Pneumoperitoneum, Robotic Surgery
Conditions
Keywords
robotic surgery, low-pressure pneumoperitoneum, recovery time, pain, pneumoperitoneum
Brief summary
During surgery that is done using a robot, the surgeon needs to put carbon dioxide gas into the belly to lift the belly wall. This is done so the surgeon can adequately see all the body organs and operate safely. Many surgeons currently use a standard pressure of 15 mmHg (a unit to measure pressure). However, many patients find the use of this pressure to be painful after surgery. New research has shown that using a lower pressure with a device called "AirSeal" can safely reduce pain and lead to faster recovery after surgery. The goal of this clinical trial is to learn if using a lower gas pressure with the AirSeal device during robotic surgery, compared to standard gas pressure with conventional devices, helps adults feel less pain and recover faster. The study includes adults aged 18 or older having robotic at New York-Presbyterian Hospital/Weill Cornell Medical Center. The main questions this clinical trial aims to answer are: 1. Does using lower gas pressure shorten the time people spend in the recovery room after surgery? 2. Does using lower gas pressure lead to less pain and reduce the need for pain medicine after surgery?
Detailed description
Robotic surgeries require the use of pneumoperitoneum, which is a standard of care as it creates a working environment to utilize minimally invasive tools to accomplish surgical procedures. However, there is no uniform standard pressure (usually between 12-15 mmHg). Moreover, maintaining the same pressure throughout the procedure can be inconsistent at best. Elevations in pneumoperitoneum cause significant stretch to the peritoneum which results in significant postoperative pain, longer post-anesthesia care unit (PACU) stay times, and higher opioid consumption. These effects are amplified to a higher degree in patients with severe obesity. If the pressures can be maintained and set to lower levels, then patients may have the opportunity to recover in the immediate postoperative period. The AirSeal Robotic Solution (CONMED Corporation) is an FDA 510(k)-cleared carbon dioxide insufflation device that is indicated for use in robotic-assisted surgery. This study is a prospective, single-center, single-blind, double-arm parallel-group randomized controlled trial that aims to determine if the use of low-pressure (8 mmHg) AirSeal insufflation, compared to standard-pressure (15 mmHg) pneumoperitoneum, provides superior patient outcomes in terms of post-operative recovery time and convalescence. During the preoperative evaluation, participants will be consented and enrolled into the trial. Participants will then be randomly allocated to either low-pressure AirSeal insufflation (8 mmHg) or standard-pressure pneumoperitoneum (15 mmHg). Patients and outcome assessors will be blinded to allocation; however, for safety purposes, the operating surgeon and anesthesiologist cannot be blinded. Intraoperative data (including operation time, estimated blood loss, abdominal pressure, and pressure deviations) will be recorded. Participant data related to comorbidities (i.e. body mass index, American Society of Anesthesiologists physical status, hypertension, diabetes, obstructive sleep apnea, chronic obstructive pulmonary disease/asthma, and smoking status) will be collected from the electronic medical record.
Interventions
DEVICEAirSeal Robotic Solution
The experimental intervention is low-pressure pneumoperitoneum at 8 mmHg using the AirSeal Robotic Solution device. The AirSeal Robotic Solution (CONMED Corporation) is an FDA 510(k)-cleared carbon dioxide insufflation device that is indicated for use in robotic-assisted surgery. It consists of a console, tri-lumen filtered tube set, and access ports that function as valveless trocars. The console of the device is mounted on a cart and regulates carbon dioxide flow and smoke evacuation by continuously measuring the intra-abdominal pressure. The trilumen filtered tube set carries carbon dioxide to the abdomen, transmits pressure information back to the console, and returns gas from the abdomen for smoke evacuation and filtration. These features allow for the device to operate in the "AirSeal" mode, whereby the pressure within the abdomen is effectively kept constant. The valveless trocars are access ports for the minimally invasive tools to enter the abdominal cavity.
OTHERStandard-pressure pneumoperitoneum (15 mmHg)
The control intervention is standard-pressure pneumoperitoneum set at a pressure of 15 mmHg. This will be delivered using the operating room's conventional valved-trocar carbon dioxide insufflator.
