João Luiz Moreira Coutinho Azevedo

Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review.

BackgroundThe aim of this study was to assess the prevalence, risks, and outcomes of injuries caused by the Veress needle described in the literature.Methods Iatrogenic injuries caused by Veress needle insertion during diagnostic or therapeutic laparoscopies in humans were researched, with no language restriction, in the Medline, Lilacs, Embase, Scielo, and Cochrane Library databases. The following words were combined: “Veress” or “insufflation needle” or “pneumoperitoneum needle,” and “complications” or “injuries” or “lesions.” The bibliographic references of the selected articles were also analyzed. We considered the following: (1) number of injuries described in the literature, (2) relationship between number of injuries and number of patients who underwent Veress needle insertion in the studies that reported Veress needle injury, (3) organs and structures injured (retroperitoneal vessels, digestive tract, and self-limited, minor injuries), and (4) outcome (death, conversion to laparotomy, laparoscopic repair, spontaneous resolution).ResultsThirty-eight selected articles included 696,502 laparoscopies, with 1,575 injuries (0.23%), 126 (8%) of which involved blood vessels or hollow viscera (0.018% of all laparoscopies). Of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specific as to which vessel was injured. Of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed).ConclusionThe insertion of the Veress needle in the abdominal midline, at the umbilicus, poses serious risk to the life of patients. Therefore, further studies should be conducted to investigate alternative sites for Veress needle insertion.

The impact of obesity on pulmonary function in adult women

INTRODUCTION Obesity can cause deleterious effects on respiratory function and impair health and quality of life. OBJECTIVE To evaluate the effects of obesity on the pulmonary function of adult women. METHODS An obese group, constituted of 20 women between 20 and 35 years old with a BMI of 35 – 49.99 kg/m2 who were non-smokers and sedentary and had no lung disease were recruited. The non-obese group consisted of 20 women between 20 and 35 years old who were sedentary and non-smokers and had no lung disease and a body mass index between 18.5 and 24.99 kg/m2. Spirometry was performed in all subjects. The statistical analysis consisted of parametric or non-parametric tests, depending on the distribution of each variable, considering p < 0.05 to be statistically significant. RESULTS The obese group presented a mean age of 25.85 ± 3.89 years and a mean BMI of 41.1 ± 3.46 kg/m2, and the non-obese group presented a mean age of 23.9 ± 2.97 years and a mean body mass index of 21.91 ± 1.81 kg/m2. There were no significant differences between the obese group and the non-obese group as to the age, vital capacity, tidal volume, forced vital capacity, and forced expiratory volume in one second. However, the obese group presented a greater inspiratory reserve volume (2.44 ± 0.47 L vs. 1.87 ± 0.42 L), a lower expiratory reserve volume (0.52 ± 0.32 L vs. 1.15 ± 0.32 L), and a maximal voluntary ventilation (108.5 ± 13.3 L/min vs. 122.6 ± 19.8 L/min) than the non-obese group, respectively. CONCLUSION The alterations evidenced in the components of the vital capacity (inspiratory reserve volume and expiratory reserve volume) suggest damage to the chest mechanics caused by obesity. These factors probably contributed to a reduction of the maximal voluntary ventilation.

Evaluation of tests performed to confirm the position of the Veress needle for creation of pneumoperitoneum in selected patients: a prospective clinical trial

PURPOSE To evaluate tests performed to confirm the position of the Veress needle inserted into the left hypochondrium for creation of pneumoperitonium. METHODS One hundred patients were submitted to laparoscopic procedure with left hypochondrium puncturing. Needle positioning tests were evaluated. The aspiration test was considered positive when organic material was aspirated; the injection test was considered positive when no increased resistance to liquid injection was observed; the recovery test was considered positive when the liquid injected was not recovered; the saline drop test was considered positive when drops of saline in the syringe disappeared quickly; the initial intraperitoneal pressure test was considered positive when pressure levels were 8 pounds mmHg. A positive aspiration test indicated iatrogenic injury, whereas a positive result in any of the other tests indicated that the tip of the needle was correctly positioned in the peritoneal cavity. Sensitivity (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) of the tests were calculated by correlating results considered true positives (a), false positives (b), false negatives (c) and true negatives (d), according to the formulas: SE = [a/(a + c)] x 100; SP = [d/(b + d)] x 100; PPV = [a/(a + b)] x 100; NPV = [d(c + d)] x 100. RESULTS With regard to the aspiration test, SE and PPV were not applicable, SP was 100% and NPV was 100%. With regard to the injection test, SE was 0%, SP was 100%, PPV was inexistent and NPV was 90%. Both recovery and saline drop tests yielded the following results: SE was 50%, SP was 100%, PPV was 100% and NPV was 94.7%. The initial intraperitoneal pressure test yielded the following results: SE, SP, PPV and NPV were 100%. CONCLUSIONS When inserting the Veress needle into the left hypochondrium, a negative aspiration test guarantees the absence of iatrogenic injury; the injection test is not reliable to determine incorrect needle positioning, but it accurately detects correct needle positioning; recovery and saline drop tests are not reliable to determine correct needle positioning, but they accurately detect incorrect needle positioning; the initial intraperitoneal pressure test is reliable to determine both correct and incorrect needle positioning, and proved to be the most reliable of the tests analyzed.

