Helium gas pneumoperitoneum can improve the recovery of gastrointestinal motility after a laparoscopic operation

The use of laparoscopic surgery contributes to faster recovery of postoperative gastrointestinal motility. Several authors have demonstrated the benefits of laparoscopic surgery using carbon dioxide (CO₂) pneumoperitoneum. However, there have been few investigations of the effects of other insufflation gases on gastrointestinal motility. The aim of this study was to investigate the effect of CO₂ and helium pneumoperitoneum on the recovery of postoperative gastrointestinal motility. For this study, male Sprague‐Dawley rats were divided into four groups: control, CO₂ insufflation (10?mmHg), helium insufflation (10?mmHg) and open laparotomy for one hour. Arterial pH values and PaCO₂ were measured after surgery. Gastrointestinal motility was evaluated by quantifying the distribution of markers placed into the stomach at the end of procedures until 24?hours after surgery. In the CO₂ insufflation group, the arterial pH value was significantly lower than that of the helium insufflation group, and significant hypercapnia persisted until six hours after surgery. The gastric emptying and transit time was significantly prolonged in the CO₂ group compared with the helium insufflation group.

This study demonstrates that helium pneumoperitoneum can improve the recovery of postoperative gastrointestinal motility because of the reduction of hypercapnia and a tendency to suffer acidosis compared with CO₂ pneumoperitoneum.     

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

BACKGROUNDLaparoscopic hepatectomy has recently become popular because it results in less bleeding than open hepatectomy. However, CO₂ embolism occurs more frequently. Most CO₂ embolisms during laparoscopic surgery are self-resolving and non-symptomatic; however, severe CO₂ embolism may cause hypotension, cyanosis, arrhythmia, and cardiovascular collapse. In particular, paradoxical CO₂ embolisms are highly likely to cause neurological deficits. We report a case of paradoxical CO₂ embolism found on transesophageal echocardiography (TEE) during laparoscopic hepatectomy, although the patient had no intracardiac shunt.CASE SUMMARYA 71-year-old man was admitted for laparoscopic left hemihepatectomy. During left hepatic vein ligation, the inferior vena cava was accidentally torn. We observed a sudden drop in oxygen saturation to 85%, decrease in systolic blood pressure (SBP) below 90 mmHg, and reduction in end-tidal CO₂ to 24 mmHg. A “mill-wheel” murmur was auscultated over the precordium. The fraction of inspired oxygen was increased to 100% with 5 cmH₂O of positive end-expiratory pressure (PEEP) and hyperventilation was maintained. Norepinephrine infusion was increased to maintain SBP above 90 mmHg. A TEE probe was inserted, revealing gas bubbles in the right side of the heart, left atrium, left ventricle, and ascending aorta. The surgeon reduced the pneumoperitoneum pressure from 17 to 14 mmHg and repaired the damaged vessel laparoscopically. Thereafter, the patient’s hemodynamic status stabilized. The patient was transferred to the intensive care unit, recovering well without complications.CONCLUSIONTEE monitoring is important to quickly determine the presence and extent of embolism in patients undergoing laparoscopic hepatectomy.     

Intra-operative risk and haemodynamic etfects of the CO2-pneumoperitoneum in laparoscopic surgery

