV) and postoperative headache. Here, we aimed to evaluate the extent of change in ONSD, resulting from pneumoperitoneum (PP) and Trendelenburg (TP) position during the laparoscopic hysterectomy (LH), by using ultrasonographic ONSD measurement. We also aimed to investigate the relation of ONSD with PONV and postoperative headache., Methods: Sixty-one patients undergoing LH with general anesthesia were enrolled in this prospective study. ONSD was measured at six time-points during the LH. The primary outcome of the study was the change in ONSD with the introduction of PP and TP. The relation of ONSD with PONV and postoperative headache were the secondary outcomes., Results: ONSD demonstrated an increasing trend from baseline to the 10th minute of the TP. A relative decrease occurred in ONSD following supine positioning which further decreased after the release of the PP. However, even after the release of the PP, the median ONSD was significantly higher compared to the baseline values (5.1 mm vs. 4.9 mm, P<0.01). Presence of PONV and headache were significantly correlated with the extent of the increase in ONSD from baseline to PP and from baseline to TP. ROC curve analysis revealed that a cut-off value of 5.85 mm for ONSD was predictive for PONV (P<0.001)., Conclusions: Combination of PP and TP leads to a significant increase in ONSD during LH. The extent of the increase in ONSD during the procedure is significantly correlated with PONV and headache occurring within the first three hours of recovery.

Background: We evaluated the relationship between ultrasonographical acquired parameters and short-term postoperative cognitive function in patients undergoing robotic-assisted radical prostatectomy (RALP)., Methods: Ninety elderly patients scheduled for RALP had their optic nerve sheath diameter (ONSD), the cross-sectional area (CSA) of the internal jugular vein (IJV) and the IJV valve (IJVV) competency assessed by ultrasound. The patients were analyzed in 2 groups based on whether displayed IJVV incompetency (IJVVI). The 3 parameters were measured before anesthesia (T0), immediately after induction of general anesthesia (T1), 5 minutes after establishing pneumoperitoneum (T2), 5 minutes after placing the patient in the Trendelenburg position (T3), and 5 minutes after the release of the pneumoperitoneum in the supine position (T4). Regional cerebral tissue oxygen saturation (rSO2) was also measured by near-infrared spectroscopy intraoperatively. The Mini-Mental State Examination (MMSE) and Confusion Assessment Method (CAM) were performed the day before surgery and on postoperative days 1, 3, and 7., Results: We found that 52% of patients had evidence of IJVVI after being placed in the Trendelenburg position after pneumoperitoneum was established (T4). Patient with IJVVI showed a significant increase of ONSD and CSA at T1, T2, T3, T4 but there was no associated decrease in rSO2. MMSE scores were reduced at postoperative day 1 and the 7 patients that developed postoperative delirium came from Group IJVVI., Conclusions: Our observations suggest that elderly patients that show IJVVI after adequate positioning for RALP may develop elevated intracranial pressure as well as mildly compromised postoperative cognitive function in the short term.

