Laparoscopic surgery involves creation of carbondioxide (CO2) pneumoperitoneum leading to a rise in intracranial pressure (ICP), which can cause expansion of optic nerve sheath diameter(ONSD).We aimed to study the magnitude of changes in ONSD occurring during pediatric laparoscopic surgery and correlate them with changes in end-tidal CO2 (EtCO2), intrabdominal pressure (IAP), and a change in patient position (P).

Thirty-five pediatric patients between 1 and 12 years undergoing laparoscopic surgeries under general anesthesia were included.The ONSD, EtCO2, IAP, and position (P) in degrees from supine were recorded 15 min post-anesthesia induction(T1) and 30 min following the establishment of pneumoperitoneum (T2).The difference between the two groups was analyzed using a paired or unpaired t-test for quantitative variables and using Chi-square or Fisher's exact test for qualitative data.Correlation between two quantitative variables was performed using Pearson's correlation coefficient.

Mean ONSD showed a significant change (P < 0.001) 30 min (T2) following pneumoperitoneum increasing by an average of 0.04cm as compared to 15 min (T1) post-anesthesia induction (0.57 ± 0.06 vs. 0.61 ± 0.06). There was a moderate to strong positive correlation between change in ONSD and change in EtCO2(correlation coefficient = 0.629, P = 0.001) 30 min post pneumoperitoneum. There was a weak correlation between change in ONSD and change in position (correlation coefficient = 0.276) and a very weak correlation between change in ONSD and change in IAP (correlation coefficient = 0.19).

Laparoscopic surgeries in children can cause significant increases in ICP as measured by the ONSD; changes in EtCO2 are the predominant factor responsible. Increasing minute ventilation to maintain normal EtCO2 may help mitigate changes in ICP in children undergoing laparoscopic surgery.

Background: Increased intra-abdominal pressure (IAP), autonomic reactions, and anesthetics all contribute to hemodynamic alterations during laparoscopic cholecystectomy. This study's objectives are to measure noninvasively the intraoperative individual responses in cardiac and systemic hemodynamics, focusing on cardiac output (CO. L/min), stroke volume (SV, mL/min), systemic vascular resistance (SVR, dyn.s.cm-5), and noninvasive mean arterial blood pressure (MABP, mmHg) during and after peritoneal insufflation (cmH2O). The secondary objective was to evaluate the utility of EC as an adjunct to standard monitoring and to assess the individual differences. Methods: The CO and associated parameters were continuously and noninvasively monitored with the electrical cardiometry (EC, ICON, Osypka, Berlin Germany). Results: Seventy-three patients showed that when the IAP increased to 13 [IQR: 13-14] cmH2O, there was an overall percentage decrease in CO (-11.29%), MABP (-9.31%), and SVR (-23.16%) compared to pre induction with minimal changes in heart rate (HR). Individual variation and extreme reactions among certain patients were noted, with CO falling by -47.14% and MABP by -61.59, respectively, which can have major repercussions. Conclusions: The EC enabled real-time, non-invasive CO monitoring and detected significant cardio-hemodynamic changes that conventional monitors could miss. EC can supplement traditional monitors and give attending anesthesiologists access to more of patients' vital information.

Perioperative lidocaine infusions show potential as a systemic analgesic and to enhance postoperative recovery. This study characterised the pharmacokinetics (PK) of lidocaine and its metabolites, monoethylglycinexylidide (MEGX) and glycinexylidide (GX), in adult surgical patients using non-linear mixed-effects modelling.

Thirty-four donor nephrectomy and 64 cholecystectomy patients received intraoperative IV lidocaine. Plasma samples were collected perioperatively and analysed in NONMEM. Covariate effects and alternative dosing regimens were investigated.

1,520 concentration-timepoints were analysed. Lidocaine PK was best fitted with a 3-compartment model, while MEGX and GX used a 2-compartment model. All parameters were scaled allometrically with total body mass and fat-free mass (FFM). Lidocaine had a typical clearance of 45.9 L/h, decreasing by 60% postoperatively, and a central volume of 25.2 L. Peripheral compartments 1 and 2 exhibited intercompartmental clearances of 142 L/h and 5.81 L/h, with volumes of 44.4 L and 29.3 L, respectively. Peripheral compartment 1's volume expanded with intraoperative fluid administration. Simulations suggested an FFM-based dosing regimen (bolus: 2.5 mg/kg over 30 min, single infusion: 2 mg/kg over 1 h, maintenance infusion: 1.5 mg/kg/h) quickly achieved and maintained a lidocaine target plasma concentration of 1.5 mg/L.

