Background Laparoscopy is a common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. Life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and an anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. This is an update of a Cochrane review first published in 2008. Objectives To evaluate the benefits and risks of different laparoscopic techniques in gynaecological and non-gynaecological surgery. Search methods This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to February 2011. Selection criteria Randomised controlled trials were included when one laparoscopic entry technique was compared with another. Data collection and analysis Data were extracted independently by the first three authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto OR) with 95% confidence interval (CI). Main results The review included 28 randomised controlled trials with 4860 individuals undergoing laparoscopy and evaluated 14 comparisons. Overall there was no evidence of advantage using any single technique in terms of preventing major vascular or visceral complications. Using an open-entry technique compared to a Veress Needle demonstrated a reduction in the incidence of failed entry, Peto OR 0.12 (95% CI 0.02 to 0.92). There were three advantages with direct-trocar entry when compared with Veress Needle entry, in terms of lower rates of failed entry (Peto OR 0.21, 95% Cl 0.14 to 0.31), extraperitoneal insufflation (Peto OR 0.18, 95% Cl 0.13 to 0.26), and omental injury (Peto OR 0.28, 95% CI 0.14 to 0.55).There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (Peto OR 0.31, 95% Cl 0.15 to 0.62). Finally, there was an advantage of not lifting the abdominal wall before Veress Needle insertion when compared to lifting in terms of failed entry, without an increase in the complication rate (Peto OR 4.44, 95% CI 2.16 to 9.13). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index who may have unusually high complication rates. Authors' conclusions An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury.Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.

Laparoscopic Entry Techniques

http://hub.hku.hk/bitstream/10722/215072/1/Content.pdf

Adiponectin ameliorates hyperglycemia-induced cardiac hypertrophy and dysfunction by concomitantly activating Nrf2 and Brg1

BACKGROUND:Epidural anesthesia may attenuate the sympathetic hyperactivity and stress response from surgery. In this study, we compared the stress response, hemodynamic variables, and recovery profiles of patients undergoing total IV anesthesia (TIVA) and intraoperative dexmedetomidine with those re

Dexmedetomidine Combined with General Anesthesia Provides Similar Intraoperative Stress Response Reduction When Compared with a Combined General and Epidural Anesthetic Technique.

/pdf/rwshhy-wrwd-dr-lprskhwpy-2et94z5gwi.pdf

روشهای ورود در لاپاراسکوپی

Several clinical trials have examined and indicated the usefulness of epidural dexmedetomidine therapy. However, there has been no systematic analysis of the findings of these trials to date. We undertook this systematic review and meta-analysis to investigate the efficacy and safety of epidural dexmedetomidine adjunctive therapy in different surgical procedures. We searched EMBASE, PubMed, the Cochrane Library, and the Clinical Trials.gov database to identify randomized controlled trials investigating the effects of epidural dexmedetomidine adjunctive therapy. The article search was conducted without language or date restrictions. The date of the last search was 27 July 2016. The mean differences (MD) or standardized mean differences (SMD) with 95% confidence intervals (CIs) were calculated for continuous variables, and risk ratios (RRs) were presented for dichotomous outcomes. Heterogeneity was assessed using τ
 2, χ
 2 and I
 2 analyses. Twelve randomized controlled trials were included in the final analysis. Compared with the control treatment, epidural dexmedetomidine administration prolonged the duration of analgesia (P   0.05) in comparison with that reported for the control therapies. Furthermore, dexmedetomidine effectively reduced post-operative pain (P = 0.03), whilst the occurrence of other side effects, such as pruritus, dizziness, dry mouth, nausea and vomiting did not differ significantly from that reported for the control therapies, except the risk of shivering was significantly higher with control therapies (P = 0.03). This systematic review and meta-analysis demonstrates that dexmedetomidine as an adjuvant in epidural procedures is generally safe and well tolerated. Furthermore, dexmedetomidine acted synergistically and provided an improved sedation and analgesic profile.

Efficacy and Safety of Dexmedetomidine as an Adjuvant in Epidural Analgesia and Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Many drugs can pass through the placenta and cause adverse effects on the foetus. Thus, during Caesarean section for puerperas who have contraindications for intravertebral anaesthesia, the use of proper drugs that have sedative, analgesic effects on the puerperas without adverse effects on the foetus is important. In this study, we investigated the effect and placental transfer of dexmedetomidine during Caesarean section under general anaesthesia. Thirty-eight puerperas were randomly divided to receive dexmedetomidine or saline before anaesthesia induction and during the operation. The dexmedetomidine-treated parturients had lower mean arterial pressure and heart rate at the delivery and at the end of the operation. The dexmedetomidine-treated parturients also needed 5.5% less propofol and 8.4% less fentanyl than the saline-treated ones. Between the dexmedetomidine-treated and saline-treated parturients, there was no difference in the maternal artery, umbilical vein, umbilical artery blood gas analysis results and the Apgar scores at 1 and 5 min. after delivery. The placental transfer rate of dexmedetomidine was 0.76. We concluded that dexmedetomidine was effective in maintaining the haemodynamic stability in the parturients during Caesarean section under general anaesthesia without adverse neonatal effects. Dexmedetomidine can pass through the placenta with a placental transfer rate of 0.76.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/bcpt.12389

Effect and Placental Transfer of Dexmedetomidine During Caesarean Section Under General Anaesthesia.

