Background and aim: The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations. Methods: A narrative review was carried out. Results: When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs. Conclusions: Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

Current studies indicate that robotic-assisted surgery is not inferior to laparoscopic or open surgery regarding oncologic or functional outcomes. An exception may be uterine cervix cancer, where the survival after minimal invasive surgery might not be as good as after open surgery. There is less bleeding and need for blood transfusion after robotic-assisted surgery, and postoperative complications are similar to open or laparoscopic surgery. Robotic-assisted surgery offers ergonomic advantages compared to laparoscopic surgery. The effect of the surgical learning curve is not sufficiently studied. Presently robotic-assisted surgery is not cost-effective due to high costs of investments. The operation is more time consuming than laparoscopic or open surgery with risks of delaying and cancellation of other operations.

Onkologiskt och funktionellt resultat vid robotassisterad kirurgi skiljer sig inte från laparoskopisk eller öppen kirurgi. Ett undantag kan vara sämre överlevnad vid cervixcancer.

Robotassisterad kirurgi är inte kostnadseffektiv i dagsläget på grund av investeringskostnaderna.

Robotassisterad kirurgi erbjuder ergonomiska fördelar och ger ingen ökning av postoperativa komplikationer. Operationstiderna är längre, men möjligen är blödning och transfusionsbehov mindre och vårdtiden kortare.

Inlärningseffekterna är ofullständigt undersökta.

Det finns etiska skäl att vara observant på undanträngningseffekter till följd av ökad användning av robotkirurgi.

Background: The aim was to evaluate safety aspects of patient-controlled sedation and analgesia (PCS) for extracor-poreal shockwave lithotripsy (ESWL) and PCS to be handled by non-anaesthesiology doctors. Methods: Thirty-four ASA I-III patients used PCS with propofol and alfentanil for ESWL in this interventional study. Strict safety limits were defined regarding respiratory rate (RR), heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation from pulse oximetry (SpO2), and transcutaneous partial pressures of oxygen (PtcO2) and carbon dioxide (PtcCO2). The pa-tients’ levels of consciousness was graded on a five-point scale and monitored with Bispectral Index (BIS). A nurse anaesthetist was supervising the procedure but was instructed to intervene only if safety limits were breached. No sup-plementary oxygen was given. Results: All patients responded to verbal stimuli during treatment. Cardiovascular sta-bility was maintained, but respiratory variables were affected. Two patients with SpO2 < 90% and two cases of RR ≤ 8 were diagnosed, and seven patients became hypercarbic (PtcCO2 ≥ 6.5 kPa). In 18 patients hypoxaemia was indicated as PtcO2 ≤ 8.0 kPa. All these 18 patients were given supplementary oxygen. There was no correlation between dose of drugs, age, weight or any vital variable. The 34 patients would use PCS again in the case of future treatment. Conclu-sions: During ESWL treatment PCS can be used with good patients’ satisfaction, and maintained cardiovascular stabil-ity, but PCS had an indisputable effect on pulmonary function with hypoxemia (resulting in need for supplementary oxygen) or hypercarbia. The person in charge of PCS must therefore be trained to perform according to the guidelines for sedation and/or analgesia by non-anaesthesiology doctors.

Circulatory arrest during pregnancy is extremely rare and there should be a well-planned strategy for its management in all hospitals. To consider the priority of the mothers life over the childs and an unwarranted pre-term delivery may lead to hesitancy and uncertainty and jeopardize both of them. In these situations, speed is a priority. Cardiopulmonary resuscitation should commence immediately. The anaesthesiologist should be well aware of the possible advantage of a caesarean section. Even if the obstetrician is responsible for the decision to perform the operation, the anaesthesiologist should strongly support the action. An emergency caesarean kit with the essential surgical instruments should be immediately available in every labour ward and emergency department.

BACKGROUND: A correlation between deep anesthesia (defined as time with Bispectral Index (BIS) &lt;45; T-BIS &lt;45 and death within 1. yr after surgery has previously been reported. In order to confirm or refute these findings, we evaluated T-BIS (&lt;45) as an independent risk factor for death within I and 2 yr after surgery and also the impact of malignancy, the predominant cause of death in the previous report.

METHODS: Mortality within 2 yr after surgery, causes of death and the occurrence of malignant disease at the time of surgery were identified in a cohort of 4087 BIS-monitored patients. Statistically significant univariate predictors of mortality were identified. In order to allow for comparison with previous data, the following multivariate analysis was first done without, and thereafter with, preexisting malignancy status, the predominant cause of death.

RESULTS: One-hundred-seventy-four (4.3%) patients died within I yr and another 92 during the second year (totaling 6.5% in 2 yr). T-BIS &lt;45 was a significant predictor of 1- and 2-yr mortality when preexisