Reduction of laparoscopic-induced hypothermia, postoperative pain and recovery room length of stay by pre-conditioning gas with the Insuflow device: a prospective randomized controlled multi-center study.
OBJECTIVE: To assess the efficacy and safety of Insuflow (Georgia BioMedical, Inc.) filter heater hydrator device in reducing the incidence, severity and extent of hypothermia, length of recovery room stay and postoperative pain at the time of laparoscopy. DESIGN: Prospective, randomized, blinded, controlled multi-center study. Patients underwent gynecologic procedures via laparoscopy; surgeons, anesthesiologists and recovery room personnel assessed the results. SETTING: Seven North American institutions. PATIENTS: Seventy-two women for safety evaluation and efficacy studies. INTERVENTIONS: Intraoperative pre-conditioning of laparoscopic gas with the Insuflow device (treatment) or standard raw gas (control) during laparoscopic surgery and postoperatively. MAIN OUTCOME MEASURES: Incidence, severity and extent of hypothermia, postoperative pain perception and length of recovery room stay. RESULTS: The Insuflow group had significantly less intraoperative hypothermia, reduced length of recovery room stay and reduced postoperative pain. Pre-conditioning of laparoscopic gas by filtering heating and hydrating was well tolerated with no adverse effects. The safety profile of the Insuflow pre-conditioned gas showed significant benefits compared to currently used raw gas. CONCLUSIONS: Pre-conditioning laparoscopic gas by filtering heating and hydrating with the Insuflow device was significantly more effective than the currently used standard raw gas and was safe in reducing or eliminating laparoscopic-induced hypothermia, shortening recovery room length of stay and reducing postoperative pain. (+info)
High-pressure trocar insertion technique.
BACKGROUND: The majority of laparoscopic complications occur at the time of Veress needle and trocar insertion. Although not very frequent, they increase the morbidity and mortality of both diagnostic and operative laparoscopic procedures. Alternative techniques of trocar insertion have been described but have not completely eliminated the risk of injury. TECHNIQUE: After Veress needle insertion and establishment of pneumoperitoneum to 25 to 30 mm Hg, insertion of a short trocar is performed in the deepest part of the umbilicus without elevation of the anterior abdominal wall. The result is a parietal peritoneal puncture directly beneath the umbilicus. The high-pressure setting used during initial insertion of the trocar is lowered as soon as safe abdominal entry is documented. EXPERIENCE: The trocar insertion technique described above was performed in 3041 procedures. No vascular injury occurred. There were two bowel perforations. No complications related to the increased intra-abdominal pressure were observed. CONCLUSION: The high-pressure abdominal entry technique has the advantage of reducing intra-abdominal trocar-related injuries without requiring additional instrumentation or additional training. (+info)
Voice-controlled robotic arm in laparoscopic surgery.
AIM: To report on our experience with a voice-directed robotic arm for scope management in different procedures for "solo-surgery" and in complex laparoscopic operations. METHODS: A chip card with orders for the robotic arm is individually manufactured for every user. A surgeon gives order through a microphone and the optic field is thus under direct command of the surgeon. RESULTS: We analyzed 200 cases of laparoscopic procedures (gallbladder, stomach, colon, and hernia repair) done with the robotic arm. In each procedure the robotic arm worked precisely; voice understanding was exact and functioned flawlessly. A hundred "solo-surgery" operations were performed by a single surgeon. Another 96 complex videoscopic procedures were performed by a surgeon and one assistant. In comparison to other surgical procedures, operative time was not prolonged, and the number of used ports remained unchanged. CONCLUSION: Using the robotic arm in some procedures abolishes the need for assist ance. Further benefit accrued by the use of robotic assistance includes greater stability of view, less inadvertent smearing of the lens, and the absence of fatigue. The robotic arm can be used successfully in every operating theater by all surgeons using laparoscopy. (+info)
Total laparoscopic hysterectomy using the harmonic scalpel.
Total laparoscopic hysterectomy (TLH) is the complete hysterectomy including transection of the uterine vessels and opening/closure of the vaginal vault performed laparoscopically. This procedure can be performed as an alternative to total abdominal hysterectomy in many cases. We previously found use of the harmonic scalpel to be extremely helpful in performing laparoscopically assisted vaginal hysterectomies. In this series, the harmonic scalpel was used to facilitate performing TLH. Our experience has shown this can be performed without major complications in a cost-effective manner. (+info)
Randomized trial comparing a radially expandable needle system with cutting trocars.
