Background: Due to its numerous benefits laparoscopic surgery become very popular

among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can

be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving

visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in

arterial blood gasses.

Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0

before induction – basal, T1 after one hour of CO2 insufflation, and T2

 at the end of the surgery.

Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ±

8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in

retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002).

Conclusion: The findings that we have presented can suggest that both approaches are safe

although hypercarbia is observed in retroperitoneal group.

Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy,

urologic laparoscopy.

Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia,

Reanimation and Intensive Care, Skopje, Republic of North Macedoni

Brzanov, Nikola

Gavrilovska-Brzanov, Aleksandra

Gjorchevska, Elena

Kartalov, Andrijan

Kokareva, Anita

Kuzmanovska, Biljana

Mojsova, Maja

Panovska Petrusheva, Aleksandra

Shosholcheva, Mirjana

Srceva, Marija

Stavridis, Sotir

UGD Academic Repository

 www.e-mja.finki.ukim.mkNumber 6. May 2019Macedonian Journal of AnaesthesiaA Journal on Anaesthesiology, Resuscitation, Analgesia and Critical CareEditor-in-ChiefMirjana ShosholchevaDeputy Editors:Andrijan KartalovBiljana KuzmanovskaAssociate EditorMarija Jovanovski-SrcevaEditorial Board:Marija Sholjakova (Macedonia)Nikola Jankulovski (Macedonia) Karin Khuenl-Brady (Austria)Quirino Piacevoli (Italy)Zorka Nikolova-Todorova (Macedonia) Radmilo Jankovic (Serbia) Olegs Sabelnikovs (Latvia)Jannicke Mellin-Olsen (Norway) Meral Kanbak (Turkey)Nebojsa Ladjevich (Serbia)Zoran Karadjov (Macedonia)Hristo Bozov (Bulgaria)Zuhal Aykaç (Turkey)Katarina Sakic (Hrvatska) Jasmina Jakupovich-Smajich (BIH)Jasminka Nancheva (Macedonia)Vojislava Neskovic (Serbia)Daniela Miladinova (Macedonia)Jordan Nojkov (Macedonia)Paul Zilberman (Israel) Antigona Hasani (Kosovo)Biljana Shirgovska (Macedonia) Atanas Sivevski (Macedonia)Hülya Bilgin (Turkey)Production Editor Vanja GievskiPublisher:Department of Anaesthesia and Reanimation, Faculty of Medicine, “Ss. Cyril and Methodius” University, Skopje, MacedoniaProofreading Daniela Nacevska StojcevskaPrinted by ASKOLOR|  10  |Macedonian Journal of AnaesthesiaNumber 6. May 2019  |  11  | ARTERIAL BLOOD GAS ALTERATIONS IN RETROPERITONEAL AND TRANSPERITONEAL LAPAROSCOPYGavrilovska-Brzanov A1, Shosholcheva M2, Kuzmanovska B1, Kartalov A1, Mojsova – Mijovska M1, Jovanovski Srceva M1, Panovska Petrusheva A1, Kokareva A1, Stavridis S3, Gjorchevska E1, Brzanov N41 University Clinic for Traumatology, Orthopedic Diseases, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency department, Faculty of Medicine, University “Ss Cyril and Methodius”, Skopje, Republic of North Macedonia2 University Clinic for General Surgery “St. Naum Ohridski” Faculty of Medicine, University “Ss Cyril and Methodius”, Skopje, Republic of North Macedonia3 University Clinic for Urology, Faculty of Medicine, University “Ss Cyril and Methodius”,Skopje, Republic of North Macedonia4 University Clinic for Abdominal Surgery, Faculty of Medicine, University “Ss Cyril and Methodius”, Skopje, Republic of North MacedoniaABSTRACTBackground: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparo-scopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery.Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperito-neal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002).Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group.Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy.Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North MacedoniaORIGINAL ARTICLE ISSN 2545-4366 | UDK: 616.6-089.819-032:616.23]:612.23Introduction:Due to its numerous benefits laparoscopic surgery became very popular, clinically applicable and universally accepted among physicians, patients and hospitals (1). The advantages over open surgery are: small incision, less postoperative pain, superior cosmetic results, brief recov-ery, fewer postoperative complications, decreased length of hospital stay and lower mortality (2). On the other side, laparoscopy requires insufflation of carbon dioxide (CO2) and creating pneumoperitoneum for achieving satisfactory visibility and further alterations in