Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

Abstract Background Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. Methods Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. Results Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p= 0.55). Conclusion This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Effect of Pneumoperitoneum on Oxidative Stress and Inflammation via the Arginase Pathway in Rats

PURPOSE: Oxidative stress during CO2 pneumoperitoneum is reported to be associated with decreased bioactivity of nitric oxide (NO). However, the changes in endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and arginase during CO2 pneumoperitoneum have not been elucidated. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats were randomized into three groups. After anesthesia induction, the abdominal cavities of the rats of groups intra-abdominal pressure (IAP)-10 and IAP-20 were insufflated with CO2 at pressures of 10 mm Hg and 20 mm Hg, respectively, for 2 hours. The rats of group IAP-0 were not insufflated. After deflation, plasma NO was measured, while protein expression levels and activity of eNOS, iNOS, arginase (Arg) I, and Arg II were analyzed with aorta and lung tissue samples. RESULTS: Plasma nitrite concentration and eNOS expression were significantly suppressed in groups IAP-10 and IAP-20 compared to IAP-0. While expression of iNOS and Arg I were comparable between the three groups, Arg II expression was significantly greater in group IAP-20 than in group IAP-0. Activity of eNOS was significantly lower in groups IAP-10 and IAP-20 than in group IAP-0, while iNOS activity was significantly greater in group IAP-20 than in groups IAP-0 and IAP-10. Arginase activity was significantly greater in group IAP-20 than in groups IAP-0 and IAP-10. CONCLUSION: The activity of eNOS decreases during CO2 pneumoperitoneum, while iNOS activity is significantly increased, a change that contributes to increased oxidative stress and inflammation. Moreover, arginase expression and activity is increased during CO2 pneumoperitoneum, which seems to act inversely to the NO system.

A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma / 대한간학회지

An 80-year-old woman with hilar cholangiocarcinoma was hospitalized due to sudden-onset abdominal pain. Computed tomography revealed hepatic necrosis accompanied with emphysematous change in the superior segment of the right liver (S7/S8), implying spontaneous rupture, based on the presence of perihepatic free air. Although urgent percutaneous drainage was performed, neither pus nor fluids were drained. These findings suggest emphysematous hepatitis with a hepatic mass. Despite the application of intensive care, the patient's condition deteriorated rapidly, and she died 3 days after admission to hospital. Liver gas has been reported in some clinical diseases (e.g., liver abscess) to be caused by gas-forming organisms; however, emphysematous hepatitis simulating emphysematous pyelonephritis is very rare. The case reported here was of fatal emphysematous hepatitis in a patient with hilar cholangiocarcinoma.

A Case of Recurrent Pneumatosis Cystoides Intestinalis Associated with Recurrent Pneumoperitoneum / 대한소화기학회지

Pneumatosis cystoides intestinalis is an uncommon condition of unknown etiology, characterized by the presence of multiple gas filled cysts in the gastrointestinal tract. Many different causes of pneumatosis cystoides intestinalis have been proposed, including mechanical, pulmonary, and bacterial causes. Approximately 85% of cases are thought to be secondary to coexisting disorders of the gastrointestinal tract or the respiratory system. The condition has been associated with the therapeutic uses of lactulose, steroids, and various cancer chemotherapeutic regimens. Lactitol is a disaccharide analogue of lactulose which is available as a pure crystalline powder. There are three previous case reports suggestive of lactulose causing pnumatosis intestinalis. We report a case of recurrent pneumatosis cystoides intestinalis associated with benign recurrent pneumoperitoneum developed probably secondary to lactitol therapy.

