Lesión esplénica accidental en cirugía ginecológica laparoscópica asociada con la técnica de entrada. Reporte de un caso y revisión bibliográfica / Incidental splenic injury during laparoscopic gynecological surgery associated with the entry technique. A case report and literature review

Resumen: ANTECEDENTES: Las lesiones accidentales del bazo durante la cirugía laparoscópica ginecológica son complicaciones raras, con gran repercusión en la morbilidad y mortalidad perioperatoria. La cirugía laparoscópica mediante compresión asistida y administración de hemostáticos es una opción viable en pacientes con lesiones esplénicas derivadas del acceso de los trocares. CASO CLÍNICO: Paciente de 48 años, con síndrome anémico secundario a trastornos (hipermenorrea y metrorragias) menstruales de seis meses de evolución, atendida en el departamento de Ginecología del Hospital General Dr. Manuel Gea González donde se clasificó con P0A0L1M0-C0O1E1I0N0 (FIGO 2011). Se decidió la histerectomía laparoscópica con salpingooforectomía bilateral. Durante el procedimiento quirúrgico tuvo sangrado activo, dependiente de la pared esplénica. Se ejerció compresión del sitio sangrante y se aplicó Surgicel® (producto hemostático absorbible-Ethicon), con adecuada hemostasia. La paciente evolucionó satisfactoriamente y fue dada de alta sin contratiempos. CONCLUSIÓN: Existen pocos reportes de lesiones esplénicas accidentales en cirugía ginecológica laparoscópica. La parte más peligrosa es la introducción de la aguja de Veress y del trócar, que pueden provocar lesiones viscerales o a vasos sanguíneos. Las pacientes con lesiones esplénicas accidentales deben ser tratadas por un equipo multidisciplinario.

Abstract: BACKGROUND: Incidental spleen injuries during gynecological laparoscopic surgery are rare complications that have a major impact on perioperative morbidity and mortality. Laparoscopic management through assisted compression and haemostatic products has been a recommended option in patients who have splenic lesions secondary to the path of laparoscopic trocars. CLINICAL CASE: 48-year-old patient with anemic syndrome secondary to 6-month-old menstrual disorders. It is protocolized in the Department of Gynecology of the Hospital Dr. Manuel Gea González where it is classified P0A0L1M0 - C0O1E1I0N0 (FIGO 2011). It is proposed for laparoscopic hysterectomy with bilateral salpingophrectomia. In the surgical act there is active bleeding dependent on splenic wall. It is compressed from the bleeding site and Surgicel® (absorbable hemostatic product - Ethicon) is applied, presenting hemostasis. The patient evolved successfully and left without incident. CONCLUSION: There are few documented reports of incidental splenic injuries in laparoscopic gynecological surgery. The most dangerous part of laparoscopy is the introduction of the Veress needle and the trocar, where visceral lesions or blood vessels may occur. Timely diagnosis of these complications is important for proper treatment. Incidental splenic injuries should be treated by a multidisciplinary team.

Effect of Nutrition Intervention on Macronutrient and Micronutrient Intake in a Group of Sleeve Gastrectomy Patients

There are several approaches to treat obesity including surgery in case of morbid obesity. The number of bariatric surgery patients has increased in Jordan, but in most cases there is a lack of proper nutrition intervention, monitoring, and follow up of patients. Our aim in this study was to assess the intakes of energy, macronutrients and certain micronutrients after 3 and 6 months post-operatively. Methods: A conventional sample of 50 patients from Jordan University Hospital participated in the study; 25 in the intervention group, and 25 in the control group. The intervention group patients were counseled regarding the use of an adequate low caloric balanced diet, post-operatively. Dietary assessment based on 3-day food intakes was carried out among all the participants before surgery and 3 and 6 months post-operatively. Results: There were no significant differences between the control and the intervention groups in the intakes of macronutrients and selected micronutrients (calcium, iron, zinc, B12 and folic acid) after 3 months postoperatively. However, there were significant increases (P< 0.05) in the intakes of protein, iron, zinc, and folate in the intervention group compared with the control group after 6 months post-operatively. Conclusion: Nutrition intervention enhanced the intake of some nutrients, especially protein intake.