Study Objective: The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy., Design: Prospective study (Canadian Task Force classification III)., Setting: Rambam Health Care Campus., Patients: Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse., Interventions: Robotic sacrocolpopexy., Measurements and Main Results: A 5-minute computerized electrocardiogram, cerebral O 2 saturation (cSO 2 ), systemic O 2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO 2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO 2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms 2 /Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms 2 /Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation., Conclusion: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate the effect of pneumoperitoneum and head position during laparoscopic surgery on intracranial pressures (ICPs) using sonographic measurements of optic nerve sheath diameter (ONSD)., Design: Prospective observational study (Canadian Task Force classification II-1)., Setting: A tertiary-level hospital., Patients: Sixty-one women aged 15 to 50 years with American Society of Anesthesiologists grade 1 risk and body mass index ≤ 29 kg/m 2 were admitted to the hospital between November 2015 and October 2016 for elective laparoscopic surgery and were included in this study., Intervention: Patients were placed in the Trendelenburg position with head down (group I; n = 33) and reverse Trendelenburg position with head up (group II; n = 28)., Measurements and Main Results: ONSD was measured via sonography at 4 time points: at baseline before pneumoperitoneum, after pneumoperitoneum, after patient was placed in respective position, and once pneumoperitoneum was released. Patient demographics were comparable in all respects. ICP as indicated by ONSD showed a significant increase after pneumoperitoneum (p = .0001 in group I and p = .0011 in group II). When patients were placed in either head position, ONSD showed a further increase in ICP. This increase was more pronounced in patients assuming the head-down Trendelenburg position compared with patients in reverse Trendelenburg (head-up) position. Baseline and preoperative ONSD measurements were not reached even after 5 minutes of desufflation., Conclusions: Pneumoperitoneum causes an increase in ICP. The patient position, either head up or head down as in gynecologic laparoscopic procedures, further worsens ICP. ONSD does not revert back to baseline until 5 minutes after desufflation., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background/aim: The aim of this study was to quantify the changes in middle ear pressure (MEP) during robot-assisted radical prostatectomy (RARP)., Materials and Methods: Thirty patients undergoing RARP were included in this study. MEP was obtained at the following time points: awake (T1), postintubation (T2), pneumoperitoneum + 1 h of Trendelenburg position (T3), pneumoperitoneum + 2 h of Trendelenburg position (T4), pneumoperitoneum + 3 h of Trendelenburg position (T5), desufflation + supine position (T6), and 1 h after extubation in the postanesthesia care unit (T7). Heart rate, mean arterial pressure (MAP), peak airway pressure (PAP), tidal volume, minute ventilation, EtCO 2 , and blood gas values were recorded., Results: MEP was significantly higher at T4, T5, T6, and T7 as compared to T1 values. PAP values were significantly increased at T3, T4, and T5 compared to T2. MAP values at T3, T4, and T5 were significantly higher compared to T1. PaCO 2 increased significantly at T4, T5, and T6 and pH decreased significantly at T4 and T5 when compared to T2., Conclusion: The combination of steep Trendelenburg position and pneumoperitoneum during RARP caused a significant increase in MEP, PaCO 2 , and EtCO 2 levels. This propensity for increased MEP may cause problems in patients with preexisting ear disease.

An 80-year-old woman without any previous otological symptoms underwent laparoscopic abdominoperineal resection for T3N0M0 low rectal carcinoma 4-5 cm from the anal verge. The total operative time was 6 h, of which she spent long hours in the Trendelenburg (35°) position due to difficult pelvic dissection. Midway through the procedure, she developed spontaneous non-traumatic bilateral otorrhagia. This case highlights the potential risk of increased intracranial pressure during prolonged periods of being in a steep Trendelenburg position caused either by the position itself or in combination with carbon dioxide pneumoperitoneum. We also consider the effect of a sudden change from this position to supine as a potential risk., (2014 BMJ Publishing Group Ltd.)

Purpose: The purpose of this study was to assess the extent of the increased intracranial pressure (ICP) resulting from CO2 pneumoperitoneum and steep Trendelenburg positioning using ultrasonographic measurement of optic nerve sheath diameter (ONSD) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP)., Patients and Methods: Twenty patients who underwent elective RALRP were enrolled in this study. ONSD and regional cerebral oxygen saturation (rSO2) were investigated noninvasively using ocular ultrasonography and near-infrared spectroscopy before anesthesia (T0), 10 minutes after anesthesia induction in the supine position (T1), 10 and 30 minutes after CO2 pneumoperitoneum with 30-degree Trendelenburg positioning (T2 and T3), and after returning to supine position without CO2 pneumoperitoneum at the conclusion of the RALRP (T4)., Results: The mean values of ONSD at all time points (T1, T2, T3, and T4) after general anesthesia significantly increased compared with that before general anesthesia (T0). During CO2 pneumoperitoneum with 30-degree Trendelenburg positioning (T2, T3), a significant increase of 12.5% in ONSD was observed in comparison with ONSD after anesthesia induction in the supine position without CO2 pneumoperitoneum (T1). Three patients had an ONSD value equivalent to an ICP above 20 mm Hg, and these patients did not experience a decrease of rSO2 or any neurologic complications., Conclusions: In patients undergoing RALRP, the increase of 12.5% in ONSD during CO2 pneumoperitoneum with steep Trendelenburg positioning was observed and thus the increase of ICP corresponding to this change of ONSD could be predicted. In 15% of the enrolled patients, ONSD increased by values equivalent to an ICP above 20 mm Hg without a deterioration of rSO2 or any neurologic complications.

