Blackwell Science, LtdOxford, UK IJU International Journal of Urology 0919-81722002 Blackwell Science Asia Pty Ltd 98August 2002 492 Arterial blood gases in urethrocystopexy H Kocoglu et al. 10.1046/j.0919-8172.2002.00492.x Original Article422426BEES SGML
International Journal of Urology (2002) 9, 422–426
Original Article
Arterial blood gases in extraperitoneal laparoscopic urethrocystopexy HASAN KOCOGLU,1 SITKI GOKSU,1 AHMET ERBAGCI,2 LUTFIYE PIRBUDAK,1 MUSTAFA SAHIN YUKSEK1 AND UNSAL ONER1 University of Gaziantep, Faculty of Medicine, Departments of 1Anesthesiology and Reanimation, and 2Urology, Gaziantep, Turkey Abstract
Background: The aim of this study was to investigate the effects of extraperitoneal laparoscopy and carbon dioxide insufflation on hemodynamic parameters, arterial blood gases and complications in urethrocystopexy operations. Methods: Twenty-five female patients who underwent extraperitoneal laparoscopic mesh urethrocystopexy operation for the correction of urinary incontinence were allocated to the study. Hemodynamic parameters were noted and blood gas analyzes were performed before the induction of anesthesia, 10 min after induction, 5 and 10 min after the beginning of carbon dioxide insufflation, at the end of carbon dioxide insufflation and 30 min after exsufflation. Results: There was no significant change in mean arterial pressure, peripheral oxygen saturation, arterial carbon dioxide pressure, and arterial oxygen saturation compared to preinsufflation and preinduction values. End-tidal carbon dioxide pressure did not increase above 45 mm/Hg during carbon dioxide insufflation. Arterial oxygen saturation and partial oxygen pressure did not decrease. Subcutaneous emphysema, pneumothorax, pneumomediastinum and pleural effusion were not noted in any patient. Conclusion: We conclude that, extraperitoneal laparoscopic urethrocystopexy is not associated with hemodynamic and respiratory impairment.
Key words
blood gas analyzes, carbon dioxide insufflation, hemodynamic parameters, laparoscopic extraperitoneal urethrocystopexy.
Introduction Various pathologic conditions have been diagnosed and treated with laparoscopy for more than two decades. However, peritoneal insufflation of carbon dioxide to create the pneumoperitoneum necessary for laparoscopy induces intraoperative ventilatory and hemodynamic changes that complicate anesthetic management of laparoscopy.1–3 Extraperitoneal laparoscopic urethropexy has recently been developed as a minimally invasive procedure to treat female stress urinary incontinence. Extraperitoneal laparoscopic urethropexy can be performed rapidly and safely in patients without previous pelvic surgery.4 Correspondence: Hasan Kocoglu MD, Gaziantep Üniversitesi Tip Fakültesi, S¸ ahinbey Tip Merkezi, 27310 Gaziantep, Turkey. Email:
[email protected] Received 12 November 2001; accepted 18 February 2002.
Retroperitoneoscopy is not associated with greater carbon dioxide absorption compared to transperitoneal laparoscopy.5 There are relatively few clinical studies on hemodynamic effects of extraperitoneal laparoscopy. In the present study, we investigated the effects of extraperitoneal laparoscopy and carbon dioxide insufflation on hemodynamic parameters, subcutaneous emphysema, pneumothorax, pneumomediastinum, pleural effusion and arterial blood gases, especially carbon dioxide pressure and oxygen saturation.
