Anesthesia for Laparoscopic Surgery: Anesthetic Management and Complications

Laparoscopic surgery results in physiologic changes that encompass multiple organ systems, with respiratory, cardiovascular and neurologic and splanchnic effects. Insufflation of the peritoneum results in reduced lung volumes, atelectasis, and endobronchial migration of the endotracheal tube. Pneumoperitoneum can result in changes to venous return, cardiac output and blood pressure. Hypercapnia due to carbon dioxide gas used in insufflation can reduce cerebral perfusion pressure. Complications during laparoscopic surgery often occur during port placement and creation of the pneumoperitoneum. Problems include injury to blood vessels during trocar entry, vascular injury in the pneumoperitoneum with limited surgical access, severe bradycardia and arrhythmias due to vagal stimulation from peritoneal stretching, subcutaneous emphysema, pneumothorax, gas embolism, and complications associated with steep Trendelenburg positioning. A thorough understanding of the physiologic changes associated with laparoscopic procedures and recognition of potential complications will facilitate in optimal patient care. This review contains 4 figures, 1 table and 52 references Keywords: Laparoscopy; laparoscopic surgery; carbon dioxide; pneumoperitoneum; capnothorax; general anesthesia; subcutaneous emphysema; insufflation

Radiographic Landmarks for Ideal Port Placement in Wrist Arthroscopy

Background The placement of wrist arthroscopy portals is traditionally performed using distances from anatomic landmarks. We sought to evaluate the safety of traditional portal placement and determine if radiographic landmarks could provide an additional method of identifying tendon intervals. Methods Six cadaveric specimens were used to evaluate the accuracy of portal placement based on anatomic and radiographic landmarks. Fluoroscopic images were used to document the location of previously described surface landmarks. Soft tissue was dissected away to identify the relationship between the transcutaneously placed portals and the extensor tendons. With soft tissue removed, tendon intervals were identified in relationship to anatomic carpal bone landmarks, and interval distances measured. Portals were then placed under radiographic imaging on the final three specimens and accuracy was examined by the removal of overlying soft tissue to confirm accurate interval placement Results The 3,4 portal was safely placed using only surface anatomic landmarks, however the 4,5 and midcarpal ulnar (MCU) portal sites were not consistently placed in the intended tendon interval, especially in larger wrists. Radiographic interval targets for the 3,4 portal were identified at the ulnar aspect of the scaphoid and the 4,5 portal at the ulnar one-third of the lunate. The radiographic site for the MCR was located at the inferior radial one-third of the capitate and the MCU portal was located at the radial aspect of the hamate. The 6R portal radiographic landmark is at the radial aspect of the triquetrum and 6U at the ulnar aspect of the triquetrum. Conclusion Portal placement in wrist arthroscopy based on anatomic landmarks alone can be unreliable in larger wrists. Radiographic imaging based on carpal bone landmarks provides an additional tool for consistent placement of portals in wrist arthroscopy and may limit unintended injury to extensor tendons. Level of Evidence This is a Level VI study.

EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit

Aims Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. Methods Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged <16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. Results Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p < 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478). Conclusions Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.

Robot-assisted pancreatic surgery—optimized operating procedures: set-up, port placement, surgical steps

Even in most complex surgical settings, recent advances in minimal-invasive technologies have made the application of robotic-assisted devices more viable. Due to ever increasing experience and expertise, many large international centers now offer robotic-assisted pancreatic surgery as a preferred alternative. In general however, pancreatic operations are still associated with high morbidity and mortality, while robotic-assisted techniques still require significant learning curves. As a prospective post-marketing trial, we have established optimized operating procedures at our clinic. This manuscript intends to publicize our standardized methodology, including pre-operative preparation, surgical set-up as well as the surgeons’ step-by-step actions when using pancreatic-assisted robotic surgery. This manuscript is based on our institutional experience as a high-volume pancreas operating center. We introduce novel concepts that should standardize, facilitate and economize the surgical steps in all types of robotic-assisted pancreatic surgery. The “One Fits All” principle enables single port placement irrespective of the pancreatic procedure, while the “Reversed 6-to-6 Approach” offers an optimized manual for pancreatic surgeons using the robotic console. Novel and standardized surgical concepts could guide new centers to establish a robust, efficient and safe robotic-assisted pancreatic surgery program.

Laparoscopic Cholecystectomy in Situs Inversus, a Novel Port Placement Technique, Two Case Reports, and Review of Literature

Background: Situs Inversus Totalis (SIT) is a rare and silent autosomal recessive disease in which all organs are on the opposite side. Diagnosis of gallbladder diseases will be difficult due to these anatomical changes. Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases but is technically challenging for patients. Case presentation: Two 52- and 64-year-old women with known SIT who complained of intermittent epigastric pain and nausea after eating fatty and bulky meals were examined. With the help of abdominal ultrasound, a gallbladder on the left side of the abdomen with multiple gallstones was shown. Conclusion: Since the successful primary cholecystectomy was performed on a patient with SIT in 1991, several modifications have been made for port insertion. Surgeons try to overcome technical problems by making various adjustments compared to conventional laparoscopic cholecystectomy. Laparoscopic cholecystectomy in patients with SIT is safe. However, laparoscopic cholecystectomy is challenging due to anatomical changes in the SIT. Our proposed method of port placement helps right-handed surgeons for safer and easier dissection.