editorial comment

1
As a retrospective study, there are limitations based on the source of data acquisition. We used routine anesthesia vari- ables obtained intraoperatively for all patients and recorded manually by the anesthesiologist. The variables chosen for this study are used by the anesthetist to monitor any patient during surgical anesthesia. The measured parameters ETCO 2 and O 2 saturation are indirect reflection of arterial carbon dioxide and oxygen tension. Nyarwaya et al 18 vali- dated the reliability of these parameters to predict oxygen tension and arterial carbon dioxide accurately. The rest of the study parameters were directly measured. CONCLUSIONS We provided data regarding the impact of extraperitoneal and intraperitoneal laparoscopic urological surgery on hemo- dynamic and respiratory variables in pediatric patients. Al- though our data are limited due to the retrospective nature of the study, and comparison between the intraperitoneal and extraperitoneal groups is somewhat difficult due to patient age and surgical time differences, we documented significant changes following CO 2 insufflation. Such data will enable urologists to better select patients for laparoscopic urological surgery, and the anesthetists may be able to better predict possible physiological changes during the laparoscopic proce- dure. Further prospective studies are needed to provide solid data regarding the effect of the laparoscopic extraperitoneal approach to urological surgery on pediatric cardiorespiratory performance. REFERENCES 1. Telsey, J. I. and Caldamone, A. A.: Laparoscopy in pediatric urology. Curr Urol Rep, 2: 132, 2001 2. Gannedahl, P., Odeberg, S., Brodin, L. A. and Sollevi, A.: Effects of posture and pneumoperitoneum during anaesthesia on the indices of left ventricular filling. Acta Anaesthesiol Scand, 40: 160, 1996 3. Giebler, R. M., Behrends, M., Steffens, T., Walz, M. K., Peitgen, K. and Peters, J.: Intraperitoneal and retroperitoneal carbon dioxide insufflation evoke different effects on caval vein pres- sure gradients in humans: evidence for the starling resistor concept of abdominal venous return. Anesthesiology, 92: 1568, 2000 4. Poppas, D. P. and Ehrlich, R. M.: Physiologic changes and com- plications in pediatric laparoscopic surgery. Dialog Ped Urol, 18: 1, 1995 5. Tobias, J. D., Holcomb, G. W., III, Brock, J. W., III, Deshpande, J. K., Lowe, S. and Morgan, W. M., III: Cardiorespiratory changes in children during laparoscopy. J Pediatr Surg, 30: 33, 1995 6. Tobias, J. D. and Holcomb, G. W.: Anesthetic management for laparoscopic cholecystectomy in children with decreased myo- cardial function: two case reports. J Pediatr Surg, 32: 743, 1997 7. Wedgewood, J. and Doyle, E.: Anaesthesia and laparoscopic sur- gery in children. Paediatr Anaesth, 11: 391, 2001 8. Yemen, T. A.: Digestive tract: surgical considerations. In: Pediatric Anesthesia, Principles and Practice. Edited by B. Bisonnette and B. J. Dalens. New York: McGraw-Hill, chapt. 53, pp. 1055–1066, 2002 9. Macrae, D. and La Rovere, J.: Normal and abnormal develop- ment of the heart and circulation. In: Pediatric Anesthesia, Principles and Practice. Edited by B. Bisonnette and B. J. Dalens. chapt. 3, pp. 36 – 44, 2002 10. El Ghoneimi, A., Valla, J. S., Steyaert, H. and Aigrain, Y.: Laparoscopic renal surgery via a retroperitoneal approach in children. J Urol, 160: 1138, 1998 11. El Ghoneimi, A., Sauty, L., Maintenant, J., Macher, M. A., Lottmann, H. and Aigrain, Y.: Laparoscopic retroperitoneal nephrectomy in high risk children. J Urol, 164: 1076, 2000 12. Diemunsch, P., Becmeur, F. and Meyer, P.: Retroperitoneoscopy versus laparoscopy in piglets: ventilatory and thermic reper- cussions. J Pediatr Surg, 34: 1514, 1999 13. Wolf, J. S., Jr., Carrier, S. and Stoller, M. L.: Intraperitoneal versus extraperitoneal insufflation of carbon dioxide as for laparoscopy. J Endourol, 9: 63, 1995 