A cirurgia laparoscópica requer a criação de um espaço de trabalho intraabdominal, através do pneumoperitônio, e para isto utiliza-se o dióxido de carbono (CO2). As alterações sistêmicas relacionadas ao sistema respiratório ocorrem pelo aumento da pressão intra-abdominal, resultando em diminuição da complacência pulmonar, atelectasia, hipercarbia e hipóxia. A insuflação de CO2 com pressões intraabdominais acima de 8 mmHg produz alterações hemodinâmicas significantes, caracterizadas por decréscimo do débito cardíaco, elevação da pressão arterial. Para que a homeostase hemodinâmica e respiratória seja mantida são necessários protocolos anestésicos adequados e métodos de ventilação mecânica como, por exemplo, a pressão expiratória final positiva final (PEEP). O presente trabalho teve por objetivo avaliar e comparar quatro protocolos anestésicos e ventilatórios distintos em cadelas submetidas à ovariohisterectomia videolaparoscópica eletiva, com uso de pneumoperitônio com CO2 e 12 mmHg de pressão intra-abdominal, sob anestesia geral total intravenosa. Para isso, 16 caninos foram distribuídos em quatro grupos: no grupo 1 (Zeepbloq) os animais receberam atracúrio (0,5 mg.kg-1), propofol (5 mg.kg-1) e fentanil (2 mcg.kg-1), todos em bolus, por via intravenosa, e seguiu-se com infusão contínua de atracúrio (0,5 mg.kg-1/hora), propofol (0,4 mg.kg-1/minuto) e fentanil (2 mcg.kg-1/hora) por bomba de infusão, e não foi realizada PEEP; no grupo 2 (Peepbloq) administrou-se o mesmo protocolo anestésico, porém realizou-se a PEEP de 10 cm de água; no grupo 3 (Zeep) os animais receberam o mesmo protocolo anestésico, com exceção bloqueador neuromuscular, e não foi realizada PEEP; no grupo 4 (PEEP) os indivíduos receberam o mesmo protocolo do grupo 3, porém realizou-se PEEP. Para o procedimento cirúrgico foi realizado pneumoperitônio de 12 mmHg com CO2 com duração variável. Foram avaliadas as seguintes variáveis: pressão arterial média, freqüência respiratória, saturação de oxigênio na hemoglobina, pressão parcial de dióxido de carbono expirado, freqüência cardíaca, eletrocardiografia e tempo do procedimento anestésico, do pneumoperitônio. Para hemogasometria foi realizada a coleta de sangue arterial, sendo obtidas variáveis de pH, pressão parcial de O2 e CO2, bicarbonato, CO2 total, excesso/déficit de bases e saturação arterial de oxigênio na hemoglobina. Não foram observados valores que representassem diferença estatística significativa entre os grupos (p<0,05). No entanto, houve diferença significativa (p<0,05) entre momentos avaliados a para pressão arterial de oxigênio, a pressão arterial média e a temperatura, independente do protocolo empregado. Ambos os protocolos empregados, anestésico e de ventilação, foram satisfatórios e, de acordo com a metodologia empregada, pode-se concluir que animais submetidos à ventilação com PEEP não apresentaram benefícios significativos quando comparados com animais ventilados com ZEEP, independente do uso ou não de bloqueador neuromuscular. / The laparoscopic surgery requires the creation of a space in the abdominal cavity through pneumoperitoneum and that using the carbon dioxide (CO2). The systemic changes related to the respiratory system occur by increased intra-abdominal pressure, resulting in decreased lung compliance, atelectasis, hypercarbia and hypoxia. The CO2 insufflation with intra-abdominal pressure over 8 mmHg produces significant hemodynamic changes, characterized by decreased cardiac output, blood pressure elevation. For the hemodynamic and respiratory homeostasis is maintained anesthetic protocols are necessary and appropriate methods of mechanical ventilation, such as the positive end-expiratory pressure (PEEP). This study aimed to evaluate and compare four different protocols anesthetics and ventilatory in female dogs submitted to ovariohysterectomy videolaparoscopic elective, with the use of pneumoperitoneum with CO2 and 12 mmHg of intra-abdominal pressure, under general anesthesia total intravenous. A total of 16 dogs were distributed into four groups: in group 1 (Zeepbloq) the animals received atracurium (0.5 mg.kg-1), propofol (5 mg.kg-1) and fentanyl (2 mcg . kg-1), all bolus, intravenously, and followed up with continuous infusion of atracurium (0.5 mg.kg-1/hour), propofol (0.4 mg.kg-1/minute) and fentanyl (2 mcg.kg-1/hour) by infusion pump, and was not held PEEP, in group 2 (Peepbloq) administered to the same protocol anesthetic, but was held on PEEP of 10 cm of water, in group 3 (Zeep) the animals received the same protocol anesthetic, except neuromuscular blocker, and was not held PEEP, and in group 4 (PEEP) individuals received the same protocol as the group 3, but was held PEEP. For the surgical procedure was performed abdominal pressure of 12 mmHg with CO2. We evaluated the following variables: mean arterial pressure, respiratory rate, oxygen saturation in hemoglobin, end tidal of carbon dioxide expired, heart rate, electrocardiography and time of the anesthetic procedure and of the pneumoperitoneum. Arterial blood was sampled for arterial blood gas analyses, and variables obtained from pH, arterial pressure of CO2 and O2, bicarbonate, CO2 total, balance of bases and arterial oxygen saturation in hemoglobin. There were no evaluate parameters that represented statistically significant difference between groups (p <0.05). However, there was a significant difference (p <0.05) between moments evaluated for the blood pressure of oxygen, the mean blood pressure and temperature, independent of protocol employee. Both protocols employees, anaesthetic and ventilation, were satisfactory and in accordance with the methodology employed, we can conclude that animals treated with ventilation PEEP did not show significant benefits when compared with animals ventilated with ZEEP, regardless of whether or not to use atracurium.

A ovário-histerectomia (OVH) é um procedimento cirúrgico realizado de maneira rotineira na clínica de pequenos animais, com objetivo terapêutico ou de promover a esterilização reprodutiva nas fêmeas. Muitas abordagens pela técnica convencional aberta já foram descritas e com viabilidade comprovada. No segmento da cirurgia de invasão mínima dentro da Medicina Veterinária, diversos métodos vêm sendo propostos variando entre si em relação ao posicionamento, quantidade e tamanho dos trocartes e método de hemostasia. Assim sendo, o objetivo deste estudo foi avaliar e descrever a viabilidade de realização da OVH em felinas com até 5 kg de peso corporal através de abordagem minilaparoscópica com uso de eltrocoagulação bipolar como método hemostático. A minilaparoscopia (MINI) não é uma modalidade recente na cirurgia laparoscópica humana. Considerada a evolução mais sofisticada da cirurgia laparoscopia, a MINI apresenta muitos outros benefícios além do estético; visto que a lesão relacionada ao dano cirúrgico não se resume as somas das incisões realizadas. A técnica reina pela delicadeza e precisão dos movimentos, sem perda da triangulação, essencial ao padrão laparoscópico. Foram avaliados os procedimentos de 15 felinas quanto à viabilidade e dificuldades do acesso minilaparoscópico, uso do cautério bipolar, o tamanho das incisões e a necessidade de ampliá-las, complicações trans e pós-operatórias assim como a dor demonstrada por esses pacientes. A avaliação da dor foi feita através de tabela específica para espécie felina com diretrizes estabelecidas e confiabilidade comprovada, auxiliada a outras duas tabelas de avaliação da dor. A conversão de minilaparoscopia à cirurgia aberta foi necessária em um dos quinze pacientes operados nesse estudo. Conclui-se que a realização da técnica de OVH por abordagem minilaparoscópica em gatas é factível. / Ovariohysterectomy (OHE) is a surgical procedure routinely performed in small animals practice, with therapeutic purpose or to promote reproductive sterilization in females. Numerous approaches have been described using conventional open technique and had their viability proven. In the segment of minimally invasive surgery in the Veterinary Medicine, several methods have been proposed, differing from each other in position, number and size of trocars and hemostasis method used. Thus, the goal of this study was to evaluate and describe the practicability of performing OHE in cats with up to 5 kg of body weight through minilaparoscopic approach, using bipolar eltrocoagulation as hemostatic method. The minilaparoscopy (MINI) is not a new modality in human laparoscopic surgery. Considered the most sophisticated evolution of laparoscopic surgery, the MINI has many other benefits beyond the aesthetic; since the injury caused by the damage of surgery is not just the sum of the incisions. The technique stands out for the delicacy and accuracy of the movement without loss of triangulation, essential for the laparoscopic model. The procedures of 15 female cats were evaluated for the viability and difficulties of minilaparoscopic approach, use of bipolar cautery, incision size and the need to enlarge it, trans and postoperative complications and pain demonstrated in these patients. Pain assessment was done through specific table for feline species with established guidelines and proven reliability, helped by other two pain assessment tables. The conversion from minilaparoscopy to open surgery was required in one of the fifteen patients operated on in this study. Therefore, the implementation minilaparoscopic approach for OHE technique is feasible in cats.

