Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery.

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.

Stable pneumorectum using an inline glove - a cost-effective technique to facilitate transanal total mesorectal excision.

AIM: Transanal total mesorectal excision (taTME) is a novel approach for resection of the rectum. Use of a standard insufflator to create pneumorectum, however, results in bellowing-large heaving motions from insufflation of air that can frustrate surgery. We report the successful application of our technique, stable pneumorectum using an inline glove (SPRING), for the performance of transanal rectal excision in a series of 17 patients using a standard laparoscopic insufflator. METHOD: A retrospective review of 17 patients using the SPRING technique was performed between October 2015 and October 2016. Characteristics of these patients were evaluated, and technique-related short-term outcome was reviewed. RESULTS: The SPRING technique was successfully used in patients who underwent both minimally invasive (n = 14) and open (n = 3) approaches in the abdominal stage of the surgery. In the 12 patients who had rectal cancer for whom SPRING was used to facilitate taTME there were no conversions to an alternative access for rectal resection, the median duration of the TME part of the operation was 95 min (62-147) and there was one R1 resection (8%). Billowing was not a significant problem in any of the 17 patients during the surgery. CONCLUSION: In this case series we have successfully shown the feasibility of the SPRING technique as a practical and cost-effective solution to the problem of billowing during taTME.

Cost-utility analysis of the insufflation of warmed humidified carbon dioxide during open and laparoscopic colorectal surgery.

BACKGROUND: An evaluation was conducted to estimate the cost-effectiveness of insufflation of warmed humidified CO2 during open and laparoscopic colorectal surgery compared with usual care from a UK NHS perspective. METHODS: Decision analytic models were developed for open and laparoscopic surgery. Incremental costs per quality-adjusted life year (QALY) were estimated. The open surgery model used data on the incidence of intra-operative hypothermia and applied risks of complications for hypothermia and normothermia. The laparoscopic surgery model utilised data describing complications directly. Sensitivity analyses were conducted. RESULTS: Compared with usual care, insufflation of warmed humidified CO2 dominated. For open surgery, savings of £20 and incremental QALYs of 0.013 were estimated per patient. For laparoscopic surgery, savings of £345 and incremental QALYs of 0.001 per patient were estimated. Results were robust to most sensitivity analyses. CONCLUSIONS: Considering the current evidence base, the intervention is likely to be cost-effective compared with usual care in patients undergoing colorectal surgery.

Effectiveness of a reusable low-cost balloon trocar dissection device in the creation of preperitoneal space during endoscopic surgery. An experimental study in swine.

PURPOSE: To evaluate a new, low-cost, reusable balloon trocar device for dissection of the preperitoneal space during endoscopic surgery. METHODS: Twenty swine (weight: 15-37 kg) were randomized to two groups, according to whether the preperitoneal space was created with a new balloon device manufactured by Bhio-Supply (group B) or with the commercially available OMSPDB 1000® balloon device manufactured by Covidien (group C). Quality and size of the created preperitoneal space, identification of anatomic structures, balloon dissection time, total procedure time, balloon resistance and internal pressure after insufflation with 300 mL of ambient air, balloon-related complications, and procedure cost were assessed. RESULTS: No significant differences in dissection time, total procedure time, or size of the created preperitoneal space were found between the groups. Balloons in group B had a significantly higher internal pressure compared to balloons in group C. None of the balloons ruptured during the experiment. Three animals in group C had balloon-related peritoneal lacerations. Despite a higher individual device cost, group B had a lower procedure cost over the entire experiment. CONCLUSION: The new balloon device is not inferior to the commercially available device in terms of the safety and effectiveness for creating a preperitoneal space in swine.

Effectiveness of a reusable low-cost balloon trocar dissection device in the creation of preperitoneal space during endoscopic surgery. An experimental study in swine

PURPOSE: To evaluate a new, low-cost, reusable balloon trocar device for dissection of the preperitoneal space during endoscopic surgery.METHODS:Twenty swine (weight: 15-37 kg) were randomized to two groups, according to whether the preperitoneal space was created with a new balloon device manufactured by Bhio-Supply (group B) or with the commercially available OMSPDB 1000(r) balloon device manufactured by Covidien (group C). Quality and size of the created preperitoneal space, identification of anatomic structures, balloon dissection time, total procedure time, balloon resistance and internal pressure after insufflation with 300 mL of ambient air, balloon-related complications, and procedure cost were assessed.RESULTS:No significant differences in dissection time, total procedure time, or size of the created preperitoneal space were found between the groups. Balloons in group B had a significantly higher internal pressure compared to balloons in group C. None of the balloons ruptured during the experiment. Three animals in group C had balloon-related peritoneal lacerations. Despite a higher individual device cost, group B had a lower procedure cost over the entire experiment.CONCLUSION:The new balloon device is not inferior to the commercially available device in terms of the safety and effectiveness for creating a preperitoneal space in swine.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography: A meta-analysis and systematic review.

AIM: To assess the safety and efficacy of carbon dioxide (CO(2)) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS: The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO(2) insufflation with air insufflation during ERCP. The trials were included in the review irrespective of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes. Sensitivity and subgroup analyses were performed if necessary. RESULTS: Seven double-blind RCTs involving a total of 818 patients were identified that compared CO(2) insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-randomization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO(2) insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insufflation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI: 0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO(2) level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI: -14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI: -0.26-0.17, P = 0.67) between the two groups. CONCLUSION: CO(2) insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

Comparison of the effectiveness and safety of a new de-airing technique with a standardized carbon dioxide insufflation technique in open left heart surgery: a randomized clinical trial.

OBJECTIVE: We have compared the effectiveness, time required for de-airing, and safety of a newly developed de-airing technique for open left heart surgery (Lund technique) with a standardized carbon dioxide insufflation technique. METHODS: Twenty patients undergoing elective open aortic valve surgery were randomized prospectively to the Lund technique (Lund group, n = 10) or the carbon dioxide insufflation technique (carbon dioxide group, n = 10). Both groups were monitored intraoperatively during de-airing and for 10 minutes after weaning from cardiopulmonary bypass by transesophageal echocardiography and online transcranial Doppler for the severity and the number of gas emboli, respectively. The systemic arterial partial pressure of carbon dioxide and pH were also monitored in both groups before, during, and after cardiopulmonary bypass. RESULTS: The severity of gas emboli observed on transesophageal echocardiography and the number of microembolic signals recorded by transcranial Doppler were significantly lower in the Lund group during the de-airing procedure (P = .00634) and in the first 10 minutes after weaning from cardiopulmonary bypass (P = .000377). Furthermore, the de-airing time was significantly shorter in the Lund group (9 vs 15 minutes, P = .001). The arterial pH during the cooling phase of cardiopulmonary bypass was significantly lower in the carbon dioxide group (P = .00351), corresponding to significantly higher arterial partial pressure of carbon dioxide (P = .005196) despite significantly higher gas flows (P = .0398) in the oxygenator throughout the entire period of cardiopulmonary bypass. CONCLUSIONS: The Lund de-airing technique is safer, simpler, and more effective compared with the carbon dioxide insufflation technique. The technique is also more cost-effective because the de-airing time is shorter and no extra expenses are incurred.