Methods The present study was conducted with the approval of the ethics committee of the Medical Faculty of Gaziantep University (Gaziantep, Turkey). The 25 female patients who underwent urethrocystopexy to correct stress urinary incontinence as part of this study
Arterial blood gases in urethrocystopexy
gave their written consent to participate. The preoperative physical status of patients were I or II, according to the classification of the American Society of Anesthesiologists (ASA). Patients were eligible for the study if they had no history of previous lung disease, showed normal preoperative blood gas analyzes, had no history of smoking, were younger than 60 years of age and were not obese (body mass index > 29). After monitoring ECG (Drager PM 8040, Lubeck, Germany), invasive arterial blood pressure, temperature, heart rate (HR), capnography, and peripheral arterial oxygen saturation (SpO2), arterial blood was taken for blood gas analyses while the patients breathed naturally. General anesthesia was induced intravenously by fentanyl (1–2 µg/kg), thiopental (5 mg/kg), and atracurium (0.5 mg/kg). After tracheal intubation, general anesthesia was maintained with isoflurane and 50% oxygen. Controlled ventilation was performed using a ventilator connected to a rebreathing circuit (Cato, Drager, Lubeck, Germany) with a fresh gas flow of > 5 L/min, and a tidal volume of 8–10 mL/kg at a rate of 12 breaths/ min. Respiratory condition was not changed until the end of the operation. Nitrous oxide was not used, and fentanyl (1 µg/kg) was given for analgesia every half hour. Isoflurane concentrations were adapted to keep the patient hemodynamically stable, while mean arterial pressure was not allowed to increase 20% above preinduction value. A basal IV infusion (4 mL/kg/ h) of lactated Ringer’s solution was administered. After the induction of anesthesia, arterial blood gas analyzes were repeated throughout the surgical procedures. Data were collected before the induction of anesthesia (T1), 10 min after induction (T2), 5 min (T3) and 10 min (T4) after the beginning of carbon dioxide insufflation, at the end of carbon dioxide insufflation (T5), and finally, 30 min after exsufflation (T6). At T6 anesthesia was terminated for ± 15 min and the patient was tracheally extubated and breathed room air spontaneously. All cases were performed by the same surgeon. The surgical method involved cystourethropexy using a distension and elevation balloon through two ports. Following the 40 mm periumblical semicircular incision, dissection extended through subcutaneous fatty tissues and a vertical incision (30 mm) was made to the sheath of the rectus abdominis muscle at midline. Next, a blunt dissection to the Retzious space was created digitally under the rectus abdominis muscle, followed by a balloon dissector. The operative field was enlarged using an elevator balloon retractor with low flow CO2 insufflation (0.2 mL/min. at 12 mmHg), and a laparoscopic telescope was inserted (port 1). The working port (port 2) was then inserted through a 5-mm incision 30 mm cranially from symphysis pubis on the midline
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under the telescopic control. After a dissection to each side of the mid-urethra and bladder neck, each periurethral endopelvis fascia was fixed laterally to the ileopectineal ligament of each side of the periurethral plane using a prolene meshe (20 × 30 mm) for each side with an automatic tacker device, with the help of vaginal elevation. Afterwards, the working ports were removed and layers were closed according to the anatomical continuation. At the end of the surgical procedure, the surgeon recorded the presence or absence of subcutaneous emphysema by finger palpation in every case. A chest radiograph was obtained for each patient immediately after the operation, to check for subcutaneous emphysema, pneumothorax, pneumomediastinum and pleural effusion. All films were reviewed in a blinded manner. Results are reported as mean ± standard deviation (SD). Data were analyzed by Wilcoxon Signed Rank Test and Spearman Correlation test, using the SPSS software statistical analyzes program (SPSS, Chicago, USA). Results were considered to be statistically significant when P < 0.05.
Results Demographic characteristics of patients are represented in Table 1. Mean operation time was 34 (28–57) min and mean insufflation time was 17 (13–32) min. After the induction of anesthesia, mean arterial pressure was decreased, but not to a statistically significant amount. Peripheral oxygen saturation did not change, and was not decreased below 95% in any case, at any time (Table 2). The arterial oxygen tension was increased for the duration of controlled ventilation (P < 0.05), and neared the preinduction value after tracheal extubation (Table 3). There was no change in carbon dioxide tension and arterial oxygen saturation after insufflation compared to preinsufflation and preinduction values (Table 3). End-tidal carbon dioxide tension did not increase above 45 mm/Hg during carbon dioxide insufTable 1 Characteristics of 25 female patients who underwent urethrocystopexy for correction of stress urinary incontinence Patient characteristics Age Weight Height Body mass index
Mean SD 55.4 years 66.4 kg 165 cm 24.46 kg/m−2
n = 25; SD, standard deviation.
