RESUMO
Post-incisional ventral hernia is estimated at 5-30%, when the content of the abdominal cavity migrates to the hernial sac (HSV), with a HSV/abdominal cavity volume ratio > 25%, conditioning systemic changes defined as "loss of domain". A 27-year-old male presented with ventral hernia with loss of domain that required pre-operative preparation techniques, using application of botulinum toxin A (IncobotulinumtoxinA) and pneumoperitoneum, both guided by image. A ventral plasty was performed with adequate return of the viscera to the abdominal cavity. The combination of both techniques seems to be a safe procedure to carry out a tension-free repair.
La hernia ventral postincisional se estima en 5 al 30%, cuando el contenido de la cavidad abdominal migra al saco herniario, con una relación VSH/VCA > 25% condicionando cambios sistémicos se define como "pérdida de dominio". Masculino de 27 años con hernia ventral con pérdida de dominio que ameritó técnicas de preparación preoperatoria, utilizando toxina botulínica A (IncobotulinumtoxinA) y neumoperitoneo, ambos guíados por imagen. Se realizó una plastia ventral con adecuado regreso de las vísceras a la cavidad abdominal. La combinación de ambas técnicas es un procedimiento seguro para realizar una reparación libre de tensión.
Assuntos
Parede Abdominal , Toxinas Botulínicas Tipo A , Hérnia Ventral , Pneumoperitônio , Masculino , Humanos , Adulto , Toxinas Botulínicas Tipo A/uso terapêutico , Pneumoperitônio/etiologia , Herniorrafia/métodos , Pneumoperitônio Artificial/métodos , Hérnia Ventral/complicações , Hérnia Ventral/tratamento farmacológico , Hérnia Ventral/cirurgia , Cuidados Pré-Operatórios/métodos , Telas Cirúrgicas , Parede Abdominal/cirurgiaRESUMO
PURPOSE: The incidence of complex hernias with loss of domain (CHLD) has been increasing and the treatment of these cases may require auxiliary techniques in addition to surgery. This study aims to refine the progressive preoperative pneumoperitonium (PPP) in patients with CHLD, to achieve an increased in wall dimensions. METHODS: Patients presented with a CHLD undergoing PPP protocol were analyzed between May 2017 and May 2019. Our PPP protocol was to use two daily insufflations of 1000 ml of ambient air during a period of 14 days. We compared the abdominal cavity volume (ACV), the hernial sac volume (HSV) and the volume ratio (VR), before and after our refined PPP. RESULTS: During our evaluation period, the protocol was performed on 16 patients. The mean age was 55.73 (± 12.87), and the mean BMI was 31.35 (± 7.33). The median of HSV was 2104.53 ml; Mean ACV was 6722.36 ml, and median of VR was 29.97% (27.46-34.38 IIQ). The averages were: daily volume of gas ± 1526.66 ml, total volume ± 17,350 ml, and the PPP period of ± 10.7 days. The increase in post-PPP ACV was 52.13% (p < 0.0001), and the VR decreased to 26.9% (p < 0.609). All patients' symptoms and complications were mild (according Clavien-Dindo grades I and II), and there were no loop injuries, no catheter complications, or any surgical re-interventions. CONCLUSION: The study suggests that the use of this method results in a significant increase in ACV, and reduction of the herniated content in a safe and efficient manner, with mild complications.
Assuntos
Hérnia Ventral , Insuflação , Pneumoperitônio , Estudos de Coortes , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Pessoa de Meia-Idade , Pneumoperitônio/cirurgia , Pneumoperitônio Artificial/efeitos adversos , Pneumoperitônio Artificial/métodos , Cuidados Pré-Operatórios/métodos , Estudos RetrospectivosRESUMO
PURPOSE: Preoperative progressive pneumoperitoneum (PPP) is mostly used for giant abdominal incisional hernias, and only a few isolated or paired cases that used PPP in the treatment of giant inguinal hernias (GIH) have been reported. The main objective of this study is to describe our technique in the use of PPP in the treatment of GIH in a series of patients who presented with this challenging condition. METHODS: We retrospectively reviewed the medical records of a series of patients treated with PPP for GIH during a 6-year period (2012-2018) at a single institution. The demographics, preoperative, and surgical characteristics were analyzed. RESULTS: In total, 7 patients were treated for GIH with PPP. The median age was 64 (range 30-89) years. The median history time with the inguinal hernia was 8 (range 2-20) years. The median time of PPP was 22 (range 15-30) days. All patients underwent the Lichtenstein technique. The median follow-up time was 12 (range 3-84) months. Three (42.8%) of the patients had preoperative complications. Two patients developed mild dyspnea during PPP, and another patient had subcutaneous emphysema during the insertion of the catheter. Two (28.5%) patients had postoperative complications. One of them developed a right scrotal abscess, and another patient developed bilateral grade III hydrocele. CONCLUSION: With our limited experience, it is too early to tell if this should be the gold standard for the treatment of GIH. To see if there is superiority among different procedures, more studies that compare the morbidity of PPP with that of other trans operative techniques are needed. Nevertheless, the procedure we propose has provided satisfactory results.
Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Pneumoperitônio Artificial/métodos , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Hérnia Inguinal/patologia , Humanos , Insuflação/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Cuidados Pré-Operatórios/efeitos adversos , Estudos Retrospectivos , Escroto/patologiaRESUMO
Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.
Assuntos
Toxinas Botulínicas Tipo A/uso terapêutico , Hérnia Umbilical/tratamento farmacológico , Hérnia Umbilical/cirurgia , Hérnia Ventral/tratamento farmacológico , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Pneumoperitônio Artificial/métodos , Pneumoperitônio/cirurgia , Toxinas Botulínicas Tipo A/farmacologia , Criança , Feminino , HumanosRESUMO
BACKGROUND: Repair of hernias with loss of domain in obese patients can lead to acute respiratory failure. OBJECTIVES: The objective of this study was to analyze preoperative progressive pneumoperitoneum (PPP) in increasing abdominal cavity volume and its impact on respiratory function. SETTING: The study was conducted at the University Hospital, State University of Londrina, Brazil, which is a referral center for the treatment of obesity. The patients were hospitalized for the duration of the study. METHODS: Sixteen obese patients were evaluated. Computed tomography was used to determine hernia sac volume (HSV) and abdominal cavity volume (ACV). Respiratory function was evaluated by measuring vital capacity and forced expiratory volume in the first second (FEV-1). All data were obtained before PPP, on the day before surgery, and on the second postoperative day. PPP was performed daily with insufflation of CO2. RESULTS: The number of insufflations was 12. The average of total volume inflated was 5.7 L. The HSV was 2953 cm3 before PPP and 1935 cm3 after PPP. The average ACV increased from 8898 to 11,317 cm3 after PPP. The relationship between HSV and ACV was 38.2% before and 16.3% after PPP. There was a favorable improvement in respiratory function with an increase in vital capacity from 1875 to 2760 mL and an increase in FEV-1 from 1060 to 1670 mL after PPP. Respiratory function tests after surgery showed values of 2600 and 1560 mL, respectively, for cavity volume and FEV-1. There were no postoperative respiratory complications. CONCLUSIONS: This technique can be used safely in the surgical preparation of obese patients with hernias with loss of domain, reducing the relation between HSV and ACV and avoiding pulmonary complications.
Assuntos
Hérnia Abdominal/diagnóstico por imagem , Hérnia Abdominal/cirurgia , Herniorrafia/métodos , Obesidade Mórbida/diagnóstico , Pneumoperitônio Artificial/métodos , Insuficiência Respiratória/etiologia , Adulto , Brasil , Estudos de Coortes , Feminino , Herniorrafia/efeitos adversos , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pneumoperitônio Artificial/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Cuidados Pré-Operatórios/métodos , Prognóstico , Testes de Função Respiratória , Insuficiência Respiratória/prevenção & controle , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Telas Cirúrgicas/estatística & dados numéricos , Resultado do TratamentoRESUMO
PURPOSE:: To investigate the potential protective effects of enoxaparin against the adverse events of carbon dioxide (CO2) pneumoperitoneum. METHODS:: Thirty four rats were divided into three groups: Group 1 (sham) underwent insertion of Veress needle into the abdomen and 90 min of anesthesia with no gas insufflation. The animals in control and enoxaparin groups were subjected to 90 min of 14 mmHg CO2 pneumoperitoneum. Enoxaparin (100 u/kg) was administered subcutaneously to the rats in enoxaparin group one hour before the operation. After 90 min of pneumoperitoneum, the rats were allowed for reperfusion through 60 min. Blood and liver samples were obtained for biochemical and histopathological examination. RESULTS:: Treatment with enoxaparin decreased the histopathological abnormalities when compared with the control group. The highest levels of oxidative stress parameters were found in control group. The use of enoxaparin decreased the levels of all oxidative stress parameters, but the difference between the control and enoxaparin groups was not statistically significant. CONCLUSION:: Enoxaparin ameliorated the harmful effects of high pressure CO2 pneumoperitoneum on the liver.
Assuntos
Anticoagulantes/uso terapêutico , Dióxido de Carbono/efeitos adversos , Enoxaparina/uso terapêutico , Fígado/efeitos dos fármacos , Oxigênio/administração & dosagem , Pneumoperitônio Artificial/efeitos adversos , Animais , Dióxido de Carbono/administração & dosagem , Modelos Animais de Doenças , Feminino , Fígado/patologia , Estresse Oxidativo/fisiologia , Pneumoperitônio Artificial/métodos , Pressão , Ratos , Ratos Wistar , Tromboembolia/prevenção & controleRESUMO
ABSTRACT PURPOSE: To investigate the potential protective effects of enoxaparin against the adverse events of carbon dioxide (CO2) pneumoperitoneum. METHODS: Thirty four rats were divided into three groups: Group 1 (sham) underwent insertion of Veress needle into the abdomen and 90 min of anesthesia with no gas insufflation. The animals in control and enoxaparin groups were subjected to 90 min of 14 mmHg CO2 pneumoperitoneum. Enoxaparin (100 u/kg) was administered subcutaneously to the rats in enoxaparin group one hour before the operation. After 90 min of pneumoperitoneum, the rats were allowed for reperfusion through 60 min. Blood and liver samples were obtained for biochemical and histopathological examination. RESULTS: Treatment with enoxaparin decreased the histopathological abnormalities when compared with the control group. The highest levels of oxidative stress parameters were found in control group. The use of enoxaparin decreased the levels of all oxidative stress parameters, but the difference between the control and enoxaparin groups was not statistically significant. CONCLUSION: Enoxaparin ameliorated the harmful effects of high pressure CO2 pneumoperitoneum on the liver.