Disseminação de células tumorais induzida pelo pneumoperitônio nos portais das operações laparoscópicas e na parede abdominal: modelo experimental em hamster / Effects of pneumoperitoneum pressure on the dissemination of tumor cells and tumor recurrence at the port site and midline incisions: experimental model in hamster

Racional - Existe muita controvérsia científica quanto ao poder da pressão pelo pneumoperitônio na disseminação de células tumorais, quer para os portais de acesso nas operações laparoscópicas, quer na do próprio peritônio parietal e/ou visceral. Objetivo - Avaliar a relação entre contaminação do trocarte com células tumorais, aerolização de células tumorais, e implante tumoral em feridas da parede abdominal com o aumento da pressão intra-abdominal durante uma intervenção cirúrgica por via laparoscópica. Material e Método - Sessenta hamsters foram submetidos à laparotomia com posicionamento de dois trocártes de 5 mm no abdomen, seguidos da instilação de células de adenocarcinoma humano na cavidade abdominal. Os animais foram divididos em 3 grupos, de acordo com o nível de pressão intra-abdominal: 10,5 e 0 mmHg. O gaz intra-abdominal era liberado da cavidade abdominal através de um filtro localizado no trocarte direito para identificação de células tumorais aerolizadas. Os trocártes, após o término da operação, eram lavados em solução salina, para identificação de células tumorais. Os animais foram sacrificados após 15 dias, realizando-se estudo histopatológico das feridas abdominais. Resultados - A elevação da pressão intra-abdominal aumentou significativamente a contaminação instrumental e o implante tumoral nas feridas abdominais. O nível de pressão intra-abdominal não teve efeito no número de células tumorais aerolizadas. Conclusão - O aumento da pressão do processo perioperatório aumenta a implantação de células tumorais. Abordagem laparoscópica com baixa pressão intra-abdominal diminui a possibilidade de implantes tumorais.

Pneumatic colonic rupture accompanied by tension pneumoperitoneum

Rupture of the colon caused by high pressure compressed air is a rare, unique and traumatic intra-abdominal injury. As the use of compressed air in industrial work has increased, so has the risk of associated pneumatic injuries from its improper use. Recently we experienced a case of pneumatic rupture of the sigmoid colon accompanied by tension pneumoperitoneum, which caused respiratory distress. The patient's respiration was very rapid with the rate of 44 breaths per minute. On arterial blood gas analysis, pH was 7.40, pO2 68 mmHg, pCO2 44 mmHg, and SaO2 90%. Chest X-ray film showed marked pneumoperitoneum and an elevated diaphragm. The respiratory distress was severe and required immediate relief by emergency decompression peritoneocentesis before surgical intervention consisting of the serosal tear repair, colonic rupture colostomy and abdominal cavity irrigation. A follow up operation 2 months later for colostomy repair completed the patient's recovery.

Pneumoperitônio näo-cirúrgico: relato de caso / Pneumoperitoneum not-surgery: case study

Este relato diz respeito a um caso de pneumoperitônio näo-cirúrgico que teve resoluçäo espontânea (tratamento conservador). Apresenta-se, também, uma revisäo da literatura sobre o assunto, salientando-se a importância da história clínica e da acuracidade diagnóstica, a fim de se evitar uma abordagem cirúrgica desnecessária.

Repercussões do pneumoperitônio sobre o sistema venoso dos membros inferiores - estudo em porcas / The effect of pneumoperitoneum in the blood circulation of the lower limbs-a swine model

A trombose venosa profunda e a embolia pulmonar são complicações dos atos cirúrgicos nem sempre diagnosticadas. Nas operações pela via laparoscópica, a insuflação do CO2 na cavidade peritoneal é provavelmente a principal determinante da estase venosa nos membros inferiores. Este trabalho foi realizado com a finalidade de determinar a influência do pneumoperitônio na dinâmica circulatória dos membros inferiores. Distribuíram-se trinta porcas em três grupos: sem pneumoperitônio, com pneumoperitônio de 10mmHg e de 15mmHg de pressão intra-abdominal. Foram medidas a frequência e débito cardíacos, pressão arterial média, pressão e diâmetro da artéria e veia femorais, velocidade do fluxo arterial e venoso femorais. Após a realização do pneumoperitônio foi encontrado aumento significativo na pressão e no diâmetro da veia femoral e diminuição significativa na velocidade do fluxo venoso femoral. A elevação da pressão venosa femoral e a diminuição da velocidade do fluxo venoso femoral foram mais intensas com o aumento da pressão intra-abdominal. Todos os parâmetros analisados retornaram aos valores iniciais após o esvaziamento do pneumoperitônio

