Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy

Kalmar, Alain; Foubert, L.; Hendrickx, Jan F. A.; Mottrie, Alexandre; Absalom, Anthony; Mortier, Éric; Struys, Michel

doi:10.1093/bja/aeq018

Cited by 216 publications

(165 citation statements)

References 16 publications

(10 reference statements)

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“…Carbon dioxide pneumoperitoneum combined with an acute Trendelenburg position for several hours has been reported to be well tolerated by patients, and it has been suggested that this is because it increases cerebral tissue oxygen saturation slightly and maintains CPP within the autoregulated range [8,9]. In addition, in another earlier study, a slight increase in rSO 2 occurred after the institution of carbon dioxide pneumoperitoneum in a steep Trendelenburg position, which suggests that cerebral ischaemia might not occur during this procedure [6].…”

Section: Discussionmentioning

confidence: 92%

Effects of high positive end‐expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position

Lee

et al. 2013

Anaesthesia

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SummaryWe investigated the effects of 10 cmH 2 O positive end-expiratory pressure on cerebral haemodynamics and cerebral oxygenation in patients undergoing laparoscopic lower abdominal surgery in the 30°Trendelenburg position during desflurane anaesthesia. Twenty-six patients were enrolled in this study. After anaesthesia induction, pneumoperitoneum was applied in Trendelenburg position. Twenty minutes later, positive end-expiratory pressure was applied. There was no change in regional cerebral oxygen saturation (p = 0.376). Cerebral perfusion pressure decreased significantly over time (p < 0.001) and positive end-expiratory pressure caused a further decrease in cerebral perfusion pressure (p = 0.036). The application of 10 cmH 2 O positive end-expiratory pressure during pneumoperitoneum in the Trendelenburg position preserved regional cerebral oxygen saturation, but cerebral perfusion pressure decreased significantly due to its secondary haemodynamic effects.

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Section: Discussionmentioning

confidence: 92%

Effects of high positive end‐expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position

Lee

et al. 2013

Anaesthesia

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“…The increase in dead space can lead to an increase in arterial-alveolar gradient for CO 2 . The study by Kalmar et al [24] found that the end-tidal CO 2 (ETCO 2 ) measurement can be around 1.41 kPa lower than arterial pCO 2 after 2 hours in the Trendelenburg position. Tidal volumes and respiratory rate need to be increased to prevent hypercarbia and respiratory acidosis.…”

Section: Discussionmentioning

confidence: 99%

“…It is difficult to accurately monitor urine output and blood loss in these patients because suction from the abdomen will contain a variable mixture of blood, urine and wash. Not all fluid will be evacuated into the suction bowls. Regular HemaCue measurements are useful if excessive blood loss is suspected [24]. Renal perfusion decreases due to a combination of raised intra-abdominal pressure and activation of the renin, aldosterone and angiotensin systems.…”

Section: Discussionmentioning

confidence: 99%

Developing a Robotic Prostatectomy Service and a Robotic Fellowship Programme - Defining the Learning Curve

et al. 2014

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Introduction: Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom's first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results. Patients and Methods: Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system. Results: The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1- 22%, Group 2- 32% and Group 3- 26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300). Conclusion: RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.

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“…Whether or not these physiologic changes can lead to cardiovascular or neurologic injury in elderly patients undergoing long robotic-assisted MIS procedures has not been well established. However, more recently, it was found that prolonged steep Trendelenburg and pneumoperitoneum was tolerated well and that regional cerebral oxygenation was preserved in male patients undergoing Robotic-assisted laparoscopic radical prostatectomies [20]. Other risks of steep Trendelenburg also involve possible injury to the eye, even blindness, as intraocular pressures are elevated for long durations of robotic-assisted MIS [21] [22].…”

Section: Discussionmentioning

confidence: 99%

Impact of Age on Surgical Outcomes after Robot Assisted Laparoscopic Hysterectomies

Eddib¹,

Hughes²,

Aalto³

et al. 2014

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Objective: To estimate the impact of patient's age on surgical outcomes in patients undergoing robotic hysterectomy. Methods: A retrospective review of prospectively collected cohort data for a consecutive series of patients undergoing gynecologic robotic surgery. Patient's age and perioperative variables were collected from the database, charts, and other hospital records of all patients undergoing robotic hysterectomy. Results: 399 patients underwent robotic surgery for gynecologic disease. 370 patients who were under age 70 were compared with 29 patients who were over age 70. When comparing all patients under age 70 with patients over age 70, the mean age was 48.4 and 77 (P < 0.05), mean BMI was 32.1 and 28.3 kg/m 2 (P < 0.05), mean procedure time was 185 and 211 minutes (min) (P = 0.09), mean console time was 123 and 148 min (P = 0.056), mean OR (Operating room) time was 237 and 273, mean EBL (Estimated blood loss) was 71 and 65 ml (P = 0.74), Hb (Hemoglobin) drop was 1.4 and 1.2 (P = 0.45), uterine weight was 212 and 95 gm (P = 0.98), and length of stay was 1.4 and 1.6 days (P = 0.33) ( Table 1). The patients over age 70, when procedures were combined, had a statistically significant lower mean BMI, uterine weight and longer Operating room (OR) time. However, when stratified by the type of procedure performed, there was no difference in surgery times among those under 70 and over 70 years of age. The elderly patients were more likely to have cancer, which was in almost half the elderly patients, and thus necessitate staging. Thus adding the performance of lymph node dissection likely resulted in the increased length of the surgery time that was noted in the combined group (Tables 1, 2). There were no operative deaths. Conclusions: Advanced age does not appear to be associated with an increased risk of morbidity, or adverse perioperative outcomes in patients undergoing robotic hysterectomy.

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Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy

Cited by 216 publications

References 16 publications

Effects of high positive end‐expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position

Effects of high positive end‐expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position

Developing a Robotic Prostatectomy Service and a Robotic Fellowship Programme - Defining the Learning Curve

Impact of Age on Surgical Outcomes after Robot Assisted Laparoscopic Hysterectomies

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