Maintaining Perioperative Normothermia During Laparoscopic and Open Urologic Surgery

293 - Laparoscopic Procedures in Urology

Background: It has been suggested that warming patients before induction of anaesthesia (prewarming) reduces the drop in core temperature (Tcore) normally associated with the induction of anaesthesia [1]. It may also reduce the incidence of surgical wound infection [2, 3]. Neither the ideal ambient temperature (Tambient), nor the duration necessary to achieve these aims, is established for adults or children. Since drops in Tcore can take some time to reverse with intra‐operative heating [4], there may be benefit in starting off at a higher Tcore. We therefore conducted a prospective randomized clinical study to assess the impact of prewarming on Tcore behaviour after induction of anaesthesia in children.Aims: We aimed to quantify the impact of prewarming vs standard ambient temperature on core temperature behaviour after induction of anaesthesia in children.Methods: Prospective clinical study with randomization to either 26°C or 21°C ambient temperature. Well children scheduled for elective surgery where presurgical anaesthetic duration exceeded 20 mins. Continuous oesophageal temperature monitoring until operative procedure commenced.Results: There were 30 children in each group. Those in the prewarmed group had significantly higher initial Tcore, a reduced drop in their Tcore and a longer time to reach the same fall in Tcore.Conclusions: The demonstrated differences are considered clinically insignificant. When the surgical procedure is short or when convective heating is available and will last for at least 45 mins, there is no clinically important ‘thermal advantage’ in prewarming. This is independent of age, weight, height and body surface area.References1 Sessler DI, McGuire J, Moayeri A, Hynson JM. Isoflurane‐induced vasodilation minimally increases cutaneous heat loss. Anesthesiology 1991; 74: 226–232.2 Melling AC, Baqar A, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomized controlled trial The Lancet 2001; 358(15): 876–880.3 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical‐wound infection and shorten hospitalization. New Engl J Med 1996; 334: 1209–1215.4 Cassey J, Armstrong P, Smith GE, Farrell PT. The safety and effectiveness of a modified convection heating system for children during anesthesia. Pediatr Anesth 2006; 16: 654–662.

To examine the association between the duration of anaesthesia and non-urological complication (NUC) rates after surgery, as the increasing complexity of minimally invasive and laparoscopic procedures in urology has resulted in longer surgery and anaesthesia, and information on the effect of this on NUC rates is limited. We identified 2196 patients who had open radical nephrectomy or nephron-sparing surgery at our institution between 1989 and 2002. Patients were subdivided into groups I, II, and III according to the duration of general anaesthesia (<4, 4-6 and > or =6 h, respectively). NUCs after surgery, and mortality during and after surgery, were evaluated. There were 1340, 723, and 133 patients in groups I, II and III, respectively. The incidences of any NUC were 3.1%, 5.8% and 13.5%, respectively. The odds ratios for the likelihood of a NUC were 1.91 (P = 0.004) and 4.84 (P < 0.001) for groups II and III, respectively. These differences remained significant even after adjusting for patient and tumour characteristics. Perioperative mortality was highest in group III, at 2.3%, vs 0.4% in groups I and II. Longer anaesthesia is associated with an increase in the incidence of perioperative complications and mortality, especially when the duration of anaesthesia is >6 h. This increase appears to be independent of patient's preoperative health status, tumour extent and blood loss.

Robotic laparoscopic surgery: a comparison of the da Vinci and Zeus systems

Aim: To present the experiences and results of laparoscopic surgeries we conducted in a year’s time in our clinic. Materials and Methods : A retrospective review of ninety-nine patients who underwent laparoscopic urological surgery between May 2013 and May 2014. Results: There were fifty-eight males and forty-two females in our study. Three of patients were pediatric. Transperitoneal approach was used for 99 patients. Mean age of all patients was 47.2 (2-76) years. The operation type and total numbers undergoing the operation were as follows: simple nephrectomy: 50; renal cyst exci­sion: 11; radical nephrectomy: 10; dismemberred pyeloplasty: 10; ureterolithotomy: 5; adrenalectomy: 3; orchiectomy: 1; orchiopexy: 1; nefroureterectomy with partial cystectomy: 3 (one of these patients was situs inversus totalis); partial nephrectomy: 2; and pyelolithotomy and hemi-nephrectomy 1. No intraoperative complications were experienced and we did not need to switch to open surgery in any of the cases. In three patients preoperatively and in one patient postoperatively blood transfusion was required. Superficial wound infection and dehiscence developed in 4 patients while two patients developed subileus and one incisional hernia. The mean postoperative hospitalization duration was 2.26 (1-4) days. Conclusion: Indication areas and popularity of the laparoscopic procedures in urology are increasing every day. Today, laparoscopic operations have increased frequency compared to open surgery due to shorter hospital stay, less pain, and high patient satisfaction. Laparoscopic surgery is a safe and feasible technique but it requires necessary experience in peripheral state hospitals. Keywords: Laparoscopy, Nephrectomy, Pyeloplasty, Adrenalectomy.