The joint parent-metabolites model adequately describes the disposition of lidocaine and its metabolites, incorporating allometric scaling and key covariates. It provides a foundation for optimising lidocaine dosing and guiding investigations to establish target plasma concentrations for safe and effective use in the general surgical population. Further research is warranted to refine and evaluate the model's utility in other surgical populations.

Tension pneumoperitoneum (TPP) is a rare but life-threatening pathology in which significant accumulation of free air in the peritoneum pressurizes the abdominal cavity, creating conditions similar to abdominal compartment syndrome. Due to compression of intra-abdominal vasculature, TPP results in hemodynamic instability. While it most commonly occurs due to viscus perforation in the setting of recent endoscopy, gastric perforation from resuscitative efforts can also lead to TPP.

We present a case of a 58-year-old female who was intubated out-of-hospital for unresponsiveness, then subsequently developed abdominal distension, mottled lower extremities, and hemodynamic instability. In the emergency department, the patient self-extubated for a brief time before suffering cardiac arrest. During resuscitative efforts, imaging showed significant abdominal free air concerning for tension pneumoperitoneum. The likely etiology was positive pressure ventilation after esophageal intubation, resulting in gastric perforation and rapid accumulation of air in the peritoneal cavity. Despite emergent abdominal needle decompression and prompt exploratory surgery, the patient expired. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TPP is a critical pathology that should be on the differential for any patient with recent unverified intubation presenting with hemodynamic instability and abdominal distension. Abdominal needle decompression is a key intervention for the patient with TPP and should be in the emergency physician's skillset. It is also a reminder that intubated patients require confirmation of correct endotracheal tube placement to prevent negative outcomes.

The rapid advancement of minimally invasive surgical techniques has made laparoscopy a preferred alternative because it reduces postoperative complications. However, inflating the peritoneum with CO2 causes a cranial shift of the diaphragm decreasing lung volume and impairing gas exchange. Additionally, CO2 absorption increases blood CO2 levels, further complicating mechanical ventilation when the lung function is already compromised. Standard interventions such as lung recruitment maneuvers or increasing positive end-expiratory pressures can counteract these effects but also increase lung parenchymal strain and intrathoracic pressure, negatively impacting cardiac output. The application of variability in tidal volume and respiratory rate during mechanical ventilation to mimic natural breathing has shown benefits in various respiratory conditions. Therefore, we aimed to evaluate the short-term benefits of variable ventilation (VV) on gas exchange, respiratory mechanics, and hemodynamics during and after capnoperitoneum, compared to conventional pressure-controlled ventilation (PCV).

Eleven anaesthetized rabbits were randomly assigned to PCV or VV. Oxygenation index (Pao2/FiO2), arterial partial pressure of carbon dioxide (Paco2), and respiratory mechanical parameters were assessed after a 15-minute-long ventilation period before, during, and after capnoperitoneum. According to a crossover design, after measurements at the 3 different stages, the ventilation mode was changed, and the entire sequence was repeated.

Capnoperitoneum compromised respiratory mechanics, decreased oxygenation, and caused CO2-retention compared to baseline measurements under both ventilation modalities (P < .05, for all). Application of VV resulted in lower Pao2/FiO2 (405. 5 ± 34.1 (mean ± standard deviation [SD]) vs 370. 5 ± 44.9, P < .001) and higher Paco2 (48. 4 ± 5.1 vs 52. 8 ± 6.0 mm Hg, P = .009) values during capnoperitoneum compared to PCV. After abdominal deflation and a lung recruitment maneuver, VV proved more beneficial for CO2 removal than PCV (41. 0 ± 2.3 vs 44. 6 ± 4.3mmHg, P = .027). No significant difference was observed in the respiratory mechanical or hemodynamic parameters between the ventilation modalities under the same conditions.