Valuability of Propofol as Anesthetics and Effect of Hypercarbia on Awakening after Propofol TCI during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: It used to induce hypercarbia that carbon dioxide insufflated into the peritoneum in laparoscopic surgery. It might stimulate sympathetic nervous system, and decrease splanchnic circulation, hepatic function, and metabolism of anesthetics. The purpose of the present study was to examine the influence of hypercarbia on concentrations of propofol at the time of eye opening and recovery of orientation after propofol target controlled infusion (TCI) during a laparoscopic cholecystectomy. METHODS: Fifty patients were divided randomly into a laparoscopic group (group 1, n = 25) and an exploratory group (group 2, n = 25). A propofol infusion was started at a propofol target concentration of 6microgram/ml, and anesthesia was maintained at 4microgram/ml by using a Diprifusor (TM) turing the operation, intraabdominal pressure was maintained automatically at 12 14 mmHg by a CO2 insufflator and controlled ventilation settings were adjusted about 50 mmHg of PaCO2 after peritoneal insufflation. This ventilatory setting was not changed throughout the operation. We evaluated the estimated plasma concentrations of propofol at the time of eye opening and recovery of orientation in each group using user interface of a Diprifusor (TM). RESULTS: In the laparoscopic group, PaCO2, and PetCO2 increased significantly at 5, 15, 30 minutes after carbon dioxide insufflation, but there was no significant difference in concentrations of propofol at eye opening and orientation after propofol TCI between the two groups. CONCLUSIONS: Hypercarbia induced by insufflation of carbon dioxide into peritoneum didn't give rise to an influence on awakening concentrations after propofol TCI during a laparoscopic cholecystectomy.

Changes in Respiratory Compliance and Peak Airway Pressure during a Laparoscopic Cholecystectomy in the Elderly / 대한마취과학회지

BACKGROUND: The advantage of a laparoscopic cholecystectomy has led to a trend toward performing it in the elderly. It is well recognised that this can cause changes in respiratory mechanics. However, few studies have measured the effects of abdominal insufflation with CO2 in the elderly. This study was done to evaluate changes in respiratory compliance and peak airway pressure during a laparoscopic cholecystectomy. METHODS: Thirty patients undergoing a laparoscopic cholecystectomy were divided into two groups; aged 65 years or more (elderly group) and under 60 years (control group). A pneumoperitoneum up to an intraabdominal pressure of 12 mmHg was created with CO2 insufflation. Respiratory and peak airway pressure were measured with a continuous spirometry. Measurements were obtained pre-insufflation, just after CO2 insufflation, at 15, 30, 45 and 60 minutes and after abdominal deflation. RESULTS: In both groups, respiratory compliance decreased significantly (P < 0.05) and equally by about 40% after CO2 insufflation. The decrement continued during the pneumoperitoneum, the changes were not significant between the groups. Each group showed an equal improvement immediately after abdominal deflation. No differences between the peak airway pressure during a laparoscopic cholecystectomy was seen in either group. CONCLUSIONS: We have demonstrated that during a laparoscopic cholecystectomy in the elderly the respiratory compliance decreased and peak airway pressure significantly increased as in the control group.

The Effects of Intraperitoneal CO2 Insufflation and/or Reversed Trendelenburg Position on Airway Pressure and Compliance / 대한마취과학회지

BACKGROUND: We studied the effects of intraperitoneal CO2 insufflation and/or the reversed Trendelenburg position on airway pressure and compliance of the total respiratory system. METHODS: We selected and randomly allocated eighty adults to a control group C or laparoscopy group L. Without premedication, propofol and vecuronium were injected for anesthesia. In the supine position we checked peak and plateau airway pressures, and calculated the dynamic and static compliance of the total respiratory system. We only used 10o reverse Trendelenburg position in group C, and used both 10o reverse Trendelenburg position and abdominal CO2 insufflation in group L. Afterwards, we checked airway pressure and compliance and compared them between groups. RESULTS: In group C, there was no change in airway pressure and compliance. But in group L, peak airway pressure (13.9 +/- 2.4 vs 21.0 +/- 3.3 cmH2O) and plateau airway pressure (11.7 +/- 2.1 vs 18.9 +/- 3.2 cmH2O) were increased and dynamic compliance (47.7 +/- 9.1 vs 30.6 +/- 5.9 ml/cmH2O) and static compliance (58.4 +/- 12.4 vs 13.1 +/- 7.3 ml/cmH2O) of the total respiratory system were decreased. CONCLUSION: In a laparoscopic cholecystectomy, intraabdominal insufflation of CO2 raises airway pressure and reduces compliance of the total respiratory system. Reverse Trendelenburg position itself does not affect airway pressure and compliance.

