Percutaneous dilatational tracheostomy (PDT) has become an increasingly popular method of establishing an airway for patients in need of chronic ventilator assistance. We report a rare case of a 42-year-old female who developed extensive subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and pneumoperitoneum after percutaneous dilatational tracheostomy. The patient suffered from amyotrophic lateral sclerosis, and underwent PDT after a period of mechanical ventilation. During PDT, tracheostomy tube was inserted into the paratracheal space. Follow-up chest radiography and computed tomography of chest and abdomen revealed extensive subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and pneumoperitoneum. The patient was treated successfully with insertion of the thoracostomy tube and conservative care.
Abdomen ; Adult ; Amyotrophic Lateral Sclerosis ; Female ; Follow-Up Studies ; Humans ; Mediastinal Emphysema ; Methods ; Pneumoperitoneum ; Radiography ; Respiration, Artificial ; Subcutaneous Emphysema ; Thoracostomy ; Thorax ; Tracheostomy* ; Ventilators, Mechanical

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.
Abdominal Wall ; surgery ; Aged ; Esophageal Stenosis ; etiology ; Female ; Fundoplication ; adverse effects ; methods ; Heartburn ; etiology ; Hernia, Hiatal ; diagnosis ; surgery ; Humans ; Laparoscopy ; adverse effects ; methods ; Male ; Middle Aged ; Pneumoperitoneum, Artificial ; adverse effects ; Postoperative Complications

PURPOSE: Current clinical data support a safe warm ischemia time (WIT) limit of 30 minutes during laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RPN). We evaluated independent factors predicting prolonged WIT (more than 30 minutes) after LPN or RPN. MATERIALS AND METHODS: A retrospective data review was performed for 317 consecutive patients who underwent LPN or RPN performed by the same surgeon from October 2007 to May 2013. Patients were divided into two groups: group A was defined as prolonged WIT (> or =30 minutes) and group B as short WIT (<30 minutes). We compared clinical factors between the two groups to evaluate predictors of prolonged WIT. RESULTS: Among 317 consecutive patients, 80 were in the prolonged WIT group. Baseline characteristics were not significantly different between the groups. In the univariable analysis, PADUA (preoperative aspects and dimensions used for an anatomical) score (p=0.001), approach method (transperitoneal or retroperitoneal approach; p<0.001), and surgeon experience (p<0.001) were significantly associated with prolonged WIT. In the multivariable analysis, PADUA score (p=0.032), tumor size (> or =25 mm; odds ratio, 2.98; 95% confidence interval, 1.48-5.96; p=0.002), and surgeon experience (p<0.001) were independent predictors of prolonged WIT. CONCLUSIONS: Surgeon experience, tumor size, and PADUA score predicted prolonged WIT after RPN or LPN. Among these factors, increasing surgical experience with LPN or RPN is the most important factor for preventing prolonged WIT.
Adult ; Aged ; Carcinoma, Renal Cell/pathology/*surgery ; Clinical Competence ; Female ; Humans ; Intraoperative Period ; Kidney Neoplasms/pathology/*surgery ; Laparoscopy/methods ; Male ; Middle Aged ; Nephrectomy/*methods ; Pneumoperitoneum, Artificial/*methods ; Retrospective Studies ; Risk Factors ; Robotic Surgical Procedures/methods ; Warm Ischemia/*methods

OBJECTIVETo observe the effect of carbon dioxide pneumoperitoneum and Trendelenburg position on cerebral blood backflow during robot-assisted radical prostatectomy in elderly patients.

METHODSFifty elderly patients (65-80 years) and 50 middle-aged patients (45-64 years) undergoing elective robot-assisted prostatectomy were enrolled in this study. For all the patients, jugular bulb and arterial blood gas was monitored and recorded before pneumoperitoneum (0), 10 min after pneumoperitoneum was achieved (T₁), 10 min (T₂) and 60 min (3) after Trendelenberg position, and 10 min in supine position after termination of pneumoperitoneum (4).

RESULTSCompared with those at 0, the mean arterial pressure, heart rate, and BIS value at 1, 2, 3 and 4 all showed no significant variations (P>0.05), but rSO2, SjvO2, and JBP increased significantly in both groups (P<0.01). Compared with those in the middle-aged group, rSO₂, SjvO₂, and JBP increased significantly and Da-jO₂decreased at 2, 3 in the elderly group (P<0.01), but jugular vein blood glucose or lactic acid content showed no significant difference between the two groups (P>0.05).

CONCLUSIONPneumoperitoneum and Trendelenburg position cause more obvious cerebral blood backflow in elderly patients than in middle-aged patients but do not affect cerebral metabolism of oxygen.