The benetits of minimally invasive surgery led to an increasing rate of laparoscopic procedures in older patients. These patients profit most from the p.op. advantages of laparoscopic surgery. On the other hand they often display cardiovascular risks with the intra-operative risk of the CO₂-pneumoperitoneum still under discussion. Methods: The haemodynamic etfects of CO₂-pneumoperitoneum were investigated. Monitoring included cardiac output (CO), central venous pressure (CVP), pulmonary arterial pressure (PAP) and wedge pressure (PAWP), femoral venous pressure (FVP), intra-oesophageal pressure (IEP), systemic vascular resistance (SVR) and transmural right-atrial pressure (TMP), and was performed in a controlled, experimental model. Results: Establishing the pneumoperitoneum caused initially a 35% decrease in CO. SVR, as an indicator of cardiac afterload, increased clearly. The increased intra-abdominal pressure led to a reduction of venous retlux from the periphery and squeezed the venous reservoir within the abdominal cavity. Cardiac preload was altered, too. The elevated cardiac afterload adapted under pneumoperitoneum. After desufflation cardiac output rose far above normal. Conclusions: These results indicate a strong cardiac stress after insufflation and desufflation. This is caused by the increased intra-abdominal pressure rather than by systemic etfects of resorbed CO₂. Laparoscopic procedures in patients with clinical signs of cardiovascular insufficiency should only be performed with substantial intra-operative monitoring. Otherwise low pressure pneumoperitoneum and/or pressure and gasless laparoscopy could be considered.     

Instruments for gasless laparoscopic surgery

Summary

In addition to physiological consequences of the pneumoperitoneum, there are many technical disadvantages. Specially designed instruments for laparoscopic procedures using CO₂ gas insufflation and valved trocars with small diameters are expensive, delicate and often single-use items. Besides restricting the surgeon's freedom of movement they lead to a lack of tactile sense and their handling requires a lot more practise compared to conventional instruments. For gasless laparoscopy we use a planar lift system (Origin^?), to attain a sufficient extension to the abdominal wall. The gasless technique allows the use of every laparoscopic instrument without exception, which originally was designed for a pneumoperitoneum. In addition conventional instruments, used in open surgery, can be employed with simple valveless trocars. Instruments without any comparable laparoscopic equivalent can be used. The disadvantage in using instruments designed for conventional surgery is that in their development ergonomic criteria for a laparoscopic application have not been considered. We developed a special instrument set where instrument length, shape and joint position have been designed to fit the needs of gasless laparoscopy. The combination of laparoscopic and ergonomically adapted conventional instruments may lead to progress in the technique of laparoscopic surgery.     

Inclusion of a Nitric Oxide Congener in the Insufflation Gas Repletes S‐Nitrosohemoglobin and Stabilizes Physiologic Status During Prolonged Carbon Dioxide Pneumoperitoneum

A method to maintain organ blood flow during laparoscopic surgery has not been developed. Here we determined if ethyl nitrite, an S‐nitrosylating agent that would maintain nitric oxide bioactivity (the major regulator of tissue perfusion), might be an effective intervention to preserve physiologic status during prolonged pneumoperitoneum. The study was conducted on appropriately anesthetized adult swine; the period of pneumoperitoneum was 240 minutes. Cohorts consisted of an anesthesia control group and groups insufflated with CO₂ alone or CO₂ containing fixed amounts of ethyl nitrite (1–300 ppm). Insufflation with CO₂ alone produced declines in splanchnic organ blood flows and it reduced circulating levels of S‐nitrosohemoglobin (i.e., nitric oxide bioactivity); these reductions were obviated by ethyl nitrite. In a specific example, preservation of kidney blood flow with ethyl nitrite kept serum creatinine and blood urea nitrogen concentrations constant whereas in the CO₂ alone group both increased as kidney blood flow declined. The data indicate ethyl nitrite can effectively attenuate insufflation‐induced decreases in organ blood flow and nitric oxide bioactivity leading to reductions in markers of acute tissue injury. This simple intervention provides a method for controlling a major source of laparoscopic‐related morbidity and mortality: tissue ischemia and altered postoperative organ function.     