The Effect of Anesthetic Technique on White Blood Cell Response to Surgery in Patients Who Underwent Laparoscopic Cholecystectomy and Cesarian Section / 대한마취과학회지

BACKGROUND: Surgical stress causes changes in the composition of white blood cells in peripheral blood. In addition, anesthesia itself has been suggested to have an immunosuppressive effect. Therefore, the aim of the present study was to investigate the effect of anesthetic technique on the changes of postoperative peripheral white blood cell (WBC) subsets in laparoscopic cholecystectomy patients and cesarian section patients. METHODS: We reviewed 100 patients who had laparoscopic cholecystectomy under conventional general anesthesia or propofol infusion. Each group contained 50 patients equally. We also reviewed 100 patients who had cesarian section under spinal and epidural anesthesia, 50 patients in each group, respectively. The changes of total WBC, lymphocytes, neutrophils and monocytes at 24 h and 48 h postoperatively were compared to baseline values within the groups and these values were compared between the groups. RESULTS: There were significant increases in total WBC and neutrophils, decreases in lymphocytes, no changes in monocytes at 24 h after surgery compared to baseline values for the groups receiving laparoscopic cholecystectomy. No differences were found between the two laparoscopic cholecystectomy groups. Cesarian section patients showed significant differences in total WBC, neutrophils, lymphocytes and monocytes at 48 h after surgery compared to baseline values for the groups. There were no significant differences between the groups. CONCLUSIONS: Neither laparoscopic cholecystectomy nor cesarian section showed significant differences in WBC subsets after surgery according to anesthetic technique.

Comparison of the Effects of Propofol and Isoflurane Anesthesia on Respiratory Gas Exchange during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Introduction of a pneumoperitoneum using CO2 is accompanied by significant alterations in respiratory function and pulmonary gas exchange during laparoscopic cholecystectomy. Previous studies have shown differing results concerning pulmonary gas exchange: a significant decrease of PaO2 was induced with isoflurane. In contrast, no significant changes were observed with propofol. The purpose of the present study was to compare the effects of propofol vs isoflurane on pulmonary gas exchange during general anesthesia for laparoscopic cholecystectomy. METHODS: Forty patients were divided randomly between isoflurane and propofol groups. After induction of anesthesia, ventilation was controlled and intra-abdominal pressure was maintained automatically at 12 mmHg by a CO2 insufflator. After the measuring of baseline values of blood pressure, heart rate, PaO2, PaCO2 and PetCO2 before CO2 insufflation, measurements were also made immediately, 30min after CO2 insufflation and 5 min after CO2 exsufflation. RESULTS: In the isoflurane group, PaCO2, PetCO2, PaO2, and P(a-et)CO2 changed significantly 30 min after CO2 insufflation and 5 min after CO2 exsufflation (P < 0.05). In the propofol group, PaCO2 and PetCO2 increased significantly 30 min after CO2 insufflation and 5 min after CO2 exsufflation (P < 0.05), but PaO2 and P(a-et)CO2 remained constant. When the two groups were compared, there were significant differences in PaO2, PaCO2, PetCO2 and P(a-et)CO2 at 30min after CO2 insufflation and 5 min after CO2 exsufflation (P < 0.05). CONCLUSIONS: These results indicate that during laparoscopic cholecystectomy the PaO2 was significantly lower and PaCO2 and P(a-et)CO2 were significantly higher in the isoflurane group compared with the propofol group.

VD/VT and Arterial Blood Gas Changes during Gynecologic Laparoscopic Surgery under Enflurane or Propofol Anesthesia / 대한마취과학회지

BACKGROUND: Laparoscopic gynecologic surgery is a standard procedure today for its small skin incision and short hospital admission stay. However pneumoperitoneum (PP) and Trendelenberg position induce adverse effects in hemodynamics and pulmonary gas exchange. The purpose of this study is to evaluate the effects of propofol compared with enflurane for pulmonary gas exchange in the Trendelenberg position and pneumoperitoneum. METHODS: Twenty women were randomly allocated to either the enflurane (n = 10) or propofol (n = 10) with fentanyl-N2O/O2 anesthesia. PaCO2, PaO2, PETCO2 were checked at pre-PP, 10 min after PP, 30 min after PP, and 10 min after CO2 deflation. In addition the Vd/Vt ratio was calculated according to the Bohr equation. Vital sign and peak airway pressure were checked at each stage. RESULTS: PaCO2 and PETCO2 increased and PaO2 decreased significantly during PP in both groups. Vd/Vt increased significantly in the enflurane group at 30 min after PP. Peak airway pressure increased significantly in both groups. Blood preassure and heart rate were not changed significantly. All of the parameters were not significantly different between groups. CONCLSIONS: Propofol compared with enflurane did not show any advantage in gas exchange during gynecologic laparoscopic surgery under Trendelenberg position and PP.