Aged ; Aged, 80 and over ; Brain ; blood supply ; Carbon Dioxide ; Head-Down Tilt ; Heart Rate ; Humans ; Jugular Veins ; Male ; Middle Aged ; Monitoring, Physiologic ; Oxygen ; Pneumoperitoneum, Artificial ; Prostate ; surgery ; Prostatectomy ; methods ; Robotic Surgical Procedures ; methods

OBJECTIVE: To summarize the clinical anesthesia experiences in 20 patients who underwent laparoscopic nephrectomy with da Vinci S robotics.
 METHODS: Anesthesia data of 20 patients from Sichuan Provincial People's Hospital, who underwent laparoscopic nephrectomy with da Vinci S robotics from August 2014 to November 2014, were analyzed and summarized. The anesthesia time, operation time, CO(2) pneumoperitoneum time, PaCO(2) and PETCO(2) were recorded.
 RESULTS: All patients were anesthetized and underwent surgery with da Vinci S robotics. The anesthesia time was (220±14) min, the operation time was (187±11) min, and the CO(2) pneumoperitoneum time was (180±13) min. The PaCO(2) and PETCO(2) were significantly elevated at 1.5 h after operation compared with those at the baseline (before pneumoperitoneum) (P<0.05). The pH value was significantly decreased at 2.5 h after operation compared to that at the baseline (P<0.05). The peak airway pressure of inspiration was significantly elevated at 0.5 h after the beginning of pneumoperitoneum compared to that at the baseline (P<0.05).
 CONCLUSION The hemodynamics is stable during the laparoscopic nephrectomy with da vinci S robotics. However, the duration of CO(2) pneumoperitoneum is significantly increased compared to that of other surgical procedures, resulting in high airway resistance and acid-base disturbance.
Acid-Base Equilibrium ; Airway Resistance ; Anesthesia ; methods ; Hemodynamics ; Humans ; Kidney ; surgery ; Laparoscopy ; Nephrectomy ; methods ; Operative Time ; Pneumoperitoneum, Artificial ; Robotic Surgical Procedures

PURPOSE: We hypothesized that regional cerebral oxygen saturation (rSO2) could replace jugular bulb oxygen saturation (SjvO2) in the steep Trendelenburg position under pneumoperitoneum. Therefore, we evaluated the relationship between SjvO2 and rSO2 during laparoscopic surgery. MATERIALS AND METHODS: After induction of anesthesia, mechanical ventilation was controlled to increase PaCO2 from 35 to 45 mm Hg in the supine position, and the changes in SjvO2 and rSO2 were measured. Then, after establishment of pneumoperitoneum and Trendelenburg position, ventilation was controlled to maintain a PaCO2 at 35 mm Hg and the CO2 step and measurements were repeated. The changes in SjvO2 (rSO2) -CO2 reactivity were compared in the supine position and Trendelenburg-pneumoperitoneum condition, respectively. RESULTS: There was little correlation between SjvO2 and rSO2 in the supine position (concordance correlation coefficient=0.2819). Bland-Altman plots showed a mean bias of 8.4% with a limit of agreement of 21.6% and -4.7%. SjvO2 and rSO2 were not correlated during Trendelenburg-pneumoperitoneum condition (concordance correlation coefficient=0.3657). Bland-Altman plots showed a mean bias of 10.6% with a limit of agreement of 23.6% and -2.4%. The SjvO2-CO2 reactivity was higher than rSO2-CO2 reactivity in the supine position and Trendelenburg-pneumoperitoneum condition, respectively (0.9+/-1.1 vs. 0.4+/-1.2% mm Hg-1, p=0.04; 1.7+/-1.3 vs. 0.5+/-1.1% mm Hg-1, p<0.001). CONCLUSION: There is little correlation between SjvO2 and rSO2 in the supine position and Trendelenburg-pneumoperitoneum condition during laparoscopic surgery.
Adult ; Aged ; Anesthesia, General ; Brain/*metabolism ; Carbon Dioxide/chemistry ; Cerebrovascular Circulation ; Head-Down Tilt ; Humans ; Jugular Veins/*metabolism ; Laparoscopy/*methods ; Male ; Middle Aged ; Oxygen/*metabolism ; Pneumoperitoneum, Artificial ; Pressure ; Respiration

OBJECTIVETo evaluate the effects of different CO(2) pneumoperitoneum conditions on renal function in rats and provide experimental evidence for improving renal graft function after transplantation.

METHODSSD rats were randomized into 10 groups (n=12) and subject to CO(2) pneumoperitoneum at different pressures (0.67, 1.33 and 2.0 kPa) for 60 or 120 min. Serum urea nitrogen (BUN), creatinine (Cr) and N-acetyl-β-D-glocosaminidase (NAG) levels were detected after pneumoperitoneum.

RESULTSAs the pressure and time of pneumoperitoneum increased, the renal function deteriorated gradually, showing significant differences between the groups (P<0.05).

CONCLUSIONIncreased pressure and prolonged duration of CO(2) pneumoperitoneum causes impairment of the renal function, suggesting the necessity of reducing the operative time and lowering the pressure of pneumoperitoneum when harvesting renal graft in living donors.

Animals ; Carbon Dioxide ; Female ; Kidney ; physiology ; Kidney Transplantation ; Laparoscopy ; methods ; Male ; Nephrectomy ; methods ; Pneumoperitoneum, Artificial ; adverse effects ; methods ; Rats ; Rats, Sprague-Dawley ; Retroperitoneal Space ; surgery ; Time Factors ; Tissue and Organ Harvesting ; methods

OBJECTIVETo evaluate the effect of different CO2 pneumoperitoneum on IL-1β and IL-6 in abdominal cavity.