Glucose homeostasis and weight loss in morbidly obese patients undergoing banded sleeve gastrectomy: a prospective clinical study

OBJECTIVE To assess glucose homeostasis and weight loss in morbidly obese patients undergoing Silastic® ring sleeve gas-trectomy. METHODS This was a prospective clinical study. Thirty-three female patients with a mean body mass index (BMI) of 42.33 ± 1.50 kg/m2 (range: 40–45 kg/m2), a mean age of 36.7 ± 9.4 years and a mean waist circumference of 118.7 ± 5.98 cm were included in this study. Type 2 diabetes mellitus was observed in 11 patients (33.3%), and glucose intolerance was observed in 4 patients (12.1%). Mean plasma fasting glucose levels were 109.77 ± 44.19 mg/dl (75–320) in the preoperative period. All Silastic® ring sleeve gastrectomy procedures were performed by the same surgical team using the same anesthetic technique. The patients were monitored for at least 12 months after surgery. RESULTS The mean weight of the patients decreased from 107.69 ± 6.57 kg to 70.52 ± 9.36 kg (p < 0.001), the mean BMI decreased to 27.4 ± 2.42 kg/m2 (p < 0.001), and the mean waist circumference decreased to 89.87 cm ± 6.66 (p < 0.001) in the postoperative period. Excess BMI loss was 86.5 ± 14.2%. Fasting glucose levels were reduced to 80.94 ± 6.3 mg/dl (p < 0.001). Remission of diabetes and glucose intolerance was observed in all patients. CONCLUSION Silastic® ring sleeve gastrectomy was effective in promoting weight loss, waist circumference reduction and control of glucose homeostasis in morbidly obese patients.

Evaluation of the positioning of the tip of the Veress needle during creation of closed pneumoperitoneum in pigs

PURPOSE Erroneous punctures and insufflations are frequent with the use of the Veress needle. Mistaken injections of gas in the preperitoneal space are not rare. The purpose of this research is to evaluate the correct positioning of the tip of the needle during creation of pneumoperitoneum. METHODS The needle was inserted into the peritoneal cavity. Tests to assess the positioning of the needle tip were carried out. Pressure, flow rate and volume were periodically recorded and the needle was removed, being immediately reinserted into the right hypochondrium and placed in the preperitoneal space. RESULTS The liquid flow test was always positive in the peritoneal cavity. No resistance to saline injection into the peritoneal cavity was observed, but increased resistance to saline injection into the preperitoneal space was observed in 45.5% of the cases. Some saline was recovered in 63.5% of the cases in the peritoneal cavity, and in 54.5% in the preperitoneal space. Saline drop test was positive in 66.6% of the cases in the peritoneal cavity and in 45.5% in the preperitoneal space. In the peritoneal cavity, initial pressure lower than 5 mm Hg was observed, and this pressure gradually increased during 123 seconds until reaching 15 mm Hg. In the preperitoneal space, initial pressure was 15 mm Hg. CONCLUSIONS Aspiration, liquid flow and saline drop tests are important, whereas recovery test is inconclusive. Initial pressure of approximately 5 mm Hg indicates that the tip of the needle is in the peritoneal cavity. The peritoneal cavity should hold ten times as much volume of gas as the preperitoneal space. The increase in pressure and volume in the peritoneal cavity can be predicted by statistics.

Veress needle insertion in the left hypochondrium in creation of the pneumoperitoneum.

PURPOSE To test the efficacy of the puncture in the left hypochondrium as an alternative method. METHODS Sixty-two patients randomly distributed into two groups were studied: Group LH, puncture in the left hypochondrium (n=30), and Group ML, puncture in the abdominal midline (n=32). The following were assessed: needle positioning tests, number of failed attempts at needle insertion, and time needed for creation of pneumoperitoneum. Gas flow, volume and intraperitoneal pressure were recorded at every 20 seconds, until a 12 mmHg pressure was reached inside the peritoneal cavity. RESULTS A similar number of positive results for the needle positioning tests were observed in both groups. Two failed attempts to reach the peritoneal cavity were observed in Group ML and one in Group LH. The time necessary for the creation of pneumoperitoneum was on average 3 minutes and 46 seconds for Group LH, and 4 minutes and 2 seconds for Group ML. Average gas flow, volume and pressure were equivalent for both groups. CONCLUSION Puncture in the left hypochondrium was as effective as puncture in the abdominal midline for the creation of pneumoperitoneum.