Electrosurgery is a commonly used technology in laparoscopy. Electrosurgical devices are being used in many medical subdisciplines in order to coagulate, cut, and ablate tissue and to produce hemostasis. The latest advance in electrosurgery is the introduction of novel simultaneous hemostatic sealing and cutting bipolar devices that minimize force by delivering energy as high current and low voltage output. One of these systems is the Gyrus Plasma Trissector (GPT), (Gyrus Group PLC, Gyrus International, Ltd.UK), a novel radiofrequency (RF) system based on bipolar technology, which consists of a proprietary PlasmaKinetic (PK) generator and specific instruments, designed as a system. The instrument consists of a 17 mm long gold‐coated curved jaw with a ceramic insulated cutting element. The PK system uses high‐powered pulsed bipolar energy to produce a plasmakinetic field around the working elements and is designed to operate at temperatures that allow effective tissue dissection but result in minimal collateral damage and adherence to tissue. The GPT was used with the Gyrus G400 WorkStation generator in laparoscopic radical prostatectomies (LRP). Our initial experience with this novel bipolar device demonstrates it to be safe and effective in dissection and hemostasis. The GPT permits us to act quickly when bloody fields are present, improves coagulation, reduces or eliminates sticking, seals large vessels such as dorsal vein complex (DVC) and allows secure grasping and dissecting of tissue.The urologist is familiar with electrosurgery, as we have become comfortable using GPT to dissect, cut, and coagulate tissue. We feel that the GPT can be used in a variety of laparoscopic procedures in urology.

AMRA (adverse metabolic or muscular reaction to anesthesia) reports submitted to The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States from 1987 to 2006 revealed a 2.7% cardiac arrest and a 1.4% death rate for 291 malignant hyperthermia (MH) events. We analyzed 6 years of recent data to update MH cardiac arrest and death rates, summarized characteristics associated with cardiac arrest and death, and documented differences between early and recent cohorts of patients in the MH Registry. We also tested whether the available data supported the hypothesis that risk of dying from an episode of MH is increased in patients with inadequate temperature monitoring. We included U.S. or Canadian reports of adverse events after administration of at least 1 anesthetic drug, received between January 1, 2007, and December 31, 2012, with an MH clinical grading scale rank of "very likely MH" or "almost certain MH." We excluded reports that, after review, were judged to be due to pathologic conditions other than MH. We analyzed patient demographics, family and patient anesthetic history, anesthetic management including temperature monitoring, initial dantrolene dose, use of cardiopulmonary resuscitation, MH complications, survival, and reported molecular genetic DNA analysis of RYR1 and CACNA1S. A one-sided Cochran-Armitage test for proportions evaluated associations between mode of monitoring and mortality. We used Miettinen and Nurminen's method for assessing the relative risk of dying according to monitoring method. We used the P value of the slope to evaluate the relationship between duration of anesthetic exposure before dantrolene administration and peak temperature. We calculated the relative risk of death in this cohort compared with our previous cohort by using the Miettinen and Nurminen method adjusted for 4 comparisons. Of 189 AMRA reports, 84 met our inclusion criteria. These included 7 (8.3%) cardiac arrests, no successful resuscitations, and 8 (9.5%) deaths. Of the 8 patients who died, 7 underwent elective surgeries considered low to intermediate risk. The average age of patients who died was 31.4 ± 16.9 years. Five were healthy preoperatively. Three of the 8 patients had unrevealed MH family history. Four of 8 anesthetics were performed in freestanding facilities. In those who died, 3 MH-causative RYR1 mutations and 3 RYR1 variants likely to have been pathogenic were found in the 6 patients in whom RYR1 was examined. Compared to core temperature monitoring, the relative risk of dying with no temperature monitoring was 13.8 (lower limit 2.1). Compared to core temperature monitoring, the relative risk of dying with skin temperature monitoring was 9.7 (1.5). Temperature monitoring mode best distinguished patients who lived from those who died. End-tidal CO2 was the worst physiologic measure to distinguish patients who lived from those who died. Longer anesthetic exposures before dantrolene were associated with higher peak temperatures (P = 0.00056). Compared with the early cohort, the recent cohort had a higher percentage of MH deaths (4/291 vs 8/84; relative risk = 6.9; 95% confidence interval, 1.7-28; P = 0.0043 after adjustment for 4 comparisons). Despite a thorough understanding of the management of MH and the availability of a specific antidote, the risk of dying from an MH episode remains unacceptably high. To increase the chance of successful MH treatment, the American Society of Anesthesiologists and Malignant Hyperthermia Association of the U.S. monitoring standards should be altered to require core temperature monitoring for all general anesthetics lasting 30 minutes or longer.