METHODSFifty-six female SD rats were randomly divided into seven groups. One group was served as control and the others received CO2 pneumoperitoneum. Pneumoperitoneum was established at 0.67 kPa and 1.0 L/min gas flow for 1, 2 or 3 h with CO2 (group C1 h, C2 h, and C3 h, respectively). CO2 pneumoperitoneum was further established at 1.07 kPa and 1.0 L/min gas flow for 1 h (group C8p), at 0.67 kPa and 2.0 L/min gas flow for 1 h(group C2f), and at 0.67 kPa and 3.0 L/min gas flow for 1 h (group C3f). After the procedures, peritoneal fluid was collected to analyze the IL-1β and IL-6 level by ELISA method.

RESULTSCO2 pneumoperitoneum caused peritoneal inflammatory reaction. With the increasing of duration and gas flow in CO2 pneumoperitoneum, the concentrations of IL-1β and IL-6 in group C2 h, C3 h and C3f were higher than those in group C1 h (P<0.05). On the other hand, the concentrations of IL-1β and IL-6 in peritoneal fluid did not change significantly when pressure was increased (P>0.05).

CONCLUSIONSThe inflammatory reaction in abdominal cavity after CO2 pneumoperitoneum may be attributed to duration and gas flow instead of the pressure within the standard pneumoperitoneum working pressures. Surgeons should reduce surgical duration and adopt low-velocity gas flow within normal working pressures in clinical practice.

Abdominal Cavity ; Animals ; Carbon Dioxide ; Female ; Interleukin-1beta ; metabolism ; Interleukin-6 ; metabolism ; Pneumoperitoneum, Artificial ; methods ; Rats ; Rats, Sprague-Dawley

PURPOSE: This study was performed to identify effects of pneumoperitoneum on hemodynamic changes of hypertensive patients undergoing laparoscopic colectomy under general anesthesia. METHODS: Data collection was done from January 2 to June 10, 2008. Seventy-six patients, including 38 hypertensive patients, who had taken antihypertensive drugs more than 1 month and 38 normotensive patients undergoing laparoscopic colectomy were enrolled in this study. The hemodynamic parameters were heart rate (HR), mean arterial pressure (MAP) and cardiac output (CO) which were measured 7 times from before induction of anesthesia to 5 min after deflation of the pneumoperitoneum. Collected data were analyzed using Repeated Measures ANOVA and Bonferroni comparison method. RESULTS: HR in the hypertensive group was significantly decreased at deflation of the pneumoperitoneum and 5 min after deflation of the pneumoperitoneum (p=.012). MAP in the hypertensive group was not different from the normotensive group (p=.756). CO in hypertensive group was significantly lower than normotensive group (p<.001) from immediately after pneumoperitoneum to 5 min after deflation of the pneumoperitoneum. CONCLUSION: The results indicate that pneumoperitoneum during laparoscopic surgery does not lead to clinically negative hemodynamic changes in heart rate, mean arterial pressure or cardiac output of hypertensive patients, who have taken antihypertensive drugs for more than 1 month.
Aged ; Anesthesia/methods ; Antihypertensive Agents/therapeutic use ; Blood Pressure/*physiology ; Cardiac Output/*physiology ; Colectomy ; Colonic Neoplasms/surgery ; Female ; Heart Rate/*physiology ; Humans ; Hypertension/drug therapy/*physiopathology ; Laparoscopy ; Male ; Middle Aged ; *Pneumoperitoneum, Artificial

OBJECTIVETo study effects of different intraabdominal pressure of carbon dioxide (Cq2) pneumoperitoneum on hemorrheology and microcirculation in rabbits.

METHODSEighteen female healthy rabbits weighing 2.2 kg to 3.5 kg were randomly divided into three groups equally based on pneumoperitoneum pressure: 0 mmHg group (group I),10 mmHg group (group II) and 15 mmHg (group III). Each group received 1 h pneumoperitoneum under different pressure. Blood samples were taken at 5 min before CO2 pneumoperitoneum, at 30 and 60 min after pneumoperitoneum for the measurements of indexes of hemorrheology. Hemodynamics including heart rate (HR), mean arterial pressure (MAP) and the volume and velocity of the microcirculation of auricle were continuously monitored, such indexes were recorded at the related time.

RESULTSAfer pneumoperitoneum at 30 and 60 min, compared with group I, HR, MAP, the whole blood viscosity, the aggregation and rigid indexes of RBC were significantly raised in group II (P < 0.05), the deformability indexes of RBC, the volume and velocity of the microcirculation were markedly decreased (P < 0.05). Even more significant changes were observed in group III (P < 0.01). The plasma viscosity and the hematocrit changed little.

CONCLUSIONAfter CO2 pneumoperitoneum, hemorrheology is decreased; Although HR, MAP are raised, the volume and velocity of the microcirculation are decreased.

Abdomen ; blood supply ; Animals ; Blood Viscosity ; Carbon Dioxide ; Female ; Hematocrit ; Hemorheology ; Microcirculation ; Pneumoperitoneum, Artificial ; methods ; Pressure ; Rabbits