The effects of CO<Subscript>2</Subscript> pneumoperitoneum on the apoptotic index in the peritoneum

During laparoscopic surgery, gases such as carbon dioxide (CO₂), helium, or normal air are insufflated into the intra-abdominal cavity so the surgeon can obtain a clear surgical field; however, this insufflation technique may cause injury to the intra-abdominal organs. This study was undertaken to evaluate the effects of different pressures of CO₂ on the apoptotic index in the peritoneum during laparoscopic surgery. A total of 30 Sprague-Dawley male rats were used in the study. CO₂ was insufflated into the intra-abdominal cavity via an angiocatheter cannula by an insufflator at pressures of 10 and 20 mm Hg over 60 min. In the control group, the cannula was inserted into the intra-abdominal cavity, but no gas was insufflated. After 60 min, the rats were killed; peritoneum was harvested from the abdominal wall and was cultured in the cell culture laboratory. Apoptotic and living cells were detected immunohistochemically, and the apoptotic index was calculated and statistically analyzed. The data collected revealed that the apoptotic index increases in proportion to the level of CO₂ pressure. CO₂ pneumoperitoneum is a very useful technique. Gas pressure must be carefully set during the operation, however, or injured mesothelial cells may cause serious malfunction.     

Laparoscopically assisted suprapubic surgery for adnexal tumors under epidural anesthesia

Objective: To evaluate the feasibility and safety of laparoscopically assisted surgery for benign ovarian tumors via a single suprapubic incision under epidural anesthesia.

Methods: Forty-three patients underwent laparoscopically assisted surgery via a single suprapubic incision under epidural anesthesia. Types of surgery were classified as follows: type I – suprapubic incision surgery without laparoscopic support, type II – suprapubic incision surgery with laparoscopic support but without CO₂ inflation; and type III – suprapubic incision surgery with laparoscopic support and CO₂ inflation.

Results: Type I, II, and III procedures were performed on 16, 21, and six patients, respectively. Most patients (n?=?35) were discharged on postoperative day 1 or 2. No surgical complication was encountered. Types of surgery exhibited different surgical characteristics. Type I was adopted for larger diameter tumors than types II or III (p?=?.016), whereas type III had a longer operative time (p?=?.024) than types I and II. Other characteristics, such as age, body mass index, and length of hospital stay, did not differ significantly among surgical types.

Conclusion: Laparoscopically assisted surgery for adnexal tumors via a single suprapubic incision under epidural anesthesia is feasible and safe, and should be viewed as an alternative approach to conventional minimally invasive surgery.     

Evaluation of the 5-French saline paediatric gastric tonometer

Objective: To evaluate the paediatric 5-French (Fr) saline-filled gastric tonometer. Design: (a) In vitro comparison of saline bath reference pCO₂ with tonometric pCO₂ measured by normal saline-filled and phosphate-buffered saline-filled 5-Fr tonometers, and by a recirculating gas tonometer. ( b) In vivo comparison of gastric intramucosal pCO₂i, measured by normal saline-filled 5-Fr tonometer (NST) and simultaneously by recirculating gas tonometer (RGT) in ten paediatric intensive care patients. (c) In vivo comparison of pCO₂i measured simultaneously by 2 NST 5-Fr tonometers, before and after enteral feeding, in ten paediatric intensive care patients. Measurements and main results: (a) Twenty consecutive measurements of pCO₂ were made at constant reference pCO₂ of 19, 38, 56, and 75 mmHg (2.5, 5.0, 7.5, and 10.0 kPa), respectively. The NST tonometer underestimated reference pCO₂ by mean bias (limits of agreement) of 58 % (20 %), and the phosphate-buffered saline-filled tonometer by 6 % (26 %). The RGT showed mean bias 5.7 % with narrow limits of agreement (1.5 %). (b) In 50 paired (NST vs. RGT) in vivo measurements over pCO₂i range 23–73 mmHg (3.0–9.7 kPa), the NST underestimated RGT pCO₂i by a mean bias of 10 mmHg (1.3 kPa), with limits of agreement + /–10 mmHg (1.5 kPa). This resulted in NST consistently overestimating pHi and underestimating pCO₂ gap (both P < 0.001). (c) One hundred simultaneous paired NST measurements were assessed (50 without, and 50 with enteral feeding). The mean biases (limits of agreement) were identical in the fasted and fed states 0.4 ± 6 mmHg, with no difference between the fed and fasting states (P = 0.7). Conclusions: There are inherent problems in the methodology of saline tonometry, which adversely affect the accuracy and reliability of the 5-Fr paediatric gastric tonometer in comparison to recirculating gas tonometry. Received: 4 October 1999/Final revision received: 20 February 2000/Accepted: 25 February 2000     