Introduction: Insuflation abdominal cavity with carbon dioxide during laparoscopic surgery increases abdominal pressure, which may cause stasis of the blood flow in inferior vena cava and common iliac veins. Moreover, reverse Trendelenburg position, in which laparoscopic cholecystectomy is performed, decreases venous return. All of this factors makes episode of venous thromboembilism (VTE), an asymptomatic state that could cause serious complications, more probable., Aim: The aim of the study was to asses influence of pneumoperitoneum during laparoscopic procedures on coagulation state and to asses relation between body mass index (BMI), age of patients undergoing laparoscopic procedures and coagulation profile in the postoperative period., Material and Methods: The study enrolled 35 patients (F:M = 28:7, mean age 48.3 ± 14.6, mean BMI 26 ± 4.5 kg/m2), without VTE risk factors, not undergoing anticoagulant therapy and without abnormal platelet count. Subjects underwent laparoscopic cholecystectomy. Alteration in coagulation profile was assesed on the basis of aPTT, PT and TT results. Blood samples were taken twice: in the day of admission (samle A) and 5 hours after surgery (sample B). Statistical analysys was performed using Wilcoxon signed rank test and Spearman correlation., Results: Mean aPTT, PT and TT value of the A sample was 34.54 ± 6.32s, 1.11± 0.14 INR; 16.35 ± 1.93s respectively. Mean aPPT, PT and TT value of the B sample was 34.4 ± 7.13s; 1.17 ± 0.11 INR; 16.41 ± 1.88s, respectively. Change of PT value pre- and postoperatively was statistical significant (p = 0.0009). There was statistical significant correlation between duration of the surgery and sample B PT and TT values (p = 0.0115 and 0.0218 respectively). No other correlation between BMI, age and sample B values was observed., Conclusions: Creation of pneumoperitoneum has no influence on shortening of clotting times. Because of early mobilisation, fast discharge and recovery that makes natural anticoaculant prevention available short after surgery, clinical risk of DVT is not high.

Background: The aim of this study was to determine the influence of different therapeutic interventions and positions on catecholamine and vasopressin levels in the pneumoperitoneum (PN) in a porcine model., Methods: In 43 pigs, a 14-mm-Hg PN was established and plasma concentrations of epinephrine, norepinephrine and vasopressin were measured in head-up, supine and head-down positions. Additionally, the effects of the following changes were studied: (1) increase in intrathoracic blood volume (ITBV) by means of hydroxyethyl starch infusion; (2) vasodilatation induced by sodium nitroprusside, or (3) selective sympathicolysis induced by esmolol. Again, catecholamines (ELISA) and vasopressin (RIA) were determined., Results: After PN, epinephrine levels did not significantly increase in the head-up position (p = 0.075) and remained also unchanged in the supine or head-down position. Plasma norepinephrine statistically significantly decreased in the head-up position (p = 0.046). Vasopressin concentrations remained unaltered. After increased ITBV, neither catecholamine nor vasopressin concentrations changed in any body position. Application of sodium nitroprusside or esmolol caused no changes., Conclusion: Changes in endogenous catecholamine levels safely prevent cardiocirculatory instability in small pigs. Volume substitution might reduce endocrine responses to PN in the head-up position., (Copyright © 2011 S. Karger AG, Basel.)

Background and Objective: Robot-assisted prostatectomy requires pneumoperitoneum in a steep Trendelenburg position, which may induce endobronchial intubation or accidental extubation. The aim of the study was to evaluate the effect of pneumoperitoneum in 30 degrees Trendelenburg position on the displacement of the tracheal tube and to measure the changes in trachea length using fiberoptic bronchoscope., Methods: Thirty male patients scheduled for robot-assisted radical prostatectomy were enrolled. After induction of general anaesthesia, the distance between the vocal cords and the tracheal tube tip (DeltaVE), between the tracheal tube tip and the carina (DeltaEC) and between the vocal cords and the carina (DeltaVC) was measured using a fiberoptic bronchoscope before and 10 min after pneumoperitoneum in neutral position (T1 and T2, respectively), and 2 h after pneumoperitoneum in 30 degrees Trendelenburg position (T3)., Results: The DeltaVC and DeltaEC decreased significantly 10 min after pneumoperitoneum in neutral position (T2) and 2 h after pneumoperitoneum in Trendelenburg position (T3) compared with those before pneumoperitoneum in neutral position (T1) (all P < 0.001). The changes in DeltaVE were not statistically significant., Conclusion: The confirmation of the tracheal tube position is recommended after pneumoperitoneum in steep Trendelenburg position during robot-assisted prostatectomy because the displacement of the tracheal tube may result in endobronchial intubation due to shortening of the carina-to-tube tip distance.