Intraperitoneal pressure and volume of gas injected as effective parameters of the correct position of the Veress needle during creation of pneumoperitoneum.

OBJECTIVE The aim of this work was to establish reliable parameters of the correct position of the Veress needle in the peritoneal cavity during creation of pneumoperitoneum. METHODS The Veress needle was inserted into the peritoneal cavity of 100 selected patients, and a carbon-dioxide flow rate of 1.2 L/min and a maximum pressure of 12 mm Hg were established. Intraperitoneal pressure (IP) and the volume of gas injected (VG) were recorded at the beginning of insufflation and at every 20 seconds. Correlations were established for pressure and volume in function of time. Values of IP and VG were predicted at 1, 2, 3, and 4 minutes of insufflation, by applying the following formulas: IP = 2.3083 + 0.0266 x time +8.3 x 10(-5) x time(2) - 2.44 x 10(-7) x time(3); and VG = 0.813 + 0.0157 x time. RESULTS A strong correlation was observed between IP and preestablished time points during creation of the pneumoperitoneum, as well as between VG and preestablished time points during creation of the pneumoperitoneum, with a coefficient of determination of 0.8011 for IP and of 0.9604 for VG. The predicted values were as follows: 1 minute = 4.15; 2 minutes = 6.27; 3 minutes = 8.36; and 4 minutes = 10.10 for IP (mm Hg); and 1 minute = 1.12; 2 minutes = 2.07; 3 minutes = 3.01; and 4 minutes = 3.95 for VG (L). CONCLUSIONS Values of IP and VG at given time points during insufflation for creation of the pneumoperitoneum, using the Veress needle, can be effective parameters to determine whether the needle is correctly positioned in the peritoneal cavity.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar. METHODS sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes. RESULTS there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed. CONCLUSIONS high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Comparative study of the changes in partial pressure of plasma carbon dioxide during carbon dioxide insufflation into the intraperitoneal and preperitoneal spaces.

BACKGROUND We aimed to compare plasma concentrations of carbon dioxide (CO(2)) in dogs that underwent intra- and preperitoneal CO(2) insufflation. MATERIALS AND METHODS Thirty dogs were studied. Ten formed a control group, 10 underwent intraperitoneal CO(2) insufflation, and 10 underwent preperitoneal CO(2) insufflation. General anesthesia with controlled ventilation was standardized for all dogs. After stabilizing the anesthesia, blood samples were collected at predetermined times and were sent for immediate gasometric analysis. Analysis of variance was used for comparing variables. RESULTS The plasma CO(2) concentration in the intraperitoneal insufflation group increased significantly more than in the preperitoneal insufflation group and was significantly greater than in the control group (P < 0.05). The pH values in the intraperitoneal group were lower than in the preperitoneal group (P < 0.05). CONCLUSION The data from this study suggest that a greater plasma concentration of CO(2) is achieved by insufflation at constant pressure into the intraperitoneal space than into the preperitoneal space.

Técnicas de sutura do tubo digestivo em plano único com nós atados no lume, em cães: pontos simples totais versus pontos extramucosos

OBJETIVO: Comparar a anastomose do tubo digestivo em plano unico com nos atados no lume por sutura com pontos totais versus pontos extramucosos. METODOS: Foram operados seis caes, com realizacao de duas seccoes transversas do jejuno a 30 cm e a 70 cm da flexura duodenojejunal e sutura, na face posterior com pontos extramucosos atados sobre a submucosa, e na face anterior com pontos totais atados sobre a mucosa. No 7o PO foram avaliadas, na face posterior, as aderencias na linha de sutura e feitos exames macroscopico e microscopico. RESULTADOS: As aderencias peritoneais foram mais profusas nas suturas extramucosas com tecido aderencial sobre a linha de sutura, sem reconstituicao da serosa, ou com a deformidade cicatricial das serosas dos cotos angulando a anastomose. A serosa teve boa reconstituicao nas suturas totais. O epitelio mucoso reconstituiu-se perfeitamente nas extramucosas, mas nao nas totais. Nas suturas totais houve focos residuais de inflamacao aguda.O realinhamento, a reestruturacao e a regeneracao das camadas (exceto a serosa, cuja regeneracao foi prejudicada por aderencias) foi melhor na sutura extramucosa que na total. A muscular da mucosa nao se regenerou em nenhuma anastomose. Os polimorfonucleares, os macrofagos, os fibroblastos e as fibras colagenas foram mais numerosos (significância estatistica) na sutura total. CONCLUSAO: As suturas totais da parede posterior da anastomose com nos atados no lume, sobre a mucosa, sao seguras, apesar da inflamacao maior. A sutura extramucosa da parede posterior, com nos atados no lume, sobre a submucosa, propicia a formacao de aderencias peritoneais, devendo ser evitada.