3.8 3.1 1 1.49
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Table 2 Changes in hemodynamic and respiratory parameters of 25 female patients who underwent urethrocystopexy
MAP†† (mm/Hg) HR‡‡ (bpm) Rhythm SpO2¶¶ (%) ETCO2*** (mmHg)
T1*
T2†
T3‡
T4§
T5¶
T6**
96 (13) 83 (6) NSR§§ 96 (1) 35 (3)
87 (3) 79 (4) NSR§§ 97 (1) 33 (2)
90 (5) 79 (4) NSR§§ 98 (1) 33 (2)
97 (8) 81 (5) NSR§§ 96 (2) 32 (2)
101 (4) 78 (4) NSR§§ 97 (2) 34 (2)
97 (5) 80 (4) NSR§§ 96 (1) 36 (2)
*Before the induction of anesthesia; †10 min after induction; ‡5 min after the beginning of carbon dioxide insufflation; §10 min after the beginning of carbon dioxide insufflation; ¶at the end of carbon dioxide insufflation; **30 min after exsufflation; ††mean arterial pressure; ‡‡heart rate; §§normal sinus rhythm; ¶¶peripheral oxygen saturation; ***end-tidal carbon dioxide pressure. Table 3 Arterial blood gas analyzes results of 25 female patients who underwent urethrocystopexy
pH SaO2§§ (%) PaO2¶¶ (mmHg) PaCO2††† (mmHg) Base excess
T1†
T2‡
T3§
T4¶
T5††
T6‡‡
7.41 (0.03) 98 (1) 86 (3) 41.2 (0.9) − 2.8 (0.6)
7.42 (0.04) 99 (1) 222 (14) * 38.3 (1.2) − 3.0 (0.6)
7.39 (0.04) 97 (2) 234 (16)* 37.8 (0.7) − 3.4 (1)
7.38 (0.02) 98 (1) 226 (12)* 39.1 (1) − 3.6 (0.7)
7.40 (0.03) 97 (2) 216 (11)* 37.5 (0.8) − 3.2 (0.3)
7.39 (0.03) 97 (1) 84 (4) 42.1 (0.5) − 3.3 (0.4)
*P < 0.05, compared to T1. †Before the induction of anesthesia; ‡10 min after induction; §5 min after the beginning of carbon dioxide insufflation; ¶10 min after the beginning of carbon dioxide insufflation; ††at the end of carbon dioxide insufflation; ‡‡30 min after exsufflation; §§arterial oxygen saturation; ¶¶arterial oxygen pressure; †††arterial carbon dioxide pressure.
flation and did not change compared to preinsufflation period. Arterial oxygen saturation and partial oxygen pressure were not decreased, even in the longest operation, and there was no statistically significant correlation between operation time and blood gas results (r: 0.15) (P > 0.05), or between insufflation time and blood gas results (r: 0.18) (P > 0.05). Subcutaneous emphysema, pneumothorax, pneumomediastinum and pleural effusion were not noted in any patient.