position from supine to Trendelenburg (3). There is a wide field of urologic interventions that can be performed laparoscopically either through retroperitoneal or transperitoneal approach (4). Retroperitoneal approach for laparoscopy was started 1979, but due to the inability to create a satisfactory pneumoperitoneum, the same was abandoned and it was only restored after Gaur announced his creative balloon technique of dissection of the retroperitoneal space previous to CO2 insuf-flation (5, 6). While retroperitoneal approach for laparoscopy may have some advantages; like secure port placement and decreased manipulation with abdominal vessels, on the other hand, it can be challenging due to limited working space, port closeness, higher CO2 insufflation for creating pneumoperitoneum and achieving better visibility and bigger Trendelenburg position which require superior anesthesia management and aggressive mechanical ventilation (MV) (7). Due to its high solubility in the blood, CO2 can enhance alterations in arterial blood gasses (ABG). Therefore, the aim of our study was to compare the alterations in ABG occurring during transperitoneal or retroperitoneal laparoscopic urological intervention. Material and Methods:This prospective non- randomized study was performed on elective urological patients, accord-ing the American Society of Anesthesiologists physical status - classification status (ASA) I/II, scheduled for urological laparoscopic intervention in the University Clinic for Anesthesia, Reanimation and Intensive Care and University Clinic for Urology - Clinical Center “Mother Theresa” for the period from January until December 2018. All morbidly obese patients with body mass index (BMI) more than 30, where excluded from the study, other exclusion criteria were cardiac or respiratory insufficiency and renal or liver dysfunction. Each patient signed Informed Consent before enrolment in the study. All patients underwent standard preoperative evaluations and physical status check-ups. For premedication, patients received diazepam 5mg orally night before surgery and in the morning of surgery. In the operation theatre standard monitoring was placed and radial artery cannula-tion was done. Induction in anesthesia was with midazolam 1 or 2 mg, fentanyl 2-10 mcg/ kg, propofol 1-2 mg/ kg, rocuronium 0,6 mg/ kg. After 2 minutes patients were intubated and placed on MV. Pressure was controlled/ volume guarantied with PEEP 5cm H2O and 50% mix of air/oxygen, changes in respirator rates and tidal volume were done when decreased oxygen satu-ration, increased PIP or increased end expiratory CO2 (Et CO2) were observed. Hemodynamic |  12  |Macedonian Journal of AnaesthesiaNumber 6. May 2019  |  13  | parameters were recorded during whole time of surgery and ABG analyses were investigated at three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Statistical analysis was done with STATISTICA version 10; IBM SPSS 20.0. For quantitative variables data are presented as mean and standard deviation (SD), for categorical variables as number and percentage. For analysis, Analysis of Variance U test and Post hoc Tukey HSD test were used. P value of less than <0.05 was considered statistically significant.Results:A total of 138 patients were operated laparoscopically during the observed period. Only 57 patients from them meet the inclusion criteria and were enrolled in the study. From the other 81 excluded patients: 54 were without ABG analysis, 24 didn’t complied with the inclusion criteria, 1 patient refused to participate in the study and 2 patients were converted to open surgery. In Figure 1 the flow chart diagram of the patients is presented. Figure 1. Study’s participants flow diagram Retroperitoneal group (n=26)Transperitoneal group (n=31)Additionally excludedConverted to open surgery (n=2)Excluded (n=79)Not meeting inclusion criteria (n=24)Not obtained ABG (n=54)Consent not provided (n=1)Assessed for eligibility (n=138)Evaluated (n=59)Total studied (n=57)In Table 1, we present the demographic characteristics and characteristic of the interventions in both retroperitoneal and transperitoneal group.Table 1. Demographic characteristics and characteristics of the surgery.Variables Retroperitoneal group (n=26) Transperitoneal group (n=31) Gender (Male/Female) 16 / 10  19/12Age (years) 44.6 ± 11.5 46.3 ±15.63BMI (normal 18.5-24.9) (overweight 25-29.9)18 208 11Insufflation time (minutes) 105 ± 80.11 107 ± 77.33Surgery time (minutes) 159.3 ± 79.06 168.1 ± 58.54Data presented as mean and SD.After CO2 insufflation and pneumoperitoneum created in every patient from both groups, EtCO2 was increased and MV was adjusted according to the changes in order to maintain EtCO2 in normal ranges. The ABG samples collected over the three investigated time points intervals were analyzed with Siemens rapid point 500 ABG analyzer over 10 minutes period after as-sembling. There was significant difference between the observed partial pressure of oxygen and partial pressure of carbon dioxide in the observed groups in investigated time points. The PaO2 in retroperitoneal vs transperitoneal group was statistically significant in T1 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and in T2 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). The data obtained in ABG analysis are presented in Table 2.Table 2. Arterial blood gas analyses.Variables Investigated times Retroperitoneal (n=26) Transperitoneal group (n=31) P valueSaO2%T0 94.2 ± 1.65 95.1 ± 1.41 > 0.05T1 97.7 ± 1.07 98.1 ± 0.5 > 0.05T2 94.6 ± 1.4 95.1 ± 1.76 > 0.05PaO2T0 95.6 ± 5.1 94.1 ± 6.7 > 0.05T1 173.3 ± 19 196.6 ± 29 < 0.05T2 95.5 ± 5.4 101.1 ± 8.2 < 0.05PaCO2T0 35.8 ± 2.3 35.1 ± 2.3 > 0.05T1 45.9 ± 4.1 38.2 ± 0.3 < 0.05T2 40.1 ± 3.2 37.01 ± 3.4 > 0.05PhT0 7.41 ± 0.02 7.41 ± 0.03 > 0.05T1 7.31 ± 0.04 7.39 ± 0.05 > 0.05T2 7.35 ± 0.05 7.35 ± 0.03 > 0.05Data presented as mean and SD, SaO2 % - oxygen saturation, PaO2 – partial pressure of oxygen, PaCO2 – partial pressure of carbon dioxide.Observed hemodynamic parameters are shown in Table 3. We observed the heart rate, sys-tolic and diastolic blood pressure. There wasn’t significance in the observed parameters in the investigated time points between groups. Only one patient in the transperitoneal group developed subcutaneous emphysema. Table 3. Hemodynamic parameters.Variables Investigated times Retroperitoneal (n=26) Transperitoneal group (n=31) P valueHRT0 90.7 ± 12 85.6 ± 11.3 > 0.05T1 71.2 ± 8.5 71.2 ± 7.0 > 0.05T2 69.9 ± 13.5 66.3 ± 10.4 > 0.05SKPT0 146.5 ± 11.2 145.7 ± 17.2 > 0.05T1 125.5 ± 10.1 122.7 ± 9.3 > 0.05T2 120.7 ± 11.5 119.5 ± 10.0 > 0.05DKPT0 85.1 ± 9.2 87.2 ± 10 > 0.05T1 76.7 ± 11.9 80.4 ± 14 > 0.05T2 77.4 ± 12.4 76.3 ± 8.0 > 0.05Data presented as mean and SD, HR – heart rate, SKP – systolic blood pressure, DKP – diastolic blood pressure.ARTERIAL BLOOD GAS ALTERATIONS IN RETROPERITONEAL AND TRANSPERITONEAL LAPAROSCOPY|  14  |Macedonian Journal of AnaesthesiaNumber 6. May 2019  |  15  | Discussion:Insufflation of CO2 in the retroperitoneal or intraperitoneal cavity creates pneumoperitoneum and increases the intraabdominal pressure. Increased intra-abdominal pressure has influence on every organ and organ system in the body (1,8-11). Intraabdominal pressure moves the diaphragm cephalic and compresses the thoracic cavity leading to decreased compliance and increased resistance, lower functional residual capacity to the lung leading to deteriorated gas exchange (11, 12). Furthermore, the gas exchange is deteriorated from the insufflated CO2 that is absorbed in the blood leading to ventilation mismatch, hypoxia, hypercarbia and ABG alterations (8, 10). There is still ongoing debate if the retroperitoneal or transperitoneal laparoscopic approach is associated with greater CO2 absorption. In our study, the investigated alterations in ABG analyses in the second time point or one hour after insufflation of CO2, showed that PaO2 is significantly decreased in retroperitoneal group, compared to transperitoneal group and on the other hand, PaCO2 is increased in the retroperitoneal group in comparison to the transperitoneal group. Further on, PaO2 was significantly decreased in the third investigated time point. These results from our evaluation are similar to the results presented from Shah and colleagues in their study of 45 patients whereby they conclude that position of patients was the superior factor that interfered with the ABG changes (8). Another study from Wolf and coauthors, conducted in 63 laparoscopic urological interventions, showed higher CO2 absorption when compared the retroperitoneal to transperitoneal approach, and also showed that retroperitoneal group had higher risk for developing subcutaneous emphysema (13). Additionally, in other prospective study on three groups with 10 patients in each of them: retroperitoneal nephrectomies, laparo-scopic