Comparative Carbon Dioxide Output Through Injured and Noninjured Peritoneum During Laparoscopic Procedures

Tension pneumoperitoneum may force gas into a small injured vessel if the opening is kept patent by surrounding tissues. However, the amount of carbon dioxide (CO₂) that penetrates through injured or noninjured peritoneum has not been systematically determined. In 25 patients undergoing elective laparoscopic ultrasonography and cholecystectomy, CO₂ output (VCO₂) and O₂ uptake (VO₂) were measured at baseline and during anesthesia, pneumoperitoneum, laparoscopic surgical procedure (Surgery), and after hemostasis of the surgical field (Postsurgery). Before anesthesia,V CO₂/BSA andV O₂/BSA were 97.7 ± 11.3 and 116.0 ± 10.0 mlmin^-1m^-2, respectively. During anesthesia, they fell to 72.3 ± 6.0 and 89.8 ± 7.6 mlmin^-1m^-2 (p < 0.05). VCO₂/BSA increased to 96.0 ± 11.1 at pneumoperitoneum (p < 0.05) and increased further to 126.1 ± 11.0 mlmin^-1m^-2 at Surgery. It fell to 111.7 ± 10.9 mlmin^{-1m -2} Postsurgery. VO₂/BSA remained unchanged during pneumoperitoneum. Minute volume increased from 2.24 ± 0.20 in anesthesia to 2.89 ± 0.25, 4.01 ± 0.32, and 3.46 ± 0.28 Lmin^-1m^-2 during pneumoperitoneum, Surgery, and Postsurgery, respectively, to maintain PaCO₂. We conclude that the amount of CO₂ absorbed following pneumoperitoneum prior to surgery is lower than that during Surgery or Postsurgery. The amount of CO₂ absorbed through the surgical field was 2.3 times higher than that through the nonsurgical field, while that from the peritoneum after hemostasis of surgical field was 1.6 times higher.     

前交叉韧带重建术后感染的早期诊断与治疗

目的 为前交叉韧带重建术后感染的早期诊断和治疗提供依据，以做到早期诊断和治疗，最大限度地保护前交叉韧带的完整性。方法 回顾性分析2016年1月-2021年12月该科室收治的40例前交叉韧带重建术后感染患者（感染组）的临床资料。其中，20例患者使用关节镜下清理术联合载抗生素硫酸钙颗粒关节腔内植入（硫酸钙组），20例患者使用关节镜下清理术联合置管冲洗引流术（置管冲洗组），选取同一时间段正常前交叉韧带重建术后患者40例作为对照组，检测两组患者术后不同时间炎症指标变化；比较感染后，两组（硫酸钙组和置管冲洗组）患者的临床表现和术后1、2和3周炎症指标变化情况，以及术后1、2、3和6周膝关节活动度（ROM）、膝关节Lysholm评分和视觉模拟评分（VAS）。结果 感染组术后3或4 d,C反应蛋白（CRP）、红细胞沉降率（ESR）、降钙素原和白细胞介素-6 (IL-6)均高于对照组，两组比较，差异均有统计学意义（P <0.05），术后10～12 d，感染组CRP、ESR、降钙素原和IL-6明显高于正常情况，对照组CRP、ESR、降钙素原和IL-6均恢复正常，两组比较，差异均有统计学意义（P &...     