Shivering är ett fenomen som uppstår hos patienterna postoperativt. Det innebär att patienten har okontrollerbara muskelskälvningar som gör att patienten darrar, skälver eller huttrar i mer än 15 sekunder. Shivering påverkar kroppen negativt, men är också obehagligt och ett onödigt lidande för patienten. I takt med den tekniska utvecklingen utarbetas nya operationstekniker och idag utförs flera operationer med laparoskopisk teknik. Pilotstudiens syfte var att undersöka före-komsten av postoperativ shivering hos patienter som opererats med laparoskopisk teknik. Denna studie har gjorts empirisk med en kvantitativ ansats. En egen konstruerad enkät tillsammans med ett mätinstrument har använts vid datainsamlingen. I pilotstudien deltog 33 patienter i ålders-spannet 23-78 år. Resultatet i pilotstudien visar att det var sex (n=6) av alla (n=33) patienterna i studien shivrade efter genomgången laparoskopisk kirurgi. Då studien är gjord i en liten skala är resultatet inte generaliserbart, men det går ändå att se att vissa påverkande faktorer så som till exempel anestesiläkemedel kan bidra till att patienterna shivrar. / Shivering is a phenomenon that occurs in patients postoperatively. This means that the patient has uncontrollable muscles tremors which allow the patient to tremble or shiver in more than 15 seconds. Previous research shows that shivering have a negative effect on the body, but is also an unpleasant and unnecessary suffering for the patient. In step, with today's rapid development in technology, more and more patients undergo surgery with laparoscopic techniques. The pilot- study aimed to investigate the incidence of postoperative shivering in patients who were surgical operated with laparoscopic technique. This empirical study has been done with a quantitative approach. Self-designed questionnaires, together with an instrument were used in the data col-lection. The pilot study enrolled 33 patients in the age range 23-78 years. The results of the pilot study suggest that the presence of shivering was little in relation to laparoscopic surgery, six (n = 6) of all (n = 33) patients in the study was shivering. When the study is made of a small scale is the result not possible to generalize, but you can still see that certain stressors, such as anesthesia drugs may contribute the patient shivering.