Background: During laparoscopic gynecologic surgery, pneumoperitoneum combined with the Trendelenburg position moves the carina towards the tip of the endotracheal tube (ETT), decreasing the margin of safety for the ETT position and increasing accidental endobronchial intubation. However, it remains to be established whether the tracheal length itself is actually changed. We conducted a prospective observational study to measure the change in the length of the trachea and the distance between the ETT tip and the carina in patients undergoing gynecologic laparoscopic surgery., Methods: Twenty-three patients scheduled for laparoscopic gynecologic surgery were enrolled. In the neutral position, the tracheal length was measured using a fiberoptic bronchoscope. The distance between the ETT tip and the carina was also measured. The tracheal length and the distance between the ETT tip and the carina were measured again 10 min after carbon dioxide (CO(2)) pneumoperitoneum (12-14 mmHg) combined with the Trendelenburg position (15 degrees )., Results: In the neutral position, the tracheal length was 11.09 +/- 0.90 cm and the distance between the ETT tip and the carina was 3.36 +/- 1.04 cm. After pneumoperitoneum combined with the Trendelenburg position, the distance between the ETT tip and the carina had decreased by 0.85 +/- 0.28 cm. The tracheal length had also decreased by 0.42 +/- 0.19 cm, which was equivalent to 49.7% of the decrease in the distance between the ETT tip and the carina., Conclusions: These results suggest that tracheal shortening may contribute to a decrease in the distance between the ETT tip and the carina, increasing the risk of accidental endobronchial intubation during laparoscopic gynecologic surgery.

Background: We investigated changes in portal venous blood flow (PVBF) during carbon dioxide (CO2) pneumoperitoneum to evaluate the effects of different insufflation profiles and body positions., Methods: An established rat model was extended by implanting a portal vein flow probe that would enable us to measure PVBF for 60 min [t0-t60] in animals subjected to a CO2 pneumoperitoneum with an intraabdominal pressure (IAP) of 9 mmHg. Forty-eight male Sprague-Dawley rats were randomized into the following four experimental and two control groups: decompression group D1 ( n = 8), desufflation for 1 min every 14 min; decompression group D2 ( n = 8), desufflation for 5 min, after 27 min; position group P1 ( n = 8), 35 degrees head-up position; position group P2 ( n = 8), 35 degrees head-down position; negative control group C1 ( n = 8), no insufflation; positive control group C2 ( n = 8), constant IAP of 9 mmHg for 60 min., Results: Pneumoperitoneum and body positions, respectively, reduced PVBF [t1-t60] significantly ( p < 0.001) by 32.0% C2, 32.8% D1, 31.1% D2, 40.8% P1, and 48.5% P2, as compared to PVBF at t0 in each group. There was a significant difference in PVBF reduction between P1 and P2 and also between C2 and both P1 and P2 ( p < 0.04)., Conclusions: CO2 pneumoperitoneum reduces PVBF significantly (>30%). Extreme body positions (35 degrees tilt) significantly intensify PVBF reduction. PVBF reduction is significantly more dramatic in subjects placed in a 35 degrees head-down position. Short desufflation periods did not improve mean PVBF, but it may have beneficial immunological and oncological effects that warrant further investigation.

Background: Increased intraperitoneal pressure in the head-down position is associated with a significant increase in intraocular pressure (IOP) in rabbits with alpha-chymotrypsin-induced glaucoma. Also, the retinal cells are weakened by the induction of increased IOP, and/or glaucoma, even when IOP is controlled by adequate therapy; therefore, these cells need to be protected from any additional aggression. Actin and vimentin are proteins of the retinal cell cytoskeleton that react readily in response to retinal injuries, including ischemia and glaucoma. Early changes in these cytoskeleton proteins determine the morphological changes observed after retinal damage. Therefore, we set out to investigate intracytoplasmic changes in vimentin and actin after a 4-h CO(2) pneumoperitoneum in the head-down position in rabbits with alpha-chymotrypsin-induced glaucoma., Methods: Twenty-one rabbits with alpha-chymotrypsin-induced glaucoma in one eye received general anesthesia for 4 h in the head-down position and were randomly allocated to have (a) no pneumoperitoneum, (b) a 10 mmHg CO(2) pneumoperitoneum, or (c) a 20 mmHg CO(2) pneumoperitoneum. At the end of the trial, both the right glaucomatous and the left control eyes were enucleated and investigated immunocytochemically for alterations in vimentin and actin, and morphologically for retinal layer disorganization., Results: Except for the preexisting morphological changes induced by glaucoma, both the control and the glaucomatous eyes in all rabbits appeared normal in terms of retinal layer organization and the distribution of intracellular vimentin and actin whatever the intraperitoneal pressure level applied., Conclusion: In rabbits with alpha-chymotrypsin-induced glaucoma, a 4-h CO(2) pneumoperitoneum of