cholecystectomies and control group of open orthopedic surgeries had similar results to our findings. They believe that due to cutting up areolar retroperitoneal tissue, retroperitoneal group has higher CO2 absorption (14). Contrary, there are studies that do not show increased CO2 absorption in retroperitoneal laparoscopies - one is the study of Ng et al., which includes prospective evaluation of 51 patients (15). As for hemodynamic parameters (heart rate, systolic and diastolic blood pressure) our study didn’t show any statistically significant results between groups. However, in the literature there are presented findings similar and contrary to ours (1, 8, 16). We believe that this is due to the fact that CO2 insufflation can provoke hemodynamic changes depending on volume status, an-esthesia management, patient’s position and the level of intraabdominal pressure that occurred from CO2 insufflation. The different interaction among these factors can provoke diverse out-comes in different patients.Conclusion:Urological laparoscopy can be performed through retroperitoneal and transperitoneal approach. The findings that we have presented can suggest that both approaches are safe although hyper-carbia is observed in retroperitoneal group. Moreover, maybe this study can obtain information about the secure approach in compromised patients and can increase the awareness of the anes-thesiologists for careful observation of these patients.References:1. Shobhana G, Gadani H, Mita P. Comparative Clinical Study Of Preinsufflation Versus Postdesufflation Arterial Blood Gas Analysis In Laproscopic Surgeries. The Internet Journal of Anesthesiology. 2009;1:25-29.2. Hamilton BD, Gatti JM, Cartwright PC, et al. Comparison of laparoscopic versus open nephrectomy in the pediatric population. J Urol. 2000;163(3):937–9.3. Iwasaka H, Miyakawa H, Yamamoto H, Kitano K, et al. Respiratory mechanics and ar-terial blood gases during and after laparoscopic cholecystectomy. CAN J ANESTHE 1996;43(2):129-133. 4. Garg M, Singh V, Sinha RJ, et al. Prospective randomized comparison of transperitoneal vs retroperitoneal laparoscopic simple nephrectomy. Urology.2014;84(2):335-39.5. Gaur DD. Laparscopic operative retroperitoneoscopy : Use of a new device. J Urol 1992; 148 : 1137-39.6.  Gaur DD, Agarwal DK, Purohit KC. Retroperitoneal laparoscopic nephrectomy: Initial case report. J Urol 1993; 149 : 103-5.7. Taue R, Izaki H, Koizumi T, et al. Transperitoneal versus retroperitoneal laparoscopic radical nephrectomy: a comparative study. Int J Urol. 2009; 16(3):263-67.8. Shah R, Nama R, Butala B, et al. Comparison of Physiological Changes between Transperitoneal and Retroperitoneal Approach for Urologic Laparoscopic Surgery. Journal of Clinical and Diagnostic Research. 2018 Apr, Vol-12(4): UC04-UC07.9. Kuzmanovska B, Kartalov A. Brain oxygenation during laparoscopy. Epilepsy and neurol-ogy 2010;37/38:33-37.10. Kuzmanovska B, Kartalov A, Srceva M. Correlation of the variations of the mean arterial pressure, heart rate, oxygenation of the blood and oxygenation of the brain during laparos-copy. Medicus 2012; 12:125-128.11. Gavrilovska-Brzanov A, Shosholcheva M, Nikolova Z, et al. Evaluation of the effect of increased intraabdominal pressure on the visceral perfusion. Medicus 2013; 18(2):37-49.12. Gavrilovska-Brzanov A, Nikolova Z, Jankulovski N, et al. Evaluation of the Effects of Elevated Intra-abdominal Pressure on the Respiratory Mechanics in Mechanically Ventilated Patients. Maced J Med Sci.2013;6:261-265.13. Wolf JS Jr, Monk TG, McDougall EM, et al. The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery. J Urol. 1995; 154(3):959-63.14. Streich B, Decailliot F, Perney C, et al. Increased carbon dioxide absorption during retro-peritoneal laparoscopy. Br J Anaesth. 2003; 91(6):793-96.15. Ng CS, Gill IS, Sung GT, et al. Retroperitoneoscopic surgery is not associated with increased carbon dioxide absorption. J Urol. 1999; 162(4):1268-72.16. Baird JE, Granger R, Klein R, et al. The effects of retroperitoneal carbon dioxide insufflation on haemodynamics and arterial carbon dioxide. Am J Surg. 1999; 177(2):164-66.ARTERIAL BLOOD GAS ALTERATIONS IN RETROPERITONEAL AND TRANSPERITONEAL LAPAROSCOPY

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

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Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

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