A case of carbon dioxide embolism during the transperineal approach in total pelvic exenteration for advanced anorectal cancer

The transanal and transperineal endoscopic approaches are useful advanced surgical options for removing rectal and anorectal cancers. Intraoperative carbon dioxide (CO₂) embolisms, however, have been increasingly reported as potentially fatal complications associated with surgery employing these approaches. We report our experience with a CO₂ embolism that was detected because of a sudden drop in end-tidal CO₂ with decreasing saturation of percutaneous arterial oxygen during total pelvic exenteration using the transperineal endoscopic approach under pneumopelvis/pneumoperitoneum. Transesophageal echocardiography confirmed that it was a CO₂ embolus. We reversed the pneumopelvis and pneumoperitoneum, which alleviated the cardiopulmonary problems, and the surgery then proceeded to achieve R0 resection. The patient was discharged without severe complications other than the CO₂ embolism.     

Dispersal of tumour cells within the peritoneal cavity during laparoscopy

Summary

Disagreement exists about whether laparoscopy results in dispersal of tumour cells during laparoscopic cancer surgery and whether this results in the development of port-site metastases. Recent experimental work suggests that CO₂, but not He, insufflation promotes the development of port-site metastases, suggesting that metabolic or immunological factors might also contribute to this problem. This study investigated whether insufflation results in an initial redistribution of tumour cells; and looked at the contribution of mechanical insufflation factors for the development of port-site metastases. A suspension of radio-labelled cancer cells was introduced into the left upper quadrant of the peritoneal cavity of 17 Dark Agouti rats, which underwent laparoscopy with CO₂ pneumoperitoneum, gasless laparoscopy, or laparotomy. Surgery continued for a further 30 min, after which the rats were killed and the radioactivity present on the peritoneal surface of the anterior and lateral abdominal wall, and the laparoscopy port sites, was determined by scanning standardised samples of the abdominal wall with a y counter. There was less contamination of the abdominal wall from laparotomy than laparoscopy, irrespective of technique. No differences in contamination between the two laparoscopy groups could be demonstrated. Contamination of the port sites was similar except at the site through which the cells were originally introduced, where a greater radioactivity concentration was seen following gasless laparoscopy. This study suggests that it is not the use of gas insufflation during laparoscopy which is responsible for redistribution of tumour cells from a tumour site, but that redistribution is related to some other aspect of the laparoscopic environment. It is possible, when this finding is considered alongside previously reported studies, that a metabolic or immune disturbance, due to other properties of CO₂ insufflation, could cause this problem. This possibility is being investigated further.     

Comparison of the Effect of Laryngeal Mask Airway Versus Endotracheal Tube on Airway Management in Pediatric Patients with Tonsillar Hypertrophy

PurposeThe laryngeal mask airway (LMA) has become an important choice in both routine and difficult airway management. We aimed to evaluate the safety and effectiveness of LMA use in pediatric patients with tonsillar hypertrophy.DesignThis study was a randomized controlled trial.MethodsThe study included 100 pediatric patients who had first or second degree tonsillar hypertrophy. Pediatric patients undergoing elective laparoscopic inguinal hernia repair were randomly divided into two groups (n = 50): LMA group and the endotracheal tube (ETT) group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (P_ETco₂). Data for primary outcomes were collected before and 5-, 15-, and 25-minute after opening pneumoperitoneum, and on closing the pneumoperitoneum. Complications such as laryngospasm, bronchospasm, desaturation, severe coughing, blood on the device after removal, and sore throat were recorded.FindingsA total of 100 pediatric patients were assessed and 97 eligible patients were randomly assigned to receive an LMA (n = 49) or an ETT (n = 48). There was no statistically significant difference in ventilation leak volume and P_ETco₂ between the LMA and ETT groups (P > .05). Compared with T_1-4, peak airway pressure was significantly lower in T₀ (LMA group 12.6 ± 0.9, 95% confidence interval 12.2 to 13.0; ETT group 12.8 ± 1.2, 95% confidence interval 12.2 to 13.3; P < .05). The incidences of laryngospasm 11 (22.9%), desaturation 18 (37.5%), and severe coughing 13 (27%) were higher in the ETT group (11 [22.9%] vs 3 [6.1%], 18 [37.5%] vs 6 [12.2%], 13 [27%] vs 3 [6.1%]; P < .05).ConclusionsThe application of LMA has a lower incidence of complications. LMA as an airway device is effective and perhaps superior in appropriate patients.     

