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

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

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

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

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

OBJECTIVETo investigate the correlation between arterial partial pressure of CO2 (PaCO2) and end expiratory tidal partial pressure of CO2 (Pet-CO2) in morbidly obese patients during anesthesia for laparoscopic gastric bypass surgery.

METHODSForty morbidly obese patients with a body mass index (BMI) between 35 and 50 kg/m(2) underwent laparoscopic gastric bypass surgery under general anesthesia. PaCO2 and Pet-CO2 were measured after intubation and before induction of pneumoperitoneum (T0), at 30 min (T1), 60 min (T2), and 120 min (T3) during pneumoperitoneum, and at 30 min (T4) and 60 min (T5) after deflation.

RESULTSAt each time point of measurement, Pet-CO2 was lower than PaCO2 in all the patients. PaCO2 and Pet-CO2 were positively correlated before, during, and after pneumoperitoneum (P<0.05). At a moderate pressure of CO2 pneumoperitoneum (16 mmHg), the level of correlation between PaCO2 and Pet-CO2 at T1, T2, and T3 differed from that before and after post-pneumoperitoneum.

CONCLUSIONSPaCO2 and Pet-CO2 are closely correlated during a moderate CO2 pneumoperitoneum in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Adult ; Anesthesia ; Arterial Pressure ; Blood Gas Analysis ; Carbon Dioxide ; blood ; Female ; Gastric Bypass ; Humans ; Laparoscopy ; Male ; Middle Aged ; Obesity, Morbid ; blood ; surgery ; Pneumoperitoneum, Artificial

Aminophylline can elicit thermogenesis in rats or increase metabolic rate during cold stress in lambs. We tested the hypothesis that aminophylline would reduce the change in core body temperature during laparoscopic abdominal surgery requiring pneumoperitoneum. Fifty patients were randomly divided into an aminophylline group (n=25) and a saline control group (n=25). Esophageal temperature, index finger temperature, and hemodynamic variables, such as mean blood pressure and heart rate, were measured every 15 min during sevoflurane anesthesia. In the aminophylline group, esophageal temperatures at T45 (36.1+/-0.38 vs. 35.7+/-0.29, P=0.024), T60 (36.0+/-0.39 vs. 35.6+/-0.28, P=0.053), T75 (35.9+/-0.34 vs. 35.5+/-0.28, P=0.025), T90 (35.8+/-0.35 vs. 35.3+/-0.33, P=0.011), and T105 (35.8+/-0.36 vs. 35.1+/-0.53, P=0.017) and index finger temperatures at T15 (35.8+/-0.46 vs. 34.9+/-0.33, P<0.001), T30 (35.7+/-0.36 vs. 35.0+/-0.58, P=0.029), T45 (35.8+/-0.34 vs. 35.2+/-0.42, P=0.020), T60 (35.7+/-0.33 vs. 34.9+/-0.47, P=0.010), T75 (35.6+/-0.36 vs. 34.8+/-0.67, P=0.028), T90 (35.4+/-0.55 vs. 34.4+/-0.89, P=0.042), and T105 (34.9+/-0.53 vs. 33.9+/-0.85, P=0.024) were significantly higher than in the saline control group. Aminophylline is effective in maintaining the core temperature through a thermogenic effect, despite reduced peripheral thermoregulatory vasoconstriction.
Abdomen/surgery ; Aminophylline/*administration & dosage ; Body Temperature/*drug effects ; Female ; Humans ; Hypothermia/*etiology/physiopathology/*prevention & control ; Laparoscopy/*adverse effects ; Male ; Middle Aged ; Pneumoperitoneum, Artificial/*adverse effects ; Single-Blind Method ; Treatment Outcome

Aminophylline can elicit thermogenesis in rats or increase metabolic rate during cold stress in lambs. We tested the hypothesis that aminophylline would reduce the change in core body temperature during laparoscopic abdominal surgery requiring pneumoperitoneum. Fifty patients were randomly divided into an aminophylline group (n=25) and a saline control group (n=25). Esophageal temperature, index finger temperature, and hemodynamic variables, such as mean blood pressure and heart rate, were measured every 15 min during sevoflurane anesthesia. In the aminophylline group, esophageal temperatures at T45 (36.1+/-0.38 vs. 35.7+/-0.29, P=0.024), T60 (36.0+/-0.39 vs. 35.6+/-0.28, P=0.053), T75 (35.9+/-0.34 vs. 35.5+/-0.28, P=0.025), T90 (35.8+/-0.35 vs. 35.3+/-0.33, P=0.011), and T105 (35.8+/-0.36 vs. 35.1+/-0.53, P=0.017) and index finger temperatures at T15 (35.8+/-0.46 vs. 34.9+/-0.33, P<0.001), T30 (35.7+/-0.36 vs. 35.0+/-0.58, P=0.029), T45 (35.8+/-0.34 vs. 35.2+/-0.42, P=0.020), T60 (35.7+/-0.33 vs. 34.9+/-0.47, P=0.010), T75 (35.6+/-0.36 vs. 34.8+/-0.67, P=0.028), T90 (35.4+/-0.55 vs. 34.4+/-0.89, P=0.042), and T105 (34.9+/-0.53 vs. 33.9+/-0.85, P=0.024) were significantly higher than in the saline control group. Aminophylline is effective in maintaining the core temperature through a thermogenic effect, despite reduced peripheral thermoregulatory vasoconstriction.
Abdomen/surgery ; Aminophylline/*administration & dosage ; Body Temperature/*drug effects ; Female ; Humans ; Hypothermia/*etiology/physiopathology/*prevention & control ; Laparoscopy/*adverse effects ; Male ; Middle Aged ; Pneumoperitoneum, Artificial/*adverse effects ; Single-Blind Method ; Treatment Outcome

Colectomy ; Embolism, Air ; etiology ; Humans ; Laparoscopy ; Male ; Middle Aged ; Pneumoperitoneum, Artificial ; adverse effects

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