The detrimental effects of capnoperitoneum on gas exchange were more pronounced with VV. However, after the release of capnoperitoneum, VV significantly improved CO2 clearance. Therefore, VV could possibly be considered as an alternative ventilation modality to restore physiological gas exchange after, but not during, capnoperitoneum.

To determine if prestretching (PS) of the abdominal wall provided improved working space during elective laparoscopic procedures in dogs.

Prospective cohort study.

Fifty client-owned dogs undergoing elective laparoscopic procedures.

Skin markings were used to evaluate stretching of the abdominal wall. The distance from the subumbilical port to the caudal aspect of the gallbladder was measured as a proxy for intra-abdominal working length (IWL). Prestretching was performed by insufflating to an intra-abdominal pressure (IAP) of 10 mmHg for 3 min. The abdomen was desufflated back to 6 mmHg for the remainder of the procedure. A computed volumetric value utilizing skin measurements and IWL was used as a proxy for intra-abdominal working space (IWS). Percentage changes in IWL and IWS were compared.

Increasing the IAP from 6 to 10 mmHg increased the IWL by 7% (IQR 9.5%) and the IWS by 10.4% (IQR 13.8%) (p = .004 and .005, respectively). Returning to 6 mmHg after prestretching resulted in a median increase in IWL of 4.4% (IQR 5.7%) and IWS of 6.9% (IQR 5.4%) compared with the initial 6 mmHg IAP measurements (p < .001 for both). Intra-abdominal working length and IWS were similar at the end of surgery compared with post-PS 6 mmHg IAP measurements.

Prestretching resulted in improved IWL and IWS, although not to the extent achieved by higher insufflation pressures. The effects of PS persisted throughout the laparoscopic procedures performed in this study.

Prestretching can provide additional laparoscopic IWL and IWS at a lower IAP.

A laparoscopic approach to hysterectomy can significantly reduce patient morbidity and improve the quality of recovery. Subsequent perioperative advances have led to an increasingly shorter hospitalization period following laparoscopic surgery, with the same-day discharge being common. However, due to infrastructural challenges, these shorter times to discharge have mostly been limited to developed countries.

To provide a descriptive analysis and evaluate the safety and feasibility of day-case laparoscopic hysterectomy in Trinidad and Tobago.

A retrospective analysis of all total laparoscopic hysterectomies over a 3-year period at a secondary medical center in Trinidad and Tobago.

The medical records of 154 women who underwent total laparoscopic hysterectomy (TLH) from January 2020 to January 2023 were reviewed. Patient demographics, indications for surgery, perioperative variables, requirements for any additional operative procedures, and perioperative complications were recorded and analyzed. The perioperative management protocol was also outlined.

The most common indication for TLH was uterine leiomyoma (45%), followed by endometrial cancer (17.5%). In this study, 96% of patients were discharged satisfactorily within 24 h of surgery, and the mean ± standard deviation (SD) duration of hospitalization was 21 ± 2 h. The mean ± SD surgical time was 91 ± 36 min, and the average estimated blood loss was 93 ± 31 ml. No patients required postoperative blood transfusion. No postoperative opioids were required in 41% of patients, and no perioperative mortality was recorded in this study, with no patients requiring re-operation. Four postoperative complications were noted (2.6%), and this included two patients who developed deep vein thrombosis (DVT) (1.3%), one port-site infection (0.6%), and one case of pulmonary embolism (0.6%). The 30-day readmission rate was 1.9%, and this comprised the patients with DVT and pulmonary embolism. On subgroup analysis, there was no difference in surgical time between patients with body mass index >30 kg/m2, uterine size >12 weeks, and previous abdominal surgery (p > 0.05).

Day-case laparoscopic hysterectomy is feasible in a low-resource setting like Trinidad and Tobago. The procedure is safe and associated with a low postoperative complication rate.