Effect of resistant starch type 2 on inflammatory mediators: A systematic review and meta-analysis of randomized controlled trials

BackgroundInflammation is the main cause in the development of chronic diseases. The enhancement of pro-inflammatory factors, such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hs-CRP) is the main risk factor in chronic diseases. Resistant starch type 2 (RS2) is non-gelatinized granules which their enzymatic hydrolysis is very low. RS2 might be able to reduce inflammatory mediators, therefore; our aim for this study was indicating RS2 effects on inflammatory mediators such as IL-6, TNF-a, and CRP among healthy and unhealthy subjects.MethodsArticles which assessed RS2 effect on IL-6, TNF-α, and hs-CRP were found by advanced search methods. Electronic databases including Google scholar, ISI web of science, SCOPUS, and PubMed, were searched up to October 2019. Treatment effect was the mean difference between changes in serum levels of inflammatory biomarkers in each arm of the clinical trials. To pool the effect of resistant starch on inflammatory biomarkers, we used random effects model.ResultsWe included eight articles in systematic review and meta-analysis. The overall effect illustrated no significant change in serum levels of hs-CRP, IL-6, and TNF-α in intervention group compared with the control group (WMD: -7.18 pg/mL, 95% CI: −27.80, 13.45; P = 0.495, I² = 100.0%, WMD: -0.003 pg/mL, 95% CI: −0.07, 0.06; P = 0.919, I² = 98.1%, WMD: -0.003 pg/mL, 95% CI: −0.004, -0.001; P < 0.0001, I² = 98.0% respectively).ConclusionIn conclusion, we found that RS2 could not reduce inflammatory mediators, but we still need more RCTs with longer intervention duration, higher dose, and studies in different countries.     

Hand-assisted laparoscopic nephrectomy in the pig: Initial report

Summary

We describe the conversion from an open surgical nephrectomy to a manually assisted laparoscopic procedure in the porcine model. A newly devised sleeve allows the surgeon's hand to be used in the abdomen while maintaining a leakage-free pneumoperitoneum. Using one hand for retraction, grasping, blunt dissection and direct tactility whilst using conventional laparoscopic instruments with the other hand, under the guidance of the laparoscope, facilitates a difficult laparoscopic procedure. We performed six manually assisted transperitoneal laparoscopic nephrectomies in pigs with the pneumo-sleeve and compared them with two entirely laparoscopic nephrectomies. The manually assisted procedures took 30-45 min, compared to 90-120 min for the entirely laparoscopic nephrectomies. No complications were seen in either group. We found the manually assisted laparoscopic nephrectomy quick and easy to perform, it has the advantages of both the open and the laparoscopic approach without the disadvantages of these procedures.     

Synergistic effect of high lactase activity genotype and galactose-1-phosphate uridyl transferase (GALT) mutations on idiopathic presenile cataract formation

ObjectivesTo evaluate the possible synergistic role of partial galactose metabolism defects, high lactase (LPH) genotype and lactose and galactose ingestion in presenile cataract formation.Design and methods51 patients with idiopathic presenile cataracts and 172 healthy cataract-free subjects were genotyped to determine their galactose-1-phosphate uridyl transferase (GALT) and LPH status. Whole milk, skimmed milk and yoghurt consumption was recorded in 19 cataract patients and 172 controls by questionnaire.ResultsGALT mutations and whole milk consumption increased the risk of cataract formation in high LPH genotype group, but not in lactose intolerant subjects. Logistic regression analysis showed the synergistic effect of GALT and LPH mutations on cataract formation.ConclusionsHigh lactase activity genotypes and mutations in galactose-1-phosphate uridyl transferase have a synergistic effect on presenile cataract formation.     