14. McCammon, K. A. and Jordan, G. H.: ETCO2 changes during pediatric laparoscopy. Dial Ped Urol, 18: 3, 1995 15. Hirvonen, E. A., Nuutinen, L. S. and Kauko, M.: Ventilatory effects, blood gas changes, and oxygen consumption during laparoscopic hysterectomy. Anesth Analg, 80: 961, 1995 16. Fujise, K., Shingu, K., Matsumoto, S., Nagata, A., Mikami, O. and Matsuda, T.: The effects of the lateral position on cardio- pulmonary function during laparoscopic urological surgery. Anesth Analg, 87: 925, 1998 17. Hirvonen, E. A., Nuutinen, L. S. and Vuolteenaho, O.: Hormonal responses and cardiac filling pressures in head-up or head- down position and pneumoperitoneum in patients undergoing operative laparoscopy. Br J Anaesth, 78: 128, 1997 18. Nyarwaya, J. B., Mazoit, J. X. and Samii, K.: Are pulse oximetry and end-tidal carbon dioxide tension monitoring reliable dur- ing laparoscopic surgery? Anaesthesia, 49: 775, 1994 EDITORIAL COMMENT The spectrum of laparoscopic urological surgery in children con- tinues to widen. The level of complexity of these cases is associated with longer operative times until we become more proficient. In addition, the best surgical approach to many surgical procedures, ie transperitoneal or extraperitoneal, remains debatable. As such, the physiological impact of insufflation on children becomes a critically important factor. The authors evaluated the effect of insufflation on several hemo- dynamic and respiratory parameters during the course of extraperi- toneal and transperitoneal laparoscopic surgeries. These changes were more significant for children placed in the left lateral position, and there were variable differences between cases performed via an extraperitoneal or transperitoneal approach. This article should serve as a springboard for further evaluation of the metabolic effects of insufflation in children undergoing laparo- scopic surgery. The stratification of patients is presented well. Ad- ditional numbers or pooled data collected in a standard fashion would allow for validation of these findings. The information gleaned from this study will allow us, along with our anesthesia colleagues, to best manage the metabolic demands that are placed on these children. As we continue to expand our horizons and seek to optimize our laparoscopic capabilities, these metabolic and physiological fac- tors will become increasingly more important. Lane S. Palmer Division of Pediatric Urology Schneider Children’s Hospital of the North Shore-Long Island Jewish Health System New Hyde Park, New York REPLY BY AUTHORS Our study was stimulated by the lack of information on the impact of CO 2 insufflation on child physiology despite the growing use of laparoscopy in the pediatric population. Since cardiopulmonary physiology in children is far more fragile compared to the adult, we were prompted to look at the hemodynamic and respiratory changes during pediatric urological laparoscopic surgeries. Although our findings shed some light on the cardio-respiratory changes induced by transperitoneal and retroperitoneal laparoscopy, the limitation of this study is that it is retrospective. The comparison between the retroperitoneal and transperitoneal groups was further limited by variation in patient age and operative surgical time. Presently in collaboration with our general surgery and anesthesia colleagues, we are prospectively evaluating the impact of CO 2 insuf- flation, body position (lateral, supine and Trendelenburg) and sur- gical technique (retroperitoneal, transperitoneal) on cardiopulmo- nary and cerebral blood flow changes. Such a prospective study will hopefully provide accurate information on the impact of laparoscopy in children. This will not only help us identify the physiological challenges associated with laparoscopic surgeries, but also may help to better select patients for this approach. HEMODYNAMIC AND RESPIRATORY EFFECT OF LAPAROSCOPIC SURGERY 1654