Background: It has been suspected that laparoscopic surgery exacerbates hypothermia to a greater extent than open surgery. Thus, this study was designed to compare the intraoperative thermoregulatory profiles of three different operative techniques: open surgery, low pressure (LP: 8 mmHg) or conventional pressure (CP: 13 mmHg) laparoscopic surgery. Methods: Forty five patients who were scheduled for radical hysterectomy were allocated to three groups, 15 in each group: group O (open surgery), group LP and group CP. Anesthesia was maintained with 2.5% sevoflurane. Intraoperative core temperature and forearm minus fingertip skin temperature gradients were measured at 15-min intervals during the first three hours. Vasoconstriction threshold was defined by the esophageal temperature at which the skin temperature gradient equalled . Results: All groups were comparable in terms of the characteristics of patients and preoperative body temperatures. Core temperatures and forearm minus fingertip skin temperature gradients were not significantly different among the three groups at all measurements. Thermoregulatory vasoconstrictions were observed in 6 of group O and 6 of laparoscopic surgical patients (4 patients from group LP and 2 patients from group CP). These 12 patients were divided into open (n = 6) and laparoscopic (n = 6) surgery group. There were no significant difference between the groups with regard to the vasoconstriction threshold and threshold time. Conclusions: Laparoscopic procedures with conventional insufflation pressure have similar profiles in terms of intraoperative thermoregulation, when compared to open surgery. Lowering insufflation pressure to 8 mmHg can not reduce the risk of intraoperative hypothermia.

Purpose: influence of benzodiazepine (midazolam)or cholinergic inhibitor (atropine or glycopyrrlate) on intra-operative body temperature remains unclear and controversial. This study compares intra-operative body temperature in 50 abdominal surgical patients under general anesthesia between the administration of midazolam and glycopyrrolate in combination, or glycopyrrolate alone. Methods: Patients who underwent abdominal surgery were recruited from September 2008 through October 2009 at Gachon University Gil hospital in incheon. Core body temperature was measured in the right ear using a tympanic membrane thermometer at induction of general anesthesia and at 1 hr, 2 hr, and 3 hr after induction. Results: There were no differences in core body temperature at any measurement point between either patient group (F=1.08, <TEX>$p$</TEX>=.377). Core body temperature decreased throughout the 3 hr after induction in both groups (F=9.22, <TEX>$p$</TEX> <.001). Specially, core temperatures at induction of general anesthesia (p<.001), 1 hr (p<.001), 2 hr (<TEX>$p$</TEX> <.001), and 3 hr (<TEX>$p$</TEX> <.001) after induction were lower than before administration of midazolam and glycopyrrolate, or glycopyrrolate alone. Conclusion: We conclude that a cholinergic inhibitor (glycopyrrolate, 0.1 mg) therefore seems not to affect intra-operative body temperature of patients given a benzodiazepine (midazolam, 0.04 mg <TEX>$kg^{-1}$</TEX>), and not to increase body temperature in patients not given a benzodiazepine during the 3 hr after the induction of general anesthesia. Intra-operative warming therefore is needed to prevent hypothermia in surgical patients who receive pre-operative administration of midazolam and/or glycopyrrolate.