压力支持通气在七氟醚麻醉下小儿腹腔镜胆总管囊肿切除术围手术期中的应用价值

目的 探讨压力支持通气(PSV)在七氟醚麻醉下小儿腹腔镜胆总管囊肿切除术围手术期中的应用价值。方法 选取2017年2月-2019年6月该院接受腹腔镜胆总管囊肿切除术的患儿54例,按随机数表法分为研究组(n=27)和对照组(n=27)。两组患儿均于七氟醚麻醉状态下接受腹腔镜胆总管囊肿切除术,术中研究组采取PSV,对照组采取压力控制通气(PCV)。统计两组患儿手术情况、不同时点血流动力学指标、围手术期不良事件和术后并发症发生情况。结果 两组患儿气腹时间、手术时间、动脉血氧分压(PaO₂)和动脉血二氧化碳分压(PaCO₂)比较,差异无统计学意义(P> 0.05),研究组气管导管拔除时间明显短于对照组,差异有统计学意义(P <0.05);两组患儿麻醉诱导前(T1)～术毕即刻(T5)组内心率(HR)及平均动脉压(MAP)比较,差异无统计学意义(F_HR=0.68,P_HR=0.410;F_MAP=0.63,PMAP=0.427),两组间HR和MAP比较,差异无统计学意义(F     

Bladder pressure monitoring and CO<Subscript>2</Subscript> gas-related adverse events during per-oral endoscopic myotomy

Per-oral endoscopic myotomy (POEM) is a minimally invasive treatment for esophageal achalasia. However, POEM has the potential risk of inducing carbon dioxide (CO₂) gas-related adverse events, such as pneumoperitoneum, pneumomediastinum, and pneumothorax. The aim of this study was to evaluate the usability of bladder pressure monitoring as an index of CO₂ gas-related pneumoperitoneum. The monitoring of bladder pressure and lung compliance and the incidence of iatrogenic pneumoperitoneum were retrospectively studied in 20 patients who underwent POEM between June 2013 and March 2015. The bladder pressure was measured using a Foley catheter. Abdominal distention was found in nine patients. The bladder pressure was significantly higher in the nine patients with the distention findings compared with patients without distention [7 (6–9) mmHg vs. 1 (0–2) mmHg; P?<?0.05]; however, the decrease in dynamic lung compliance was not significantly different compared with patients without distention [??7 (??9.3 to ??5.1) vs. ??5 (??10.2 to ??1.3) ml/cmH₂O; P?=?0.62]. Based on postoperative changes on CT scans; the following were the observations: pneumomediastinum (55%), minor pneumothorax (5%), pleural effusion (45%), atelectasis (15%), pneumoperitoneum (85%), and subcutaneous emphysema (15%). No significant clinical status was found among the patients postoperatively. Bladder pressure monitoring might be useful for detecting pneumoperitoneum during POEM.     

Venous haemodynamics during laparoscopic surgery: A cause for concern

Summary. During laparoscopic surgery, intra-abdominal pressure is increased by the pneumoperitoneum. This may impede venous return from the legs and so predispose to venous thrombosis. The aim of this study was to investigate femoral venous velocity and femoral venous diameter during pneumoperitoneum, and to assess the reversibility of this effect by use of an intermittent calf compression device. Fourteen patients undergoing laparoscopic cholecystectomy were studied. A duplex scanner was used to assess femoral venous velocity (both with and without use of a calf compression device), and diameter, before, during and after establishment of a pneumoperitoneum. There was a significant reduction in the femoral venous velocity (from 0.15-0.105 m/s, P<0.01) and a significant increase in femoral venous diameter (from 6.55-9.3 mm, P<0.01) during pneumoperitoneum. The use of a calf compression device reversed this effect (augmented velocity of 0.395 m/s during pneumoperitoneum, P<0.01). These results indicate that laparoscopic surgery affects venous haemodynamics and this effect can be reversed with calf compression devices.     

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery

Abstract

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum.

Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student’s t-test.

Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51?years (range 18–76) and average BMI was 28.1?kg/m² (range 19.0–41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p?=?.01).

Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.