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As a retrospective study, there are limitations based on thesource of data acquisition. We used routine anesthesia vari-ables obtained intraoperatively for all patients and recordedmanually by the anesthesiologist. The variables chosen forthis study are used by the anesthetist to monitor any patientduring surgical anesthesia. The measured parametersETCO2 and O2 saturation are indirect reflection of arterialcarbon dioxide and oxygen tension. Nyarwaya et al18 vali-dated the reliability of these parameters to predict oxygentension and arterial carbon dioxide accurately. The rest ofthe study parameters were directly measured.

CONCLUSIONS

We provided data regarding the impact of extraperitonealand intraperitoneal laparoscopic urological surgery on hemo-dynamic and respiratory variables in pediatric patients. Al-though our data are limited due to the retrospective nature ofthe study, and comparison between the intraperitoneal andextraperitoneal groups is somewhat difficult due to patientage and surgical time differences, we documented significantchanges following CO2 insufflation. Such data will enableurologists to better select patients for laparoscopic urologicalsurgery, and the anesthetists may be able to better predictpossible physiological changes during the laparoscopic proce-dure. Further prospective studies are needed to provide soliddata regarding the effect of the laparoscopic extraperitonealapproach to urological surgery on pediatric cardiorespiratoryperformance.

REFERENCES

1. Telsey, J. I. and Caldamone, A. A.: Laparoscopy in pediatricurology. Curr Urol Rep, 2: 132, 2001

2. Gannedahl, P., Odeberg, S., Brodin, L. A. and Sollevi, A.: Effectsof posture and pneumoperitoneum during anaesthesia on theindices of left ventricular filling. Acta Anaesthesiol Scand, 40:160, 1996

3. Giebler, R. M., Behrends, M., Steffens, T., Walz, M. K., Peitgen,K. and Peters, J.: Intraperitoneal and retroperitoneal carbondioxide insufflation evoke different effects on caval vein pres-sure gradients in humans: evidence for the starling resistorconcept of abdominal venous return. Anesthesiology, 92: 1568,2000

4. Poppas, D. P. and Ehrlich, R. M.: Physiologic changes and com-plications in pediatric laparoscopic surgery. Dialog Ped Urol,18: 1, 1995

5. Tobias, J. D., Holcomb, G. W., III, Brock, J. W., III, Deshpande,J. K., Lowe, S. and Morgan, W. M., III: Cardiorespiratorychanges in children during laparoscopy. J Pediatr Surg, 30: 33,1995

6. Tobias, J. D. and Holcomb, G. W.: Anesthetic management forlaparoscopic cholecystectomy in children with decreased myo-cardial function: two case reports. J Pediatr Surg, 32: 743,1997

7. Wedgewood, J. and Doyle, E.: Anaesthesia and laparoscopic sur-gery in children. Paediatr Anaesth, 11: 391, 2001

8. Yemen, T. A.: Digestive tract: surgical considerations. In:Pediatric Anesthesia, Principles and Practice. Edited by B.Bisonnette and B. J. Dalens. New York: McGraw-Hill,chapt. 53, pp. 1055–1066, 2002

9. Macrae, D. and La Rovere, J.: Normal and abnormal develop-ment of the heart and circulation. In: Pediatric Anesthesia,Principles and Practice. Edited by B. Bisonnette and B. J.Dalens. chapt. 3, pp. 36–44, 2002

10. El Ghoneimi, A., Valla, J. S., Steyaert, H. and Aigrain, Y.:Laparoscopic renal surgery via a retroperitoneal approach inchildren. J Urol, 160: 1138, 1998

11. El Ghoneimi, A., Sauty, L., Maintenant, J., Macher, M. A.,Lottmann, H. and Aigrain, Y.: Laparoscopic retroperitonealnephrectomy in high risk children. J Urol, 164: 1076, 2000