The transgender community makes up a significant portion of the American population, yet there is a paucity of data available to surgeons and anesthesiologists. The purpose of this article is to provide information to surgeons, anesthesiologists, and other medical professionals. This narrative review explores the importance of medical information that healthcare professionals should be aware of ahead of gender-affirming surgeries. This review paper's purpose is to explore perioperative considerations for physicians before gender-affirming surgeries. Physicians should be aware of the hormone therapies, medical conditions, and physical alteration procedures associated with the transgender population. It is also of significant importance that doctors are aware of how to approach surgery during the intraoperative period. Physicians should be knowledgeable about the proper dosage and interactions corresponding to certain drugs and incorporate proper surgical management to prevent the risk of patients sustaining an injury. Following gender-affirming surgery, physicians should be aware of the postsurgical pain, nausea, and vomiting exhibited by their patients and address these issues accordingly. Vaginoplasties, metoidioplasties, and phalloplasties are all unique procedures and therefore require different postoperative care. It is through better familiarization with the complex needs of transgender patients and gender-affirming surgical procedures that physicians will develop a more inclusive quality of care for this disadvantaged population. The importance of professionals being informed regarding transgender-specific issues and treatment lies in improving the quality of treatment and care provided to this underserved population.

To compare the indicators, postoperative pneumoretroperitoneum-related complications, and postoperative recovery of laparoscopic preperitoneal inguinal hernia repair under different CO2 pneumoperitoneum pressures.

The total of 187 adult patients with primary inguinal hernia who successfully underwent transabdominal preperitoneal prosthesis (TAPP) from September 2021 to September 2023 in the Department of General Surgery, Haimen People's Hospital affiliated to Nantong University, were collected. These patients were randomly divided into low abdominal pressure group (group A: pneumoperitoneum pressure = 8 mmHg), sub-low abdominal pressure group (group B: pneumoperitoneum pressure = 10 mmHg), moderate abdominal pressure group (group C: pneumoperitoneum pressure = 12 mmHg), and standard pressure group (group D: pneumoperitoneum pressure = 14 mmHg), with 40 patients each.

The operation time in group C (43.90 ± 9.75) was significantly lower than group A (51.98 ± 12.65, p 0.001), group B (46.70 ± 10.59, p 0.001), and was higher than that in group D without significant statistical differences (38.15 ± 7.98, P = 0.05). The peritoneal suturing time in group C (5.03 ± 1.07) was significantly higher than group A (4.23 ± 0.70, p 0.001), group B (4.55 ± 0.85, p = 0.03), and was significantly lower than that in group D (6.95 ± 1.96, p 0.001).

Selecting sub-low abdominal pressure (12 mmHg) can help to have a shorter operation time, with less blood loss, and it did not add pneumoretroperitoneum-related complications. Changing the pneumoperitonium pressure during different phases of the surgery is also an optimal option.

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.

Fatty acid binding protein 4 (FABP4) has been shown to increase cardiovascular disease. The FABP4 levels in serum and adipose tissue and the possible regulatory mechanisms during colorectal cancer surgery in elderly patients remain unknown.

Four hundred elderly patients with colorectal cancer were recruited, 200 underwent laparoscopic surgery (LS) and 200 underwent open surgery (OS). Blood samples and mesenteric adipose tissue were collected at T1 (beginning of surgery) and T2 (end of surgery). Immunohistochemistry and biochemical analysis were used to evaluate the FABP4, cardiac troponin T (cTnT), creatine kinase-MB (CK-MB) and myoglobin (MYO) levels. Correlations between FABP4 and cTnT, CK-MB, MYO were further analyzed.

The expressions of FABP4 in mesenteric adipose tissue were significantly increased at T2 than T1 in OS group. The serum levels of FABP4, cTnT, CK-MB and MYO were significantly increased at T2 than T1 in OS group, and the OS group induced higher FABP4, cTnT, CK-MB and MYO levels than LS group at T2. Pearson's correlation analysis revealed that serum levels of FABP4 were strongly correlated with cTnT, CK-MB, and MYO.

OS induced significantly increased FABP4 expressions in adipose tissue and caused cardiac injury in elderly patients with colorectal cancer. FABP4 is closely associated with cardiac injury, raising the possibility that adipose tissue may be causally involved in the pathogenesis of heart dysfunction during open surgery.

