Kyong Shil Im

Transient occlusion of uterine arteries with endoscopic vascular clip preceding laparoscopic myomectomy.

BACKGROUND To determine whether performing transient occlusion of uterine arteries (TOUA) immediately before laparoscopic myomectomy can reduce intraoperative complications. SUBJECTS AND METHODS In a retrospective case-control study, laparoscopic myomectomy with and without TOUA was examined. Data were analyzed from 89 laparoscopic myomectomies performed by a single surgeon (Y.-S. Kwon) at Ulsan University Hospital (Ulsan, Korea) between March 2011 and December 2011. Surgical outcomes included preoperative myoma size, number of myoma, operative time, and operative blood loss. RESULTS Forty-nine women underwent laparoscopic myomectomy with TOUA with endoscopic vascular clipping, whereas 40 control patients underwent laparoscopic myomectomy alone. The TOUA group had no case of nerve or vascular injury during the operation time. The mean time of occlusion of both the uterine arteries was 15 minutes. The TOUA group had less mean blood loss during the operation than the group with laparoscopic myomectomy alone (111.9 versus 203.4 mL; P<.001). There were no significant differences in size and number of uterine myomas and intraoperative complications between the two groups. Moreover, there was not even a single case of conversion of laparoscopy to laparotomy in either group. CONCLUSIONS TOUA performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery with lower blood loss and no differences in other intraoperative complications.

Treatment for Postoperative Wound Pain in Gynecologic Laparoscopic Surgery: Topical Lidocaine Patches

BACKGROUND This article reports our early experience with the use of lidocaine patches for pain control in the immediate postoperative period after laparoscopic gynecologic surgery. SUBJECTS AND METHODS A prospective, double-blind, placebo-controlled clinical trial was conducted on 40 patients undergoing a gynecologic laparoscopy who were randomized to receive either topical patches of 700 mg of lidocaine (n=20) or placebo patches (n=20). The patch was divided evenly into four smaller patches, which were applied at the four port sites and changed every 12 hours for 36 hours after surgery. Postoperative pain was evaluated using the visual analog scale (VAS) score and the Prince Henry and 5-point verbal rating pain scale (VRS), and the analgesic requirement was also evaluated at 1, 6, 12, 24, and 36 hours after surgery. RESULTS The VAS score for wound pain was lower in the lidocaine patch group at 1 and 6 hours after surgery than the control group (P=.005 and <.0005, respectively). The VAS scores for postoperative pain were lower in the lidocaine patch group at rest 1 hour after surgery (P=.045). The 5-point VRS score for postoperative pain was lower in the lidocaine patch group at 6 and 12 hours after surgery (P=.015 and .035, respectively) than in the control group. CONCLUSIONS Topical lidocaine patches at the laparoscopic port sites reduced postoperative pain, particularly postoperative wound pain after gynecological laparoscopic procedures.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery

Background Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA. Methods The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 µg/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed. Results The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA. Conclusions The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.

Conservative adenomyomectomy with transient occlusion of uterine arteries for diffuse uterine adenomyosis.

This study aimed to determine the feasibility and safety of adenomyomectomy with transient occlusion of uterine arteries (TOUA) in patients with symptomatic diffuse uterine adenomyosis.

Heparin resistance during cardiopulmonary bypass.

The hemostatic system is activated during cardiopulmonary bypass (CPB) procedures, and the use of heparin attenuates the coagulation. However, heparin resistance occurs in between 4 and 22% of patients undergoing cardiac surgery, and the preoperative use of heparin is usually responsible for this. Sometimes, critically ill patients are referred for intra-aortic balloon pump (IABP) insertion, and anticoagulation therapy with heparin is recommended to prevent thrombosis and embolization. The author experienced heparin resistance in patients who underwent percutaneous coronary intervention (PCI) and IABP insertion.