12. Diemunsch, P., Becmeur, F. and Meyer, P.: Retroperitoneoscopyversus laparoscopy in piglets: ventilatory and thermic reper-

cussions. J Pediatr Surg, 34: 1514, 199913. Wolf, J. S., Jr., Carrier, S. and Stoller, M. L.: Intraperitoneal

versus extraperitoneal insufflation of carbon dioxide as forlaparoscopy. J Endourol, 9: 63, 1995

14. McCammon, K. A. and Jordan, G. H.: ETCO2 changes duringpediatric laparoscopy. Dial Ped Urol, 18: 3, 1995

15. Hirvonen, E. A., Nuutinen, L. S. and Kauko, M.: Ventilatoryeffects, blood gas changes, and oxygen consumption duringlaparoscopic hysterectomy. Anesth Analg, 80: 961, 1995

16. Fujise, K., Shingu, K., Matsumoto, S., Nagata, A., Mikami, O.and Matsuda, T.: The effects of the lateral position on cardio-pulmonary function during laparoscopic urological surgery.Anesth Analg, 87: 925, 1998

17. Hirvonen, E. A., Nuutinen, L. S. and Vuolteenaho, O.: Hormonalresponses and cardiac filling pressures in head-up or head-down position and pneumoperitoneum in patients undergoingoperative laparoscopy. Br J Anaesth, 78: 128, 1997

18. Nyarwaya, J. B., Mazoit, J. X. and Samii, K.: Are pulse oximetryand end-tidal carbon dioxide tension monitoring reliable dur-ing laparoscopic surgery? Anaesthesia, 49: 775, 1994

EDITORIAL COMMENT

The spectrum of laparoscopic urological surgery in children con-tinues to widen. The level of complexity of these cases is associatedwith longer operative times until we become more proficient. Inaddition, the best surgical approach to many surgical procedures, ietransperitoneal or extraperitoneal, remains debatable. As such, thephysiological impact of insufflation on children becomes a criticallyimportant factor.

The authors evaluated the effect of insufflation on several hemo-dynamic and respiratory parameters during the course of extraperi-toneal and transperitoneal laparoscopic surgeries. These changeswere more significant for children placed in the left lateral position,and there were variable differences between cases performed via anextraperitoneal or transperitoneal approach.

This article should serve as a springboard for further evaluation ofthe metabolic effects of insufflation in children undergoing laparo-scopic surgery. The stratification of patients is presented well. Ad-ditional numbers or pooled data collected in a standard fashionwould allow for validation of these findings. The information gleanedfrom this study will allow us, along with our anesthesia colleagues,to best manage the metabolic demands that are placed on thesechildren. As we continue to expand our horizons and seek to optimizeour laparoscopic capabilities, these metabolic and physiological fac-tors will become increasingly more important.

Lane S. PalmerDivision of Pediatric UrologySchneider Children’s Hospital of the North Shore-Long Island

Jewish Health SystemNew Hyde Park, New York

REPLY BY AUTHORS

Our study was stimulated by the lack of information on the impactof CO2 insufflation on child physiology despite the growing use oflaparoscopy in the pediatric population. Since cardiopulmonaryphysiology in children is far more fragile compared to the adult, wewere prompted to look at the hemodynamic and respiratory changesduring pediatric urological laparoscopic surgeries. Although ourfindings shed some light on the cardio-respiratory changes inducedby transperitoneal and retroperitoneal laparoscopy, the limitation ofthis study is that it is retrospective. The comparison between theretroperitoneal and transperitoneal groups was further limited byvariation in patient age and operative surgical time.

Presently in collaboration with our general surgery and anesthesiacolleagues, we are prospectively evaluating the impact of CO2 insuf-flation, body position (lateral, supine and Trendelenburg) and sur-gical technique (retroperitoneal, transperitoneal) on cardiopulmo-nary and cerebral blood flow changes. Such a prospective study willhopefully provide accurate information on the impact of laparoscopyin children. This will not only help us identify the physiologicalchallenges associated with laparoscopic surgeries, but also may helpto better select patients for this approach.

HEMODYNAMIC AND RESPIRATORY EFFECT OF LAPAROSCOPIC SURGERY1654