Cardiac Function and Hemodynamic Changes during Minimally Invasive Hysterectomy with Pneumoperitoneum and Steep Trendelenburg Position for Patients with Endometrial Cancer Who Are Obese

Abstract

To assess the effect of carbon dioxide (CO 2) pneumoperitoneum and steep Trendelenburg position on patients' cardiac function and hemodynamics during minimally invasive staging surgery for endometrial cancer. Design: Single-center prospective longitudinal study. Setting: University-affiliated tertiary hospital. Patients: Patients with endometrial cancer undergoing minimally invasive surgery. Interventions: After consent, the patients' hemodynamic parameters were assessed by the Non-Invasive Cardiac System (NI Medical, Petah Tikva, Israel) at 5 time points: before general anesthesia, after induction of general anesthesia, after CO 2 insufflation of the peritoneum, after steep Trendelenburg position, and at the end of surgery. Measurements and Main Results: Twenty-three women were recruited. The median age of the patients was 68 years (interquartile range [IQR] 62−75), with a median body mass index of 34.9 kg/m 2 (IQR 31.2−39.5) and an American Society of Anesthesiologists score ≥2. The initial median mean arterial pressure was 108 mmHg (IQR 101−113), and the baseline median cardiac output was 7.2 L/min (IQR 5.6−8.7). The median mean arterial pressure significantly decreased by 18% after insufflation (p = .001), again after Trendelenburg position (p = .003), and did not fully recover at the end of surgery in comparison with the preanesthesia baseline (p = .001). The median stroke volume significantly decreased by 17% after insufflation compared with the baseline (p = .01) and then gradually recovered to the baseline levels by the end of surgery. The median cardiac power significantly decreased by 35% after insufflation (0.009), remained low during Trendelenburg position (p = .009), and recovered by the end of surgery to 18% below the baseline levels (p = .035). Conclusion: Significant hemodynamic changes occur during minimally invasive staging surgery for endometrial cancer. CO 2 insufflation is accompanied by the most dramatic hemodynamic deterioration during surgery, and this does not get affected much with Trendelenburg. Knowledge of the hemodynamic values of women classified as high risk when using a noninvasive technique during surgery is obtainable and may assist both surgeon and anesthesiologist to ensure a safer procedure.

Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy

“…The risk of conversion to laparotomy increases with BMI, and studies of RS in patients with BMI > 50 kg/m 2 report higher conversion rates as compared with lower BMI patients, 19.6% versus 8% [29] and 6.5% versus 4.3% [18], although this is lower than with LS [11]. One of the reasons for this is due to increased intolerance of steep Trendelenburg position and insufflation, which are known to impact on cardiac function [30] and increase the likelihood of complete airway closure [31]. Although BMI was associated with insufflation pressure in our cohort, the use of pressures ≤ 15 mmHg may have helped to increase the tolerability of the procedure, in combination with the lift from the robot arms helping create intra-abdominal space and reducing peak airway pressures, as has been reported previously [32].…”

Risk of Upper-body Adverse Events in Robot-assisted Total Laparoscopic Hysterectomy for Benign Gynecologic Disease

“…Pneumoperitoneum and steep Trendelenburg position significantly impact on cardiac and hemodynamic function during minimally invasive hysterectomy [20]. Thus, these complications may be even more pronounced in RA-TLH when compared to traditional TLH, if operative times are indeed prolonged as well as due to the unique setup of the robot limiting intraoperative position shifts and restricted anesthesiologist access to the patient [14,19].…”