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, leading to myocardial ischaemia and heart failure. Transoesophageal echocardiography (TOE) assists haemodynamic management intraoperatively but requires subspecialist skills and enables limited inferences to be drawn regarding the impact of afterload on myocardial performance. Minimally invasive haemodynamic monitoring enabling real-time visualisation of a patient's 'pressure field' has been suggested as a potential adjunct or alternative to TOE, with the added advantage of providing continuous quantitative information about both stroke volume and the afterload to ventricular ejection in a single visualisation. We describe an example of successful concurrent use of pressure field haemodynamic monitoring and TOE in a patient with severe aortic regurgitation having a prolonged laparoscopic robot-assisted pelvic exenteration.

Purpose: Gender-affirming mastectomy surgery is highly desired within both transmasculine and nonbinary patient populations. The development of cardiac arrhythmias has been reported within this population. Acute intraoperative bradycardia in patients undergoing gender-affirming mastectomy has not been well described previously. This study aimed to describe the frequency of acute intraoperative relative bradycardia in patients undergoing gender-affirming mastectomies and identify potential risk factors that contribute to its occurrence. Methods: A retrospective review was performed for all patients who underwent gender-affirming mastectomy at a single institution. Data regarding patient demographics, comorbidities, and perioperative course were collected. Patients were separated into those who did and did not develop acute intraoperative bradycardia. The definition of relative intraoperative bradycardia was a heart rate below sixty beats per minute. Logistic regression was performed to determine which variables were predictive of bradycardia. Results: A total of 337 patients underwent gender-affirming mastectomy between January 2018 and January 2023. Of these patients, 144 (42.7%) experienced acute intraoperative relative bradycardia, with 97 (67.4%) requiring anesthetic intervention and 5 (3.5%) requiring halting or abortion of surgery. Two patients (1.4%) required compressions for asystole. Fluoxetine as an outpatient medication (OR: 2.63, P = .002) and harvest of a nipple graft (OR: 2.77, P = .018) were associated with a significantly increased risk of developing acute intraoperative bradycardia. Conclusion: Acute intraoperative relative bradycardia may be a unique phenomenon in patients undergoing gender-affirming mastectomies due to variables specific to this patient population. A future study comparing patients undergoing gender-affirming mastectomy to those undergoing elective breast surgeries is forthcoming to assess further risk factors.

Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning.

A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10 mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion.

Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.

There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH.

Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors.

Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

Laparoscopic cholecystectomy is characterized by reduced postoperative pain, shorter hospital stays, rapid return to preoperative physical activity, and less psychological impact on the patient. During laparoscopic cholecystectomy, the intra-abdominal insufflation of carbon dioxide with secondary increase in intra-abdominal pressure can cause important hemodynamic consequences, like decreased cardiac output and blood pressure, as well as compensatory increase in heart rate. The purpose of this study is to evaluate changes in cardiovascular parameters during general anesthesia in patients undergoing laparoscopic cholecystectomy. Retrospective data from 342 patients with cholecystectomy for cholelithiasis performed at Railway Hospital Galati, Romania, were reviewed. All patients received the same intraoperative anesthetics. Female patients were 85.7% (n = 293). More than half of the patients, 53.51% (n = 183), were 40-59 years old, and only 16.37% (n = 56) were under 40 years old. Patients with a normal body mass index (BMI) represented 45.6% (n = 156), 33.3% (n = 114) were underweight, and 12% (n = 42) had grade 1 obesity (BMI 25-29.9 kg/m2). The minimum intraoperative blood pressure correlated with patient gender (p 0.015 < 0.005), with men having a higher blood pressure than women (p 0.006 < 0.05), and for BMI, a higher BMI was associated with elevated blood pressure (p 0.025 < 0.05). Older age correlated with an increased maximum intraoperative blood pressure (p < 0.001 < 0.05) and with maximum intraoperative heart rate (p 0.015 < 0.05). Patients undergoing laparoscopic cholecystectomy experienced significant hemodynamic changes with pneumoperitoneum, but this type of surgical intervention was safe for patients regardless of their age.

The following case discusses the surgical considerations for a patient presenting with cardiogenic shock secondary to a phaeochromocytoma crisis with stress cardiomyopathy. The patient underwent an interval laparoscopic adrenalectomy. Pneumoperitoneum insufflation was performed at lower pressures; manipulation of the adrenal tumour was minimised, and the adrenal vein was ligated early. However, as intraoperative blood pressure (BP) remained elevated and rising, further gentle dissection revealed an aberrant inferior phrenic vein draining the adrenal nodule. BP was finally reduced following ligation of the inferior phrenic vein, demonstrating the clinical significance of an unusual dual venous drainage from the adrenal nodule in this patient.

Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients.

Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional.

Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.

Giant ovarian cysts (GOCs)complicated with progressive bulbar paralysis (PBP) are very rare, and no such literature about these cases have been reported. Through the diagnosis and treatment of this case, the perioperative related treatment of such patients was analyzed in detail, and early-stage ovarian mucinous carcinoma was unexpectedly found during the treatment, which provided reference for clinical diagnosis and treatment of this kind of diseases.

In this article, we reported a 38-year-old female patient. The patient was diagnosed with PBP 2 years ago. Examination revealed a large fluid-dominated cystic solid mass in the pelvis measuring approximately 28.6×14.2×8.0 cm. Carbohydrate antigen19-9(CA19-9) 29.20 IU/mL and no other significant abnormalities were observed. The patient eventually underwent transabdominal right adnexal resection under regional anesthesia, epidural block. Postoperative pathology showed mucinous carcinoma in some areas of the right ovary. The patient was staged as stage IA, and surveillance was chosen. With postoperative follow-up 1 month later, her CA19-9 decreased to 14.50 IU/ml.

GOCs combined with PBP patients require a multi-disciplinary treatment. Preoperative evaluation of the patient's PBP progression, selection of the surgical approach in relation to the patient's fertility requirements, the nature of the ovarian cyst and systemic condition are required. Early mucinous ovarian cancer accidentally discovered after operation and needs individualized treatment according to the guidelines and the patient's situation. The patient's dysphagia and respiratory function should be closely monitored during the perioperative period. In addition, moral support from the family is also very important.

This review article considers the physiology, differential diagnosis and immediate management of vasovagal response, vascular injury and carbon dioxide embolism caused during the creation of the laparoscopic pneumoperitoneum. These pathologies account for over half of all laparoscopic complications and therefore, by taking a systematic approach to these possibly life-threatening events, laparoscopy can become even safer.

We investigated the rates of acute kidney injury (AKI) post robot-assisted laparoscopic prostatectomy (RALP).

A comprehensive search was conducted to identify studies that reported the rates of AKI post-RALP. A random effects model was used, and the pooled rates of AKI were calculated.

We identified 10 studies with 60,937 patients to be included. The mean age was 65.1 years. The mean anaesthesia time was 234.3 min (95% CI: 177.8-290.9). The mean operation time was 212.2 min (95% CI: 188.7-235.6). The mean estimated blood loss was 314.1 mL (95% CI: 153-475.3). The mean intraoperative IV fluids administered were 1985 mL (95% CI: 1516.3-2453.7). The pooled rate of AKI post RALP was 7.2% (95% CI 19-23.9).

The rates of AKI after RALP are significant. Further studies are needed to detect the risk factors for AKI and to determine the rates of chronic kidney disease post-RALP.

The impact of blood pressure targets and surgical approach (laparoscopic or open) on continuous urinary oxygenation (PuO2), a validated surrogate of renal medullary PO2, during general surgery, is unclear. We aimed to assess the effects of different blood pressure targets and surgical procedures on PuO2. We randomized patients receiving either laparoscopic or open surgery into two mean arterial pressure (MAP) target groups: usual MAP or a high MAP. We measured PuO2 in real-time and analyzed it according to the type of surgery and blood pressure target. The study was retrospectively registered on the 5th of July 2023 (ACTRN12623000726651). We included 43 participants who underwent either laparoscopic (n = 20) or open surgery (n = 23). We found that PuO2 significantly decreased during both laparoscopic and open surgery under a usual blood pressure target (- 51% and - 49%, respectively). However, there was a sharper fall with laparoscopic surgery resulting in a higher PuO2 with open surgery (mean difference: 11 ± 1 mmHg higher; p < 0.001). Targeting a higher MAP resulted in a higher PuO2 over time during laparoscopic surgery (mean difference: 7 ± 1 mmHg, p < 0.001). In contrast, targeting a usual MAP resulted in a higher PuO2 during open surgery (mean difference: 7 ± 1 mmHg, p < 0.001). Surgical approach and intraoperative blood pressure targets significantly impact urinary oxygenation. Further studies with larger sample sizes are needed to confirm these findings and understand their potential clinical implications.Registration number: ACTRN12623000726651; Date of registration: 05/07/2023 (retrospectively registered).