Laparoscopic Adenomyomectomy Under Transient Occlusion of Uterine Arteries with an Endoscopic Vascular Clip

BACKGROUND To introduce the safe and effective surgical technique of laparoscopic adenomyomectomy with transient occlusion of uterine arteries (TOUA) in patients with symptomatic uterine adenomyoma. SUBJECTS AND METHODS In a prospective case study, we examined all cases of laparoscopic adenomyomectomy with TOUA performed by a single surgeon at Ulsan University Hospital, Ulsan, Korea, between May 2011 and September 2012. Surgical outcomes included operative time, intraoperative injury of blood vessels, nerves, and pelvic organs, as well as intraoperative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia and the recurrence of adenomyomic lesions by ultrasonography at the 6-month follow-up after laparoscopic adenomyomectomy with TOUA. RESULTS Thirty-four women who were refractory to medical treatment or who wanted surgical treatment for preserving their uterus underwent laparoscopic adenomyomectomy with TOUA using an endoscopic vascular clip. The mean age was 43.79 ± 4.94 years. The mean diameter of the adenomyomas was 5.29 ± 1.82 cm. The mean TOUA time, operation time, and hospital stay were 7.33 ± 4.12 minutes, 84.09 ± 31.48 minutes, and 3.82 ± 1.24 days, respectively. The mean estimated blood loss was 148.18 ± 93.99 mL, and no injury to the uterine arteries or pelvic nerves occurred. No cases of conversion to a laparotomy or major complications occurred. At the 6-month follow-up, complete remission of dysmenorrhea and menorrhagia occurred in 72.2% and 87.5% of patients, respectively. CONCLUSIONS Laparoscopic adenomyomectomy with TOUA could be a safe and effective surgical method for women with symptomatic uterine adenomyoma who want to preserve their fertility.

Transient occlusion of uterine arteries in laparoscopic uterine surgery.

BACKGROUND AND OBJECTIVES This study was conducted to determine the feasibility and effectiveness of transient occlusion of the uterine arteries (TOUA) during laparoscopic surgery for benign uterine tumors, with preservation of fertility. METHODS Patients with uterine myoma or adenomyoma underwent laparoscopic uterine surgery, with or without TOUA, performed by a single surgeon (Y.-S.K.). Surgical outcomes included operative time; occurrence of intraoperative injury of blood vessels, nerves, and pelvic organs; and intraoperative blood loss. RESULTS Of the 168 surgical patients included in this study, 144 were enrolled consecutively during the study period, and 24 had undergone adenomectomy before the study period. A total of 104 women (70 with myoma; 34 with adenomyoma) seeking uterine preservation underwent laparoscopic surgery with TOUA for benign uterine tumors. Sixty-four women (40 with myoma; 24 with adenomyoma) underwent surgery without TOUA. The mean total surgical time of the TOUA groups was 74.85 minutes for uterine myoma and 84.09 minutes for uterine adenomyoma. The mean estimated blood loss during laparoscopic myomectomy and adenomyomectomy was less in the TOUA groups than in the non-TOUA groups (109 vs. 203.4 mL in myomectomy, P < .05; 148.1 vs. 158.9 mL in adenomyomectomy; P < .05). Time to perform TOUA was 13.9 minutes in laparoscopic myomectomy and 7.33 minutes in laparoscopic adenomyomectomy. The hospital stay of the TOUA groups was 3.32 days for uterine myoma and 3.82 days for uterine adenomyoma. No intraoperative conversion to laparotomy was necessary, and no major complications occurred during any of the procedures. CONCLUSION Laparoscopic uterine surgery with TOUA could be a safe and effective surgical method for women with symptomatic benign uterine tumors who wish to preserve fertility.

