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.
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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.
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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)
The effects of preperitoneal carbon dioxide insufflation on cardiopulmonary function in pigs.
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BACKGROUND AND OBJECTIVES: Although considerable experimental and clinical knowledge exists on the physiology of pneumoperitoneum, insufflation of the preperitoneal space has not been extensively studied. The purpose of this study is to evaluate the physiology associated with preperitoneal carbon dioxide (CO2) insufflation in a porcine model. METHODS: Eleven pigs weighing 35 to 45 kg were anesthetized and placed on mechanical ventilation. A pulmonary artery catheter and an arterial line were inserted. Balloon dissection of the preperitoneal space and insufflation to 10 mm Hg for 1.5 hours, followed by an increase to 15 mm Hg for an additional 1.5 hours, was performed. Hemodynamic and arterial blood gas values were determined every 15 minutes throughout the stabilization and three-hour insufflation period. Hemodynamic parameters and blood gas values were analyzed using one-way analysis of variance with respect to insufflation time and pressure. RESULTS: Analysis of hemodynamics (CO, CVP, PAD, PAS, PCWP) did not demonstrate statistical significance with respect to time. However, there was a statistical difference in CO (p=.01), CVP (p<.01), and PCWP (p=.034) when comparing a pressure of 15 mm Hg to a pressure of 10 or 0 mm Hg. The other parameters did not demonstrate significant differences among the three pressure groups. Arterial PCO2 and pH were highly significant with respect to time (p<.01 and P<.01, respectively) and among the pressure groups (p<.01 and P<.01, respectively). CONCLUSIONS: Insufflation of the preperitoneal space with CO2 gas does not cause significant alterations in hemodynamics and blood gas changes at a pressure of 10 mm Hg. However, when a pressure of 15 mm Hg is used to insufflate this space, there is evidence of decreased pH and cardiac output, with elevated CVP and CO2 retention. This correlates with greater pneumodissection of the gas within the layers of the abdominal wall when elevated pressures are used. (+info)
Carcinoid of the appendix during laparoscopic cholecystectomy: unexpected benefits.
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Carcinoid tumors of the midgut arise from the distal duodenum, jejunum, ileum, appendix, ascending and right transverse colon. The appendix and terminal ileum are the most common location. The majority of carcinoid tumors originate from neuroendocrine cells along the gastrointestinal tract, but they are also found in the lung, ovary, and biliary tracts. We report the first case of elective laparoscopic cholecystectomy in which we found a suspicious lesion at the tip of the appendix and proceeded to perform a laparoscopic appendectomy. The lesion revealed a carcinoid tumor of the appendix. (+info)
Changes in plasma potassium concentration during carbon dioxide pneumoperitoneum.
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Hyperkalaemia with ECG changes had been noted during prolonged carbon dioxide pneumoperitoneum in pigs. We have compared plasma potassium concentrations during surgery in 11 patients allocated randomly to undergo either laparoscopic or open appendectomy and in another 17 patients allocated randomly to either carbon dioxide pneumoperitoneum or abdominal wall lifting for laparoscopic colectomy. Despite an increasing metabolic acidosis, prolonged carbon dioxide pneumoperitoneum resulted in only a slight increase in plasma potassium concentrations, which was both statistically and clinically insignificant. Thus hyperkalaemia is unlikely to develop in patients with normal renal function undergoing carbon dioxide pneumoperitoneum for laparoscopic surgery. (+info)
The mouse as a model to study adhesion formation following endoscopic surgery: a preliminary report.
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Our aim was to investigate the feasibility of a mouse model to study adhesion formation following endoscopic surgery. Following preliminary studies to establish anaesthesia and pneumoperitoneum pressure, a prospective randomized study was carried out to investigate the effect of CO2 pneumoperitoneum on postoperative adhesions. In group I (control group), the duration of pneumoperitoneum was shorter than 5 min. In groups II, III and IV, pneumoperitoneum was maintained for 60 min without flow, with a continuous low flow (1 ml/min) and a continuous high flow (10 ml/min) through the abdominal cavities of the mice using non-humidified CO2, respectively. Adhesions were scored after 7 days by laparotomy. The total adhesion scores were 0.9 +/- 0.8 (n = 15) in control group, 2.4 +/- 0.8 (n = 15) (P < 0.001 versus control group) in group II with no flow, 2.6 +/- 1.3 (n = 15) (P < 0.001 versus control group) in group III with a continuous low flow and 4.3 +/- 0.9 (n = 15) (P < 0.001 versus control group and P < 0.001 versus group II and III) in group IV with a continuous high flow. In conclusion, the mouse can be used as a model to study adhesion formation following endoscopic surgery. Duration of CO2 pneumoperitoneum is a co-factor in adhesion formation. (+info)
Transfundal insertion of a Veress needle in laparoscopy of obese subjects: a practical alternative.
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Because induction of artificial pneumoperitoneum through the infra-umbilical route is associated with complications in laparoscopic procedures, especially in obese patients, we performed a prospective randomized study comparing the conventional infra-umbilical route with a transfundal route, in which the Veress needle is inserted into the peritoneal cavity through the uterine fundus. One hundred obese subjects (body mass index >/=25 kg/m(2)) scheduled for laparoscopic sterilization were randomized into two groups. In the infra-umbilical group pneumoperitoneum was achieved at a ratio (punctures/pneumoperitoneum) of 56/49 (1.14). There was one failure in this group. In the transfundal group the ratio was 53/51 (1.04). There was no clinically significant bleeding in either of the groups; nor were there any major complications. One subject in whom the infra-umbilical route failed was moved to the transfundal group. This subject also underwent dilatation and curettage at the time of laparoscopy. Postoperatively she contracted chlamydial pelvic inflammatory disease. No other infections were detected postoperatively in either of the groups. In conclusion, the transfundal route of inducing artificial pneumoperitoneum proved to be easy, safe and effective. (+info)
Anesthetic implications of laparoscopic surgery.
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Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease. (+info)