Anesthetic Management of Laparoscopic Surgery in Infant with Congenital Megacolon: A case report / 대한마취과학회지

Many benefits are reported after laparoscopy. As experience, equipment, and techniques have improved, minimally invasive laparoscopic surgery is being applied to younger children. With the advent of this new surgical approach, specific modifications become necessary in anesthetic techniques. During laparoscopy, the pneumoperitoneum performed by peritoneal insufflation of CO2 may induce intraoperative ventilatory and hemodynamic changes that complicate anesthetic management. We present a case of laparoscopic Duhamel operation in a 10-month-old infant weighing 10 kg. After induction with thiopental sodium and vecuronium, anesthesia was maintained with enflurane and 50% nitrous oxide in oxygen. Rapid hypercarbia developed about 5 minutes after introduction of pneumoperitonium, so we gave intermittent manual hyperventilation to avoid hypercarbia untill we finished the surgery. In children, CO2 absorption may be more efficient due to the physiological properties of the immature peritoneum. The functional residual capacity (FRC) is low in children. During laparoscopy, FRC is decreased further due to a variety of factors. In spite of the changes in FRC, arterial oxygenation has not been shown to deteriorate in normal infants. In our case, the changes in end-tidal CO2 tension (PETCO2) during laparoscopy did not influence the hemodynamic change. But insufflation of CO2 induced a significant increase in PETCO2, and produced a fast reaction time of PETCO2.

The Effect of 0.5% Bupivacaine Instillation for the Postoperative Pain after Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Although post operative pain has been reduced significantly since the advent of laparoscopic surgery, many patients still complain of moderate abdominal and shoulder pain after surgery. METHOD: Patients scheduled for elective laparoscopic cholecystectomy were assigned to three groups by simple randomization(12 patients per group). Group I patients(control) had no specific treatment, group II patients had 10 ml of normal saline instillation, and group III patients had 10 ml of 0.5% bupivacaine instillation. Instillation was made directly into the gallbladder bed and right subdiaphragmatic space under direct vision by the surgeon at the end of the procedure and before evacuating the pneumoperitoneum. RESULT: Compared to that of the group I, VAS of group II and III did not show any statistically significant difference. Compared to the group I, group II & III showed no significant difference in numbers of requests of Tiaprofenic acid during the 36hours after the surgery. CONCLUSION: Topical instillation of 0.5% bupivacaine 10 ml to the gallbladder bed and right subdiaphragmatic space after laparoscopic cholecystectomy is not effective for the post operative pain control.

The Topical Intraperitoneal Anesthesia of 0.5% Bupivacaine Before Laparoscopic Cholecystectomy is Effective on the Postoperative Pain Control / 대한마취과학회지

BACKGROUND: Recently, laparoscopic cholecystectomy becomes more favorite method than traditional open cholecystectomy. But postoperative pain control is still remaining problem. METHOD: Patients scheduled for elective laparoscopic cholecystectomy were assigned to two groups by simple randomization (15 patients per group). Group C (control) had no specific treatment and group B (bupivacaine) received 20 ml of 0.5% bupivacaine with epinephrine 1:200,000 before surgery. Immediately after the creation of a pneumoperitoneum, the surgeon sprayed the bupivacaine near and above the operation field. Operation was started 10 minutes after then. We attempted to investigate that the degree of postoperative pain which was assessed using the visual analogue scale (VAS) and the verbal rating scale (VRS) in the recovery room at postoperative 1 h., as well as the analgesic requirements during the first 24 h. postoperatively. RESULT: VRS of group B was significantly lower than group C (p<0.05), but VAS was not significantly different. Six patients in group B and only one in group C requested no analgesics. Group C had statistically more frequent request for analgesics than group B (p<0.05). CONCLUSION: The topical intraperitoneal anesthesia of 20 ml of 0.5% bupivacaine with epinephrine 1 : 200,000 before laparoscopic cholecystectomy is effective on the postoperative pain control. So, we recommmend that this simple and effective management is routinely treated in patients undergoing laparoscopic cholecystectomy.