Abdominal inflation with CO2 is used to facilitate laparoscopic surgeries, however, providing adequate mechanical ventilation in this scenario is of major importance during anesthesia management. We characterized high-frequency percussive ventilation (HFPV) in protecting from the gas exchange and respiratory mechanical impairments during capnoperitoneum. In addition, we aimed to assess the difference between conventional pressure-controlled mechanical ventilation (CMV) and HFPV modalities generating the high-frequency signal intratracheally (HFPVi) or extrathoracally (HFPVe). Anesthetized rabbits (n = 16) were mechanically ventilated by random sequences of CMV, HFPVi, and HFPVe. The ventilator superimposed the conventional waveform with two high-frequency signals (5 Hz and 10 Hz) during intratracheal HFPV (HFPVi) and HFPV with extrathoracic application of oscillatory signals through a sealed chest cuirass (HFPVe). Lung oxygenation index ([Formula: see text]/[Formula: see text]), arterial partial pressure of carbon dioxide ([Formula: see text]), intrapulmonary shunt (Qs/Qt), and respiratory mechanics were assessed before abdominal inflation, during capnoperitoneum, and after abdominal deflation. Compared with CMV, HFPVi with additional 5-Hz oscillations during capnoperitoneum resulted in higher [Formula: see text]/[Formula: see text], lower [Formula: see text], and decreased Qs/Qt. These improvements were smaller but remained significant during HFPVi with 10 Hz and HFPVe with either 5 or 10 Hz. The ventilation modes did not protect against capnoperitoneum-induced deteriorations in respiratory tissue mechanics. These findings suggest that high-frequency oscillations combined with conventional pressure-controlled ventilation improved lung oxygenation and CO2 removal in a model of capnoperitoneum. Compared with extrathoracic pressure oscillations, intratracheal generation of oscillatory pressure bursts appeared more effective. These findings may contribute to the optimization of mechanical ventilation during laparoscopic surgery.NEW & NOTEWORTHY The present study examines an alternative and innovative mechanical ventilation modality in improving oxygen delivery, CO2 clearance, and respiratory mechanical abnormalities in a clinically relevant experimental model of capnoperitoneum. Our data reveal that high-frequency oscillations combined with conventional ventilation improve gas exchange, with intratracheal oscillations being more effective than extrathoracic oscillations in this clinically relevant translational model.

Patients with Eisenmenger syndrome (ES) requiring noncardiac surgery are at a significantly high risk of perioperative morbidity and mortality. However, perioperative management of patients with ES requiring laparoscopic surgery remains unclear.

We describe the case of a patient with ES who underwent laparoscopic hysterectomy under general anesthesia with a peripheral nerve block. The objectives of the perioperative management included the following: (1) maintaining systemic vascular resistance and cardiac output through euvolemia, facilitated by the infusion of noradrenaline, and (2) preventing a reduction in oxygen-carrying capacity and factors that elevate pulmonary vascular resistance, such as pain, hypoxia, and decreased body temperature. Although laparoscopic procedures involved an increased risk in patients with ES, they are less invasive than open surgeries.

This report describes the successful anesthetic management of a patient with ES, ensuring a balance between systemic and pulmonary vascular resistance.

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons. It can be spontaneous or secondary to chest trauma, esophageal perforation, medically induced factors, etc. Its common symptoms are chest pain, tightness in the chest, and respiratory distress. Most mediastinal emphysema patients have mild symptoms, but severe mediastinal emphysema can cause respiratory and circulatory failure, resulting in serious consequences.