Sharp trocar insertion for laparoscopic procedures carries with it increased risk for vascular and visceral complications and incisional hernia. In a trial, which randomized 87 patients to treatment with either sharp trocars or a radially expanding needle system with blunt dilator, results showed that with the latter system there was statistically improved patient assessment of pain, a lower complications rate, and shorter procedure time. In the group of patients randomized to treatment with conventional trocars, there were a total of six instrument-related adverse events (6/42): four cases (five incidences) of abdominal wall injuries and one small bowel perforation caused by a Veress needle. Of the 45 patients randomized to the blunt dilator/cannula treatment, there was one adverse event (1/45) that was unrelated to the blunt dilator/cannula system: Veress needle injury to abdominal vasculature. The radially expanding access system demonstrates statistically improved patient postoperative comfort and improved patient safety. (+info)
Needlescopic decapsulation of a splenic epithelial cyst.
As technology advances, the techniques of laparoscopic surgery are being refined and their application is expanding to include many disease processes and organs. The new-generation laparoscopic instruments are becoming smaller (less than 5 mm). Expected advantages include improvements in cosmesis and patient satisfaction, and decreased postoperative analgesic requirements. Non-neoplastic cysts of the spleen are rare, and their management has evolved from total open splenectomy to laparoscopic cyst decapsulation. A 22-year-old woman with a symptomatic 10-cm epithelial cyst was treated by splenic decapsulation with needlescopic instruments (3 mm or smaller). Three trocars were used: one 12-mm umbilical and two 3-mm subcostal ports. The cyst was punctured by a Veress needle, and after drainage of straw-coloured fluid, circumferential decapsulation with 5-mm laparoscopic shears through the umbilical port site was done. The patient was discharged within 24 hours, having had a single intramuscular injection of meperidine and an excellent cosmetic result. (+info)
A laparoscopic approach under local anesthesia for peritoneal dialysis access.
OBJECTIVE: Presented herein is a technical description of a time-proven laparoscopic approach to establishing successful long-term peritoneal dialysis access. DESIGN: Using a two-port technique, the peritoneal catheter is inserted through a paramedian port site while continuously monitoring the implant procedure with a laparoscope from a second port location. A long rectus sheath tunnel created with a nontrocar port device keeps the dialysis catheter oriented toward the pelvis. Helium abdominal insufflation enables full surgical laparoscopy under local anesthesia. Validation of the effectiveness of the technique is made by comparison to previous implantation experience using an open dissection method. PATIENTS: Laparoscopic implantation of peritoneal catheters was performed in 150 patients, and placement by open dissection was accomplished in 63 patients. MAIN OUTCOME MEASURE: The incidence of complications and revision-free catheter survival between implantation methods were compared. RESULTS: Catheters implanted laparoscopically had a significantly lower incidence of flow dysfunction (p < 0.05) and better survival (p < 0.001) than those placed by open dissection. CONCLUSIONS: Compared to implantation by open dissection, the laparoscopic approach provides the patient reduced perioperative discomfort. The procedure can be performed safely with the patient under local anesthesia on an ambulatory basis. Laparoscopic implantation significantly reduces the incidence of catheter flow dysfunction and permits simultaneous identification and correction of other problems that could complicate dialysis therapy. (+info)
Ergonomics: requirements for adjusting the height of laparoscopic operating tables.
BACKGROUND AND OBJECTIVES: In the last few years many new instruments and devices have been developed and introduced into the operating room (OR). A debate has been ongoing about the optimal ergonomic posture for the operating staff. From practical experience, we have learned that the operating tables cannot be adjusted adequately to allow surgeons of different stature to maintain a comfortable posture. The goal of this study was to establish the most ergonomic table height for the particular physique of the surgeon and the different types of laparoscopic instrument handles that he or she uses. METHODS: In a simulated model, two probands of different stature (50th [BS 50] and 95th [BS 95] percentile) used laparoscopic instruments with four different handle designs (shank, pistol, axial, and rod). The instruments were inserted into a board in three different angles ([IA] = 20 degrees, 30 degrees, 40 degrees). Additionally the elbow angles (EA) of the volunteers were fixed to either 90 degrees or 120 degrees. For every variable (size of surgeon and his or her elbow angle, design of handle, insertion angle of the instrument) the height of the board, as a parameter for the level of the abdominal wall of a patient with pneumoperitioneum, was measured from the floor. RESULTS: All parameters had an effect on the optimal operating table height. The lowest required operating table level was 30 cm, the highest was 60.5 cm. In laparoscopic surgery-long shafted instruments and patients with pneumoperitoneum-the tabletops are too high for over 95% of all surgeons. As skin incision and wound suture are performed the conventional way, the operating tabletop must be adjustable up to the common height of 122 cm. The maximal difference between the optimal heights of the OR-table for one volunteer using two different handles with different insertion angles of the instruments (BS 95, EA 90 degrees, IA 20 degrees, rod handle to BS 50, EA 120 degrees, IA 40 degrees, axial handle) was about 27 cm. CONCLUSION: New operating tables with a much lower adjustability are necessary to fulfill ergonomic requirements. The use of differently designed handles can hinder the ergonomic posture of the surgeon, because each handle requires a different working height. (+info)