Background: Conventional laparoscopy is aided by CO2 insufflation, but this may impair cardiorespiratory function, induce stress responses, and result in life-threatening complications. CO2 insufflation is usually conducted under general anesthesia, whereas gasless laparoscopy supposedly eliminates most of these disadvantages. In this study, we compared the changes of concentration of serum cortisol, tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, IL-10, and heat shock protein 70 (Hsp70) in patients undergoing gynecological laparoscopic surgery in order to explore the severity of the stress response following CO2 pneumoperitoneum or abdominal wall-lifting methods combined with the different anesthetic techniques performed. Subjects and Methods: Fifty-seven patients scheduled for gynecological laparoscopy from July 2009 to February 2010 with American Society of Anesthesiologists I–II evaluation and scheduled operation times of less than 100 minutes were randomly divided into three gro...

Comparison of the stress response in patients undergoing gynecological laparoscopic surgery using carbon dioxide pneumoperitoneum or abdominal wall-lifting methods

ObjectiveTo investigate the neonatal effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia.MethodsForty parturients with a single newborn who were sch...

https://journals.sagepub.com/doi/pdf/10.1177/0300060517698330

Effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia.

Objective
To explore the anesthetic effect and neonatal effects of dexmedetomidine combined with ropivacaine in the cesarean section under epidural anesthesia.


Methods
Between January 2012 and March 2013 at the First Affiliated Hospital with Nanjing Medical University, sixty parturients with a single baby at full term in vertex presentation scheduled for caesarean section under epidural anesthesia, were randomly divided into 3 groups (n=20 each) according to the random digits table: dexmedetomidine + ropivacaine (RD), fentanyl + ropivacaine (RF) and normal saline + ropivacaine (RN). After identification of the epidural space and a negative aspiration test for blood or cerebrospinal fluid, 15 ml of 0.75% ropivacaine, was administered epidurally in three the groups with addition of 1 μg/kg of dexmedetomidine in RD group, 1 μg/kg of fentanyl in RF group and 2 ml of normal saline in RN group. Recording the mean arterial pressure (MAP) and heat rate (HR) before anesthesia (T0), at 10 min (T1) and 30 min (T2) after the end of epidural administration, and at end of operation (T3). Recording the onset time, maximum sensory analgesic level, time to maximum sensory analgesic level, time to two segmental dermatomal regressions, and time to chief complaint of postoperative pain. The modified bromage degrees, sedation scores and traction reaction were also assessed. The Apgar scores at 1 and 5 min were also recorded after delivery, and the blood samples were drawn from umbilical vein for gas analysis.


Results
MAP, HR and the motor block (Bromage scale) were no statistics differences among the three groups(P>0.05). Compared with RN group, the onset time and the time to maximum sensory analgesic level were significantly earlier [(6.3±2.4), (8.7±2.3) min vs(10.9±2.7)min; (11.5±3.9), (16.2±4.6) min vs(19.8±5.2) min , P<0.05], the time to two segmental dermatomal regressions and the time to chief complaint of postoperative pain were prolonged significantly[(22.5±4.6), (18.5±3.9) min vs(13.5±3.8)min; (415±92), (355±86) min vs( 273±68) min, P<0.05], level of sedation and degree of traction reaction were better in RD group and in RF group, and the incidence of shivering was lower in RD group (5% vs 40%, P<0.05), the incidence of dizziness was higher in RF group (20% vs 0, P<0.05). Compared with RF group, the same results were also seen about the onset time, the time to maximum sensory analgesic level, the time to two segmental dermatomal regressions and the time to chief complaint of postoperative pain, and the level of sedation was better, the incidence of drowsiness was lower in RD group. There were no statistics differences about both the blood gas analysis of umbilical vein and the Apgar scores at 1 and 5 min after delivery.


Conclusion
Administration of dexmedetomidine combined with ropivacaine can provide early onset, establishment of sensory anesthesia, much better sedation levels, decrease the degree of traction reaction and theincidence of shivering, and without adverse neonatal effects.


Key words: 
Dexmedetomidine; Anesthesia, epidural; Cesarean section

Application of dexmedetomidine combined with ropivacaine in the cesarean section under epidural anesthesia

Clinical effects of prophylactic use of phentolamine in patients undergoing pheochromocytoma surgery.

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