Laparoscopic dismembered pyeloplasty with less trauma than open surgery is commonly performed for ureteropelvic junction obstruction despite a longer operating time and a long learning curve. We describe in this paper a new technique, which combines laparoscopic and open procedure in dismembered pyeloplasty, that we have developed in 51 patients and achieved excellent results. The surgical procedure can be divided into two steps: laparoscopic dissection of the renal pelvis and proximal ureter transperitoneally; then accomplishing the pyeloplasty through the extended port incision above the ureteropelvic junction as in open surgery. All 51 operations were successful without conversion to open surgery. No intraoperative complications were observed. The operating time was 40 minutes to 90 minutes with an average of 57.5 minutes. The estimated blood loss was 15 ml to 30 ml with an average of 21.2 ml. Aberrant artery vessel and primary stricture as the cause of ureteropelvic junction obstruction was noted in 2 and 49 patients, respectively. Thirty-nine patients had fever to differing extents in the 4 days postoperation and no severe infection was observed. Four patients had urinary leakage with their drains being retained for 6 days, 6 days, 5 days or 8 days after the operation. The mean followup was 10.8 months (range 3 months to 36 months). The followup showed good results with symptom resolution in all the patients. Renal ultrasonography demonstrated that the average separation of the collecting systems decreased from preoperative 2.7 cm (range 2.0 cm to 4.7 cm) to postoperative 1.5 cm (range 1.0 cm to 2.3 cm). Excretory urography at 3 months postoperatively showed improved drainage. Of the 51 patients, 35 underwent two or more excretory urograms, demonstrating stable renal function, improved drainage and no evidence of recurrent obstruction. At the last followup visit, each patient was doing well. Combination of laparoscopic and open procedure in dismembered pyeloplasty offers a simpler, timesaving method in a minimally invasive fashion with low morbidity for patients with ureteropelvic junction obstruction. Ensuring quality of repair, the method provides a minimally invasive alternative with good results. It is worth future clinical application.

To the Editor. —Dr Frank and colleagues ' attempted to determine the specific value of perioperative forced-air warming on patient outcome. However, failure to randomize surgeons and failure to control for and report several important variables, 2 such as preoperative total body thermal baselines, intraoperative core temperature changes, administration of vasodilator or vasoconstrictor drugs, patient body fat content, and patient weight—to—surface area ratios significantly weaken the results. Peripheral prewarming significantly changes postinduction core temperature decline, as 81% of the typical 1.6°C first-hour temperature decline is ascribed to redistribution rather than actual loss of body heat, necessitating specific considerations beyond simple initial core temperature. The core temperature of warmed patients will decline identically to that of unwarmed patients during the first hour despite forced-air warming. The duration and course of intraoperative forced-air warming therapy clearly are important as significant effects are demonstrated only after 90 to 120 minutes. Further, core temperature declines with application