Hernioplastía laparoscópica: una propuesta terapéutica para la hernia inguinal recidivante y la hernia inguinal bilateral / Laparoscopic hernioplasty: a therapeutic proposal for the recurrent inguinal hernia and the bilateral inguinal hernia

Los pacientes portadores de Hernia lnguinal Recurrente (HIR) y Hernia lnguinal Bilateral (HIB), constituyen dos grupos de alto riesgo de re-recidiva cuando son reparados con técnicas tradicionales. La reparación por vía laparoscópica con técnica Transabdominal Preperitoneal (TAPP) se ha ido consolidando como segura y efectiva. Se presenta la experiencia acumulada en 28 pacientes (40 reparaciones) operados por el autor con dicha técnica. Todos varones cuyo promedio de edad fue de 52 (30-82) años. Con HIR 1 0, con HIB 17 y un caso de hernia unilateral primaria asociado a colelitiasis. La hospitalización postoperatoria alcanzó a 1,1 (1-3) días. Morbilidad menor alcanzó al 22,5 por ciento. No hubo conversión ni mortalidad. Todos los pacientes tuvieron una breve estadía hospitalaria, mínimo disconfort y dolor postoperatorio y rápido reintegro laboral. No ha habido recidivas hasta el cierre de la serie, que alcanza a 14,2 (1-27) meses de seguimiento. Sus resultados se comparan favorablemente con técnicas similares tradicionales. Se propone utilizar esta técnica rutinariamente en este tipo de pacientes

Neumoperitoneo asintomático posterior a maniobra de rucitación cardiopulmonar: revisión de un caso / Pneumoperitoneum symptomatic posterior a handiwork of resuscitation cardiopulmonary: review of in case

Reportamos un caso ingresado de emergencia por el Servicio de Medicina Interna con el diagnóstico de casi ahogamiento por inmersión con agua salada complicado con neumonía basal bilateral por aspiración. A este paciente se le practicaron en el sitio del accidente, maniobras de resucitación cardiopulmonar por personal no entrenado, 24 horas posterior a la hospitalización se evidencia neumoperitoneo y neumodiastino a los RX de tórax control sin cuatro clínico de abdomen agudo quirúrgico. La laparotomía exploradora identificó lesión gástrica puntiforme causante del neumoperitoneo. Se revisa la metodología diagnóstica empleada y como se desarrolló el neumoperitoneo sin que se presentaran manifestaciones clínicas de peritonitis

Oxido nitroso: uma boa opçåo como gás para pneumoperitôneo nas colescistectomias por videolaparoscopia sob anestesia geral / Nitrous oxide: good option as pneumoperitoneum gas in videolaparoscopic cholecystectomy under general anesthesia