Operating room fire using an alcohol-based skin preparation but without electrocautery

To the Editor, An operating room fire is rare but a well-known hazard that can result in significant patient morbidity. Due to their well-established antimicrobial properties, alcohol-based skin preparations are commonly used in the operating room despite their known flammability. The risk of an operating room fire with alcohol-based prep solutions is greatest in an oxygen-enriched atmosphere and the use of electrocautery as the ignition source. We report the occurrence of an operating room fire while using an alcohol-based skin preparation but without the use of electrocautery. An otherwise healthy 46-yr-old female patient was admitted to our institution for adhesiolysis of a flexion in her right third finger. She preferred general anesthesia. After routine monitors were applied and prior to induction of anesthesia, the patient’s lungs were preoxygenated with 100% oxygen at a flow rate of 5 L min. Anesthesia was induced with propofol 100 mg iv, lidocaine 40 mg iv, fentanyl 100 lg iv, and rocuronium 30 mg iv, followed by tracheal intubation. Anesthesia was maintained with 1-2 vol% of sevoflurane, with an oxygen to nitrous oxide ratio of 1:1 administered at a fresh gas flow rate of 3.0 L min. The patient was positioned supine on an operating room table with the affected hand placed on a hand surgery table that was well padded to prevent pressure sores or contusion to the ulnar nerve. An 18-in pneumatic tourniquet was applied to the patient’s right upper arm and a cotton drape was placed on the hand surgery table. The patient’s right arm was then prepped with an 83% ethyl alcohol solution (Green Ethyl Alcohol Solution 0.83ml/ml , Green Pharm, Korea). At this point, a fire suddenly ignited over the patient’s right arm. The fire was extinguished immediately with a wet cotton drape, and water and ice water were used to cool the wound. The patient’s right forearm became slightly swollen and red, and two small-sized blisters formed. The Safety Incident Management Committee investigated the cause of the fire. The surgeon explained the burn incident to the patient’s family, obtained their informed consent, and then performed the adhesiolysis using the finger tourniquet. During the investigation into the cause of the fire, no electrical short circuit was found around the patient or in the patient monitoring devices. The fire was considered to have been caused by pooling of the alcohol-based skin preparation fluid underneath the cotton drape on the hand surgery table. This produced alcohol vapour that was ignited by a static spark. Operating room fires from alcohol-based skin preparations usually occur in an oxygen-enriched atmosphere and are mainly associated with the use of electrocautery; however, ethyl alcohol is known to ignite and burn in room air (21% oxygen). A surface wiped down with alcohol requires only a single spark at room air oxygen concentrations to ignite. In this case, the operating room fire occurred during alcoholbased skin preparation without the use of electrocautery. Therefore, special precautions are necessary when alcoholbased skin preparations are used. The Emergency Care Research Institute has recommended that alcohol-based skin preparation solutions should not be allowed to pool and should be dry or dried before using electrocautery. In conclusion, the likelihood of fire can be reduced with awareness of the risk and by using simple prevention measures in every case. Anesthesiologists have a role to J. B. Kim, MD H. J. Jung, MD K. S. Im, MD (&) Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu St Mary’s Hospital, Uijeungbu-City, Gyeonggi-do, Korea e-mail: idonga@catholic.ac.kr

Cardiopulmonary bypass weaning difficulty due to anomalous origin of coronary artery -A case report-

We report a case of hemodynamic instability after aortic valve replacement, due to the anomalous origin of the right coronary artery. During the cardiopulmonary bypass weaning process, hemodynamic instability occurred. The cause was not identified at first, and compression of the anomalous right coronary artery was thought to be the culprit, thereafter.

Barotrauma developed during intra-hospital transfer -A case report-

A 74-year-old male patient receiving ventilatory support due to aspiration pneumonia developed bilateral pneumothorax, pneumopericardium, pneumomediastinum, pneumo-retroperitoneum, and subcutaneous emphysema, after manual ventilation while being transferred from the intensive care unit (ICU) to the operating room (OR). These complications were assumed to be secondary to inappropriate manual ventilation of the intubated patient. In addition, it is likely that the possible migration of an already marginally acceptable endotracheal tube (ETT) position during transport was the cause of these complications. Finally, aggravation of a latent pneumothorax might have contributed to these complications.