PurposeThere is currently an increasing trend for percutaneous surgical interventions mainly in children with cerebral palsy (CP). The purpose of this study was to evaluate the effectiveness and safety of percutaneous proximal gracilis tenotomy (PPGT) in children with CP scheduled for hip adductor tenotomy.MethodsThis is a prospective study of 59 hips in 31 consecutive patients with CP scheduled for hip adductor tenotomy in the setting of multilevel tenotomies or hip osteotomy (femoral or Dega). A pediatric orthopedic surgeon conducted a percutaneous adductor longus and gracilis tenotomy through the same stab wound. Another surgeon extended the wound to explore what had been cut during the PPGT, and completed the tenotomy if necessary (open proximal gracilis tenotomy; OPGT). Hip abduction with the hip and knee extended (HA) was assessed by a third surgeon (1) immediately before PPGT, i.e., directly after percutaneous adductor longus tenotomy (prePPGT), (2) after PPGT (postPPGT), and (3) following OPGT (postOPGT), using a goniometer, in a standardized reproducible manner. All three surgeons were blinded to each other’s findings. Primary end-points included the percentage of muscle portion sectioned percutaneously and the improvement of HA angle. Comparison between HA before and after PPGT was performed using a paired t test with 95 % confidence interval (CI), and comparison between HA after PPGT and OPGT was performed using a Student’s t-test with 95 % CI. The bleeding was assessed and other iatrogenic lesions were identified. The relationship between HA after PPGT and the percentage of muscle portion sectioned percutaneously was evaluated by calculating the Pearson correlation coefficient (p < 0.01).ResultsMean HA measured 33.71 degrees prePPGT and increased to 45.90 degrees postPPGT (p < 0.0001). The postOPGT HA averaged 48.71 degrees with no statistically significant gain compared with postPPGT (p = 0.21). The muscular portion of gracilis origin was cut to an average of 91.95 %; completely in only 14 hips, between 90 and 100 % in 35 hips, between 70 and 90 % in 9 hips, and between 60 and 70 % in 1 hip. The gain in HA did not correlate with the extent of the muscular portion sectioned percutaneously (R = −0.043). Minimal accidental section of adductor brevis postPPGT was encountered in 39 hips. Considerable bleeding postPPGT with hematoma formation requiring hemostasis during the open control procedure occurred in 30 hips. Partial iatrogenic injury of the anterior branch of the obturator nerve was encountered in one patient bilaterally with severe adductor contracture, due to an anatomic too medial variant.ConclusionsThis is the only prospective study concerning the outcome of PPGT. Although PPGT is fast, simple and effective, it is not as safe as the open procedure even when performed correctly by an experienced surgeon, mainly because of the increased risk of bleeding. The findings of the current study do not support its use as a ‘standard-of-care’ technique in children with hip adductor contracture.Level of evidenceLevel II therapeutic study—prospective comparative study.

Introduction: Laparoscopic surgery is subject to certain limitations that can be a problem when performing complex minimally invasive operations. Robotic surgery was developed precisely to overcome such technical limitations. The question therefore arises whether robotic surgery leads to significantly better results compared with standard laparoscopic surgery.Methods: Based on comparative systematic reviews and meta-analyses, this paper examines whether the robotic technique when used for abdominal and visceral surgery procedures confers advantages on the patient compared with the standard laparoscopic technique.Results: Even for demanding visceral surgery procedures, the perioperative complication rate for robotic surgery is not higher than for open or laparoscopic surgical procedures. In cancer cases, the oncological accuracy of robotic resection for gastric, pancreatic, and rectal resection is seen to be adequate. Only the operating time is generally longer than for standard laparoscopic and open procedures. But, on the other hand, in some procedures blood loss is less, conversion rates are lower and hospital stay shorter.Conclusion: To evaluate the future role of the robotic technique for visceral surgery, high-quality prospective randomized trials are urgently needed.

What's New in Shoulder and Elbow Surgery.

332 Background: Use of laparoscopic nephrectomy for live kidney donors has been shown to reduce hospitalization and postoperative pain, thereby optimizing patient recovery. In the current cost-conscious health care environment, however, payers and policymakers are concerned these benefits might be offset by the need for expensive disposable laparoscopic equipment. Methods: A retrospective cross-sectional analysis was performed of patients who underwent live donor nephrectomies at our institutions from Jan. 1994 to Oct. 1997. Multivariate regression was used to assess differences between laparoscopic and open procedures in length of stay(LOS), hospital charges (in constant 1997 dollars), complications, and readmissions while adjusting for patient age, race and gender, and date of surgery, surgeon and hospital. Results: Of 134 living donors, 66 underwent open and 68 had laparoscopic procedures by 9 surgeons. Laparoscopic patients were older than open nephrectomy patients (42 vs. 39 years), but they were similar in race and gender. LOS was significantly shorter for the laparoscopic than for the open nephrectomy group. Complication and readmission rates also were lower for the laparoscopic group. Even though laparoscopic supplies were 3 times more expensive than open supplies ($2,946 vs. $982, p<.001), there was no overall difference in total hospital charges between groupsTable.Conclusions: Kidney donors undergoing laparoscopic procedures experience less morbidity and significantly shorter LOS than donors having open procedures. Although laparoscopic supplies are expensive, overall in-hospital resource utilization is comparable for the two groups, making laparoscopic nephrectomy an attractive new technology for donorsand their insurers.