Backgoruind and oblectives - Nitrous oxide is less iritating than carbon dioxide when injected into the abdominal cavity, besides inducing less hemodynamic and respiratory changes. The objective of this study was to demonstrate that: a) N2O used as pneumoperitoneum gas is little absorbed by the splancnic circulation; b) Intraperitoneal N2), associated or not with inhaled N2O, does not change PETCO2, and cannot be responsible for postoperative vomiting; c) the association of inhaled and intraperitoneal N2O reduces alfentanil requirement as compared to ventilation with 100 per cent oxygen. Methods - After Institutional approval, thirty two patientes of both sexes, ASA physical status 1 or 2, submmited to laparoscopic cholecystectomy, gave their informed consent to participate. Patients were premedicated with intramuscular midazolan (0.1mg.Kg-1). Monitoring included blood presure, ECG, gas analyser, pulse oximeter, oxygen analyser and peripheral nerve stimulator. Anhestesia was included with droperidol (0.15 mg.Kg-1), alfentanil (40ug.Kg-1), propofol (0.5 mg.Kg-1) in continuous infusion, atracurium (0.5 mg.Kg-1) and 100 per cent oxygen by mask, followed by tracheal intubation. Ventilation was controlled with 7 ml.Kg-1 tidal voleme and the ventilatory rate was adjusted to maintain PETCO2 at 32-36 mmHg, 97-98 per cent HbO2 saturation, 33-35 per cent FlO2 and intratracheal pressure of 10-12 cmH2O. Metropolol, 0.05-1 mgKg-1, was injested after tracheal intubation. The patients were allocated into two groups: Group O, ventilated with 100 per cent O2; Group N, ventilated with N2O 66-67 per cent in O2. Maintenance of anesthesia was done with propofol infusion (35 ug.Kg-1) and intermitent doses of alfentanil in both groups. Alfentanil doses systolic and diastolic arterial pressures and heart rate were registered. The PETCO2 was adjusted to 32-36 mmHg with constant tidal volume and changes in ventilatory rate if necessary. The N2O was insuflated into the abdominal cavity up to obtaining 10-12 mmHg pressure and the initial volume was registered. Samples were colected from the gastric cavity and the N2O concentration was measured in the abdominal cavity at the end of the procedure. In Group O, the expired N2O was monitored to detect absorption by splacnin circulation. In Group N, the time after discontinuation of N2O required for the expires concentration to reach 15 per cent and zero, were registered. Data were statisticaly analyzed with Student's "t" test, ANOVA and chi square test. Results - In Group O, alfentanil doses were higher than in Group N (p<0.001). Initial intraperitoneal insuflation volume of N2O were 1.76 +- 0.47 Land l.92 +- 0.59 L respectively in Groups O and N. In both groups, the N2O concentration in the desinsuflation gas was near 100 per cent and N2O was not detected in the gastric cavity gas. In Group O, N2O was not detected in the expiratory gases. In 3.38 +- 1.09 min the N2o concentration was reduced to 15 per cent and 8.38 +- 3.36 min it was zero in Group N. Conclusions - The authors concluded that: 1- N2O used by peritoneal route is not absorbed by splancnic circulation; 2- the association of inhalation and intraperitoneal N2O does not induce significant hemodynamic or respiratory changes; 3- because it is little absrbed and unlikely to produce explosive mixtures, the authors recommend N2O to be used as pneumoperitoneum gas in laparoscopic cholecistectony

Colorectal injury by compressed air: a report of 2 cases

We report two colorectal trauma patients whose rectosigmoid region was ruptured due to a jet of compressed air directed to their anus while they were playing practical jokes with their colleagues in their place of work. It was difficult to diagnose in one patient due to vague symptoms and signs and due to being stunned by a stroke of the compressed air. Both patients suffered from abdominal pain and distension, tension pneumoperitoneum and mild respiratory alkalosis. One patient was treated with primary two layer closure, and the other with primary two layer closure and sigmoid loop colostomy. Anorectal manometry and transanal ultrasonography checked 4 weeks after surgery, revealed normal anorectal function and anatomy. The postoperative courses were favorable without any wound infection or intraabdominal sepsis.

Crise asmática: associaçäo de pneumoperitônio hipertensivo e pneumotórax / Asthmatic crisis: association of hipertensive pneumoperitoneum and pneumothorax

Apresenta-se um caso de pneumotórax com pneumoperitônio hipertensivo com insuficiência respiratória aguda no HUPE-UERJ de 21/9 a 8/10/82 (mat. 553335). Esta associaçäo já foi descrita por vários autores (1,2 e 4) e ocorre com maior freqüência quando se utiliza ventilaçäo mecânica com níveis de pressäo positiva maior que 40cmH2O