Sponsors
Weill Medical College of Cornell University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
DOUBLE (Subject, Outcomes Assessor)
Intervention model description
Randomization will be performed using a computer-generated permuted block sequence pre-loaded into REDCap with allocation concealed until the day of surgery. Allocation will be blinded to participants and outcome assessors. Surgical staff cannot be blinded to allocation for safety reasons.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Aged 18 years or older * Scheduled to undergo robotic-assisted surgery at New York-Presbyterian/Weill Cornell Medical Center * American Society of Anesthesiologists physical status I-III * Able to understand and provide written informed consent in English
Exclusion criteria
* American Society of Anesthesiologists physical status IV or higher (i.e. a severe systemic disease that is a constant threat to life such as decompensated heart failure) * Chronic opioid use (≥30 morphine milligram equivalents per day for ≥30 days within the past 6 months) * Current pregnancy * Inability to understand and provide informed consent in English * Inability to provide informed consent due to cognitive impairment or other conditions impacting decision-making capacity * Scheduled open or laparoscopic surgeries
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Average post-anesthesia care unit (PACU) length of stay in minutes from PACU admission to PACU discharge order | From PACU arrival (5 minutes post-surgery) to PACU discharge-order (1 to 4 hours post-surgery) | The PACU is the area where participants recover from anesthesia after surgery. The PACU recovery time will be computed in minutes as the interval between the documented PACU arrival timestamp and the documented PACU discharge-order timestamp which will both be abstracted from the institutional electronic medical record. The discharge-order timestamp represents the clinical decision that the participant is fit to leave the PACU and is therefore not confounded by factors such as transport delays. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Average numeric rating scale (NRS) pain score (0-10) at PACU admission | PACU arrival (5 minutes post-surgery) | Postoperative pain intensity is measured using a verbally administered numeric rating scale (NRS) ranging from 0 to 10. 0 indicates no pain while 10 indicates the worst pain that the participant can imagine or has experienced. The score will be recorded as an integer. The pain scores will be taken from the participants within 5 minutes of documented PACU arrival. |
| Average numeric rating scale (NRS) pain score (0-10) at PACU discharge | PACU discharge (1-4 hours post-surgery) | Postoperative pain intensity is measured using a verbally administered numeric rating scale (NRS) ranging from 0 to 10. 0 indicates no pain while 10 indicates the worst pain that the participant can imagine or has experienced. The score will be recorded as an integer. The pain scores will be taken from the participants within 10 minutes of PACU discharge order time stamp. |
| Average numeric rating scale (NRS) pain score (0-10) at post-operative day 1 (POD1) | Post-operative day 1 (24 hours after surgery) | Postoperative pain intensity is measured using a verbally administered numeric rating scale (NRS) ranging from 0 to 10. 0 indicates no pain while 10 indicates the worst pain that the participant can imagine or has experienced. The score will be recorded as an integer. The pain scores will be taken from the participants on POD1 between the hours of 08:00 and 12:00. If the participant is discharged, a telephone call will be made during those hours. |
| Average numeric rating scale (NRS) pain score (0-10) at post-operative day 3 (POD3) | Post-operative day 3 (72 hours after surgery) | Postoperative pain intensity is measured using a verbally administered numeric rating scale (NRS) ranging from 0 to 10. 0 indicates no pain while 10 indicates the worst pain that the participant can imagine or has experienced. The score will be recorded as an integer. The pain scores will be taken from the patients on POD3 between the hours of 08:00 and 12:00. If the participant is discharged, a telephone call will be made during those hours. |
| Average morphine milligram equivalents (MME) in the post-anesthesia care unit (PACU) | PACU arrival to PACU discharge (1-4 hours post-surgery) | Cumulative opioid consumption will be measured using morphine milligram equivalents (MME) which will convert all administered opioids regardless of agent or route of administration to an equivalent amount of oral morphine using standard conversion factors. Opioid dosage data will be abstracted from the electronic medical record. The total MME administered between the PACU arrival timestamp and the documented PACU discharge-order timestamp will be recorded. A lower cumulative MME indicates less opioid requirements. |
| Average morphine milligram equivalents (MME) over the first 24-hour post-operative period | Post-operative day 1 (24 hours after surgery) | Cumulative opioid consumption will be measured using morphine milligram equivalents (MME) which will convert all administered opioids regardless of agent or route of administration to an equivalent amount of oral morphine using standard conversion factors. Opioid dosage data will be abstracted from the electronic medical record. The total MME administered within the first 24 hours after surgery will be recorded. A lower cumulative MME indicates less opioid requirements. |
| Proportion of participants experiencing postoperative nausea or vomiting in the post-anesthesia care unit (PACU) | PACU arrival to PACU discharge (1-4 hours post-surgery) | Postoperative nausea or vomiting is defined as any event of nausea or emesis. Episodes will be abstracted from the electronic medical record and corroborated by asking the patient. Events will be recorded during the PACU stay |
| Proportion of participants experiencing postoperative nausea or vomiting on post-operative day 1 (POD1) | Post-operative day 1 (24 hours after the surgery) | Postoperative nausea or vomiting is defined as any event of nausea or emesis. Episodes will be abstracted from the electronic medical record and corroborated by asking the patient. Events will be recorded on POD1 |
| Proportion of participants experiencing postoperative nausea or vomiting on post-operative day 3 (POD3) | Post-operative day 3 (72 hours after the surgery) | Postoperative nausea or vomiting is defined as any event of nausea or emesis. Episodes will be abstracted from the electronic medical record and corroborated by asking the patient. Events will be recorded on POD3 |
| Proportion of participants who require intra-operative conversion from robotic-assisted surgery to open surgery | During the surgery (about 60 to 240 minutes) | Conversion events will be abstracted from the operative note posted on the electronic medical record. |
| Proportion of participants with clinical or radiographic subcutaneous emphysema | From start of surgery to PACU discharge (1-4 hours after surgery) | Cases will be identified by intraoperative inspection of the abdominal wall during the procedure, clinical examination during the PACU stay, and any postoperative imaging that is clinically obtained. |
| Proportion of participants who sustained intraoperative pressure elevation (defined as sustained increase to ≥12 mmHg for ≥10 minutes in the AirSeal arm) | During the surgery (about 60 to 240 minutes) | Pressure measurements will be obtained from the AirSeal console and elevations will be recorded regardless of reason. |
Countries
United States
Contacts
CONTACTCheguevara Afaneh, MD
PRINCIPAL_INVESTIGATORCheguevara Afaneh, MD
New York-Presbyterian/Weill Cornell Medical Center
Outcome results
None listed