Discussion An increase (7–30%) in end-tidal carbon dioxide tension is commonly observed during laparoscopy during general anesthesia performed for urologic, abdominal and gynecologic surgical procedures. This increase results from pulmonary elimination of the carbon dioxide diffusing into the body from the peritoneal cavity.6 Prior reports have suggested that patients absorb greater amounts of carbon dioxide in the retroperitoneal or extraperitoneal approach (compared to transperitoneal laparoscopy) and demonstrate an increased incidence of carbon dioxide-related morbidity, such as subcutaneous emphysema, pneumomediastinum, and pneumothorax. However, Collins7 reported that the peritoneal mem-
brane may have a greater absorption capacity. Christopher et al.5 reported that retroperitoneoscopic surgery was not associated with increased carbon dioxide absorption. Bannenberg et al.8 performed intraperitoneal and extraperitoneal insufflation in 16 pigs for 1 h at 15 mm/ Hg pressure. The extraperitoneal approach was associated with lower end-tidal carbon dioxide, arterial carbon dioxide pressure, and respiratory acidosis. Coupled with the larger space and therefore greater absorptive area available in the peritoneal cavity, this finding may explain the greater systemic absorption of carbon dioxide during intraperitoneal insufflation. Mullett et al.9 reported that CO2 diffusion into the body is more marked during extraperitoneal than intraperitoneal CO2 insufflation, but is not influenced markedly by the duration of intraperitoneal insufflation. In another study, it was found that one hour after CO2 desufflation, reabsorption was complete.10 Bozkurt et al.11 showed that the pH, PaO2, base excess, arterial oxygen saturation, and SpO2 decreased, and PCO2 increased by insufflation of carbon dioxide intraperitoneally, and improved following deflation. Glascock et al.12 reported that the absorption of CO2 was significantly greater and more rapid during extraperitoneal laparoscopic pelvic lymph node dissection
Arterial blood gases in urethrocystopexy
than that of transperitoneal method during 120 min and 136 min of CO2 insufflation period, respectively. However, Villers et al.13 reported that extraperitoneal endosurgical pelvic lymphadenectomy with CO2 insufflation is a rapid, safe, and effective method (average operating time was 84 min) and is an alternative to conventional transperitoneal laparoscopic lymphadenectomy. Wright et al.14 reported similar results dictating that there was a median rise in arterial PCO2 over the first 15–20 min, followed by a second phase of only gradual change. The rise in arterial PCO2 during extraperitoneal insufflation was significantly slower than that of pneumoperitoneum. Our results are contradictory to Glascock et al.12 and parallel to other reports. This may be due to the shorter duration of CO2 insufflation time than that of the study of Glascock et al.12 Subcutaneous emphysema occurred in 12.5% of the transperitoneal and 45% of the retroperitoneal group.15 Lower body mass index was observed in patients with subcutaneous emphysema intraoperatively in extraperitoneal laparoscopy.16 In a larger series, subcutaneous emphysema and pneumothorax were more common after extraperitoneal pelvic laparoscopy.17 During the extraperitoneoscopy there may be an increased potential for subcutaneous emphysema because of nearer insufflation area to the port site. However, we did not observe any emphysema, pneumomediastinum or pneumothorax in any case in our study, even in low body mass index patients. This could be the result of a port site air leak, resulting in subcutaneous air tracking elimination or minimization. The majority of clinical studies on the effects of carbon dioxide insufflation during laparoscopy are based on observations during laparoscopic cholecystectomy,18,19 and gynecologic and urologic transperitoneal and extraperitoneal pelvic laparoscopy.20 Cardiovascular effects of intraperitoneal carbon dioxide insufflation include decreased cardiac index and stroke volume; and increased diastolic blood pressure, MAP and heart rate. Others have demonstrated a decrease in lung and chest wall compliance during transperitoneal laparoscopy.18 However, there is increasing evidence that the extraperitoneal approach may have some advantages from a hemodynamic and cardiorespiratory viewpoint.7,8,21 Cardiac arrhythmia after CO2 insufflation is evident with an incidence of 5−10% with an emphasis of ventricular premature beats and bradycardia.22 Bozkurt et al.11 reported that transient arrhythmia was observed in ten infants 1 min after pneumoperitoneum, but there were no statistically significant alterations in heart rate and systolic blood pressure. We did not observe any arrhythmia in our study and arterial blood pressure did not change during pneumoperitoneum.
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Our study suggests that there is no increase in arterial carbon dioxide pressure or decrease in arterial oxygen pressure and saturation, neither is there acidosis in extraperitoneal carbon dioxide insufflation if performed within less than half an hour.
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