A 75-year-old man, living alone, presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol. Due to the remoteness of his residence and lack of neighbors, the patient was found by his nephew and brought to the hospital the next morning after the disease onset. Computed tomography (CT) showed free gas in the abdominal cavity, mediastinal emphysema, and subcutaneous pneumothorax. Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated. Therefore, we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia. An operative incision of the muscle layer of the patient's abdominal wall was made, and a large amount of subperitoneal gas was revealed. And a continued incision of the peritoneum revealed the presence of a perforation of approximately 0.5 cm in the gastric antrum, which we repaired after pathological examination. Postoperatively, the patient received high-flow oxygen and cough exercises. Chest CT was performed on the first and sixth postoperative days, and the mediastinal and subcutaneous gas was gradually reduced.

After gastric perforation, a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm, and upper gastrointestinal angiography can clarify the site of perforation. In patients with mediastinal emphysema, open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure. In addition, thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.

The right ventricle (RV) plays a central  role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period.

To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment.

This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.

The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers.

Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour).

Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal.

CRD42018090261.

Laparoscopic surgery with capnoperitoneum brings many advantages to patients, but also emphasizes the negative impact of anesthesia and mechanical ventilation on the lungs. Even though many studies use electrical impedance tomography (EIT) for lung monitoring during these surgeries, it is not clear what the best position of the electrode belt on the patient's thorax is, considering the cranial shift of the diaphragm. We monitored 16 patients undergoing a laparoscopic surgery with capnoperitoneum using EIT with two independent electrode belts at different tomographic levels: in the standard position of the 4th-6th intercostal space, as recommended by the manufacturer, and in a more cranial position at the level of the axilla. Functional residual capacity (FRC) was measured, and a recruitment maneuver was performed at the end of the procedure by raising the positive end-expiratory pressure (PEEP) by 5 cmH2O. The results based on the spectral analysis of the EIT signal show that the ventilation-related impedance changes are not detectable by the belt in the standard position. In general, the cranial belt position might be more suitable for the lung monitoring during the capnoperitoneum since the ventilation signal remains dominant in the obtained impedance waveform. FRC was significantly decreased by the capnoperitoneum and remained lower also after desufflation.

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Many surgeons in low- and middle-income countries have described performing surgery using gasless (lift) laparoscopy due to inaccessibility of carbon dioxide and reliable electricity, but the safety and feasibility of the technique has not been well documented. We describe preclinical testing of the in vivo safety and utility of KeyLoop, a laparoscopic retractor system to enable gasless laparoscopy.

Experienced laparoscopic surgeons completed a series of four laparoscopic tasks in a porcine model: laparoscopic exposure, small bowel resection, intracorporeal suturing with knot tying, and cholecystectomy. For each participating surgeon, the four tasks were completed in a practice animal using KeyLoop. Surgeons then completed these tasks using standard-of-care (SOC) gas laparoscopy and KeyLoop in block randomized order to minimize learning curve effect. Vital signs, task completion time, blood loss and surgical complications were compared between SOC and KeyLoop using paired nonparametric tests. Surgeons completed a survey on use of KeyLoop compared to gas laparoscopy. Abdominal wall tissue was evaluated for injury by a blinded pathologist.

Five surgeons performed 60 tasks in 15 pigs. There were no significant differences in times to complete the tasks between KeyLoop and SOC. For all tasks, there was a learning curve with task completion times related to learning the porcine model. There were no significant differences in blood loss, vital signs or surgical complications between KeyLoop and SOC. Eleven surgeons from the United States and Singapore felt that KeyLoop could be used to safely perform several common surgical procedures. No abdominal wall tissue injury was observed for either KeyLoop or SOC.

Procedure times, blood loss, abdominal wall tissue injury and surgical complications were similar between KeyLoop and SOC gas laparoscopy for basic surgical procedures. This data supports KeyLoop as a useful tool to increase access to laparoscopy in low- and middle-income countries.

Takotsubo cardiomyopathy (TCM) is a rare stress-induced condition that appears rarely in suspected acute myocardial infarction cases. It causes unexplained left ventricular failure, but most cases are reversible with supportive treatment. In this report, we present the case of a 70-year-old female who developed acute hypotension after a laparoscopic Toupet fundoplication on postoperative day one, requiring care in the surgical intensive care unit. Following consultation with the cardiology service and further imaging and tests, she was diagnosed with TCM. This report outlines the potential mechanisms and management of TCM in the intensive care unit, emphasizing the importance of prompt diagnosis and treatment.