Subcutaneous Emphysema and Hypercarbia Following Laparoscopic Cholecystectomy by Increased Intraabdominal Pressure: A case report / 대한마취과학회지

Subcutaneous emphysema is a complication of the pneumoperitoneum necessary to perform laparoscopy and will be seen more often as laparoscopic techniques are applied to a growing number of intraabdominal procedures. We report a case of subcutaneous emphysema and hypercarbia without pneumothorax or pneumomediastinum during laparoscopic cholecystectomy, which was treated by multiple puncture with 18G needle on emphysematous site. The suspected cause is inadvertent subcutaneous insufflation of carbon dioxide through the trocar sites by increased intra-abdominal pressure for the establishment of pneumoperitoneum. Immediate recognition, evaluation, and treatment of subcutaneous emphysema is necessary since this can be life-threatening complication.

Effects of Clonidine on Blood pressure and Heart rate, and Anesthetic Requirement During Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy has become popular in the recent year. However, CO2 insufflation and patient's position changes during laparoscopic surgery can create severe hemodynamic changes, and increase anesthetic requirement. The major aim of this study is to assess the effect of oral clonidine on the cardiovascular lability during the operative and post-operative periods and enflurane requirement during operative period. METHODS: 43 patients(ASA I or II) undergoing elective laparoscopic cholecystectomy were selected for this study. The patients were randomly allocated into 3 groups: group 1(n=14) received no clonidine, group 2(n=15) 0.2 mg of clonidine and group 3(n=14) 0.3 mg of clonidine. Blood pressure and heart rate were continuously monitored during both the operative and post-operative periods. The enflurane concentration was also continuously adjusted to maintain blood pressure and heart rate within the range of 20% changes of baseline values. RESULTS: Since enflurane concentration was controlled to maintain systolic blood pressure within 20% of baseline values, there was no statistically significant difference in vital signs in the three groups during anesthesia. However, vital signs including systolic and diastolic blood pressure during their time in PACU (post anesthesia care unit) between the control and the clonidine treated groups were significantly different. The results of the blood pressure for the groups were found as follows. group 1) 134.9 +/-22.3 mmHg and 77.1 +/-12.4 mmHg, group 2) 116.8 +/-11.1 mmHg and 68.9 +/-12.2 mmHg and group 3) 113+/- 9.2 mmHg and 65.9+/- 9.2 mmHg for systolic and diastolic blood pressure respectively. Also, both the clonidine 0.2 mg and 0.3 mg treated groups, showed significantly decreased anesthetic requirement compared with the control group (P<0.05). There were dose dependent changes between 0.2 mg and 0.3 mg clonidine pretreated groups. CONCLUSIONS: Preoperative clonidine administration was effective in decreasing anesthetic supplement during laparoscopic cholecystectomy, and lessening the severity of hemodynamic changes during PACU.

Changes in Airway Pressure, Blood Gas and Postoperative Emesis of 50% N2O in Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: The use of laparoscopic techniques in general surgery has gained increasing popularity. The small, limited incisions are well accepted by patients and there is the benefit of a faster recovery. But the contribution of N2O to nausea and vomiting is still controversial. This study was undertaken to evaluate the effect of N2O for airway pressure, blood gas and postoperative emesis in laparoscopic cholecystectomy. METHODS: Twenty ASA physical status I, II patients for elective laparoscopic cholecystectomy were randomly divided into two groups. First group (n=10) of patients was anesthetized with isoflurane(0.5~1.5 vol%)-O2 (2 l/min)-air (2 l/min). Second group (n=10) of patients was anesthetized with isoflurane (0.5~1.5 vol %)-O2 (2 l/min)-N2O(2 l/min). After induction of anesthesia, ventilation was controlled with tidal volume 10 ml/kg and respiratory rate 11/min and not changed throughout the operation. After measuring of control value of PaCO2, pH and airway pressures before CO2 insufflation, repeatedly measured at 20 min, 40 min after CO2 insufflation and 10 min after CO2 exsufflation. We observed the patients concerning nausea and vomiting for postoperative period. RESULTS: There were no significant intraoperative differences between the both groups with respect to PaCO2, pH and airway pressures. In the both groups, PaCO2 and airway pressure throughout the operation are significantly increased in comparison to control values. The pH is significantly decreased in comparison to control values. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSIONS: N2O had no clinically apparent effects on airway pressure, blood gas and postoperation emesis during laparoscopic cholecystectomy.