Assuntos
Animais , Feminino , Ratos , Oxigênio/administração & dosagem , Pneumoperitônio Artificial/efeitos adversos , Dióxido de Carbono/efeitos adversos , Enoxaparina/uso terapêutico , Fígado/efeitos dos fármacos , Anticoagulantes/uso terapêutico , Pneumoperitônio Artificial/métodos , Pressão , Tromboembolia/prevenção & controle , Dióxido de Carbono/administração & dosagem , Ratos Wistar , Estresse Oxidativo/fisiologia , Modelos Animais de Doenças , Fígado/patologiaRESUMO
ABSTRACT BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n = 20) or open (Group O, n = 20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15 min after start of surgery (T1), 30 min after start of surgery (T2), 45 min after start of surgery (T3), 60 min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.
RESUMO JUSTIFICATIVA E OBJETIVOS: A cirurgia laparoscópica se tornou uma ferramenta cirúrgica popular em comparação com a cirurgia aberta tradicional. Há poucos dados sobre pacientes pediátricos no que se refere ao pneumoperitônio afetar a oxigenação cerebral enquanto a concentração de CO2 no fim da expiração continua normal. Portanto, este estudo teve como objetivo avaliar as alterações da saturação de oxigênio cerebral com espectroscopia de infravermelho próximo durante cirurgia laparoscópica em crianças. MÉTODOS: O estudo recrutou 40 crianças programadas para apendicectomia laparoscópica (Grupo L, n = 20) ou aberta (Grupo A, n = 20). Variáveis hemodinâmicas, saturação de oxigênio cerebral regional direita e esquerda (RrSO2 e LrSO2), fração inspirada de oxigênio, pressão expiratória final de dióxido de carbono (PETCO2), pico de pressão inspiratória (Ppico), volume minuto respiratório, concentrações de sevoflurano inspirado e expirado e temperatura corporal foram registrados. Todos os parâmetros foram registrados após a indução da anestesia e antes do início da cirurgia (T0, basal), 15 minutos após o início da cirurgia (T1), 30 minutos após o início da cirurgia (T2), 45 minutos após o início da cirurgia (T3), 60 minutos após o início da cirurgia (T4) e no fim da cirurgia (T5). RESULTADOS: Houve diminuição progressiva em ambos os níveis de RrSO2 e LrSO2 nos dois grupos, mas não foi estatisticamente significativa em T1, T2, T3, T4. Os níveis de RrSO2 do Grupo L em T5 foram significativamente menores do que os do Grupo A. Um paciente do Grupo L apresentou um valor rSO2 < 80% do valor basal. CONCLUSÕES: A insuflação de dióxido de carbono durante o pneumoperitônio em pacientes pediátricos pode não afetar a oxigenação cerebral em cirurgia laparoscópica.
Assuntos
Humanos , Masculino , Feminino , Criança , Oxigênio/metabolismo , Pneumoperitônio Artificial/métodos , Encéfalo/metabolismo , Dióxido de Carbono/administração & dosagem , Insuflação/métodos , Laparoscopia/métodos , Estudos Prospectivos , Espectroscopia de Luz Próxima ao InfravermelhoRESUMO
BACKGROUND: The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. PATIENTS AND METHODS: Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. EXCLUSION CRITERIA: The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. RESULTS: (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) and at the end of surgery (0.29±0.05) as well. CONCLUSION: We did not demonstrate any significant mesenteric-splanchnic ischemia which could be detected by serum IMA levels during robotic radical prostatectomies performed under steep Trendelenburg position and when IAP is maintained in between 11-14 mmHg.
Assuntos
Posicionamento do Paciente/métodos , Pneumoperitônio Artificial/métodos , Pressão , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Análise de Variância , Pressão Arterial , Biomarcadores/sangue , Gasometria , Débito Cardíaco , Decúbito Inclinado com Rebaixamento da Cabeça , Hemodinâmica , Humanos , Isquemia/etiologia , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente/efeitos adversos , Pneumoperitônio Artificial/efeitos adversos , Prostatectomia/efeitos adversos , Valores de Referência , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Albumina Sérica , Albumina Sérica Humana , Circulação Esplâncnica , Fatores de TempoRESUMO
BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.