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京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22345号 / 医博第4586号 / 新制||医||1042(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 上本 伸二, 教授 妹尾 浩, 教授 小西 靖彦 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13166号 / 論医博第2153号 / 新制||医||1029(附属図書館) / (主査)教授 一山 智, 教授 松原 和夫, 教授 万代 昌紀 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Laparoscopic Surgery has been revolutionized by the world of Surgical Robotics. Robot-Assisted Surgeries have been proven to have many advantages over the fundamental, traditional "by-hand" procedures previously conducted, and still currently being done for certain operations. Robot-assisted surgery may offer benefits to patients through the use of minimally invasive techniques, which may result in reduced blood loss, reduced blood transfusion, fewer complications, reduced postoperative pain, shorter hospital stays, and reduced recovery times (Ho et al., 2011). Studies have proven that robotic surgery may lead to patients recovering faster depending on the timeframe and the type of procedure (Tang et al., 2018). These benefits provide the highest quality care for the patient that can be provided. Robotic-assisted surgical platforms may overcome many of the shortcomings of laparoscopy while preserving the patient benefits (Boggess, 2007). Laparoscopic Surgery provides many benefits over open surgery as well and including the Robotic Surgical Assist allows for further/amplified benefits for the parties involved. The idea is to minimize the need for lengthy patient recovery time, discomfort, and complications caused by the procedure itself. The pain, discomfort, and disability, or other morbidities as a result of surgery is more frequently due to trauma involved in gaining access to the area to perform the intended procedure rather than from the procedure itself (Mack, 2001). Regulating certain areas of the procedure, such as required incision size, allows the patient a smoother recovery. With laparoscopic surgery, it limits risks and complications as a minimally invasive approach but, with robot-assisted laparoscopic surgery, it is even more as such. Currently, there seems to be a struggle in the field of medicine between how best to improve the surgical robots in comparison to how to better optimize, or create, smaller surgical devices to assist in surgeries. A factor that was found to be lacking in the field of medicine was the definition of actions done during surgical procedures. While used widely from a medical standpoint, from an operational standpoint it is not common practice to question the mathematical symbolization of the movements and actions done during surgery. The goal of this research is to determine, analyze, evaluate, and simplify the parameters that are present during Laparoscopic Surgery. These parameters will be compared between traditional surgery and robot-assisted surgery. The robot-assisted condition will be established using the Semi-Robotic Laparoscopic Surgery Support System developed by a University of Central Florida Senior Design Team finalized in the academic semester of Spring 2020. This system utilizes the aspects and features of a surgical robot while maintaining a small form factor and cheap production and purchasing price. Ultimately, this will allow for further evaluation of technologies exploiting the developed surgical robot for research in semi-autonomous control, and safety mechanisms in the context of robotic surgery. It is important to note that this technology is developed as a kinematic guide for laparoscopic surgery. This guiding assist is similar to the features incorporated in robot-assisted laparoscopic surgery which is what allows us to use this surgical assist device to represent the robot-assisted condition. This technology optimizes the condition of conventional laparoscopic surgery by introducing a braking mechanism into the standard procedure without requiring the major application of the full surgical systems. Through the utilization of this guiding system, this research has established and compared the kinematic and workspace parameters for robot-assisted laparoscopic surgery when the system is equipped vs. when it is equipped and activated; creating two different conditions of Workspace Controlled Laparoscopic Surgery and Kinematically Constrained Laparoscopic Surgery. It was deemed necessary to accomplish an understanding of both domains as well as in comparison to traditional laparoscopic surgical practices in order to engage the argument from a holistic point of view. Throughout this research, it was determined that, when evaluating traditional Laparoscopic Surgery, there are a series of parameters that are present when discussing the workspace of the human abdomen and the kinematics of the trocar, surgical tool, and camera placed into that workspace. Between these parameters, a variety of similarities was discovered using geometric rules and algebraic functional relationships within the kinematics. Upon equipping the Semi-Robotic Laparoscopic Surgery Support System to the procedure, certain parameters get "zeroed out" due to the fixed nature of the device from one abdominal insertion point to the next. While most parameters may maintain the same behaviors upon the installation of the technology, the majority of these same parameters get "zeroed out" when the technology is activated. The overall purpose and intent of this research is to define, evaluate, and compare various surgical parameters associated with the practice of laparoscopic surgery while running a comparison between the effectiveness of traditional surgery against robot-assisted surgery that can be made from a new perspective by evaluating the differences in their respective parameters. Results which will be discussed include: specific parameter definitions and labeling, how these parameters benefit the medical field, direct parameter comparison between the evaluated conditions of traditional surgery and robot-assisted surgery (represented by kinematic guiding technology and comparing when the device is applied, Workspace Controlled condition, versus when the braking system is activated, Kinematically Constrained condition), and how these different surgical techniques modify the conditions of surgery for the surgeon and the patient.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24799号 / 医博第4991号 / 新制||医||1066(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 武藤 学, 教授 石見 拓, 教授 川口 義弥 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24472号 / 医博第4914号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 山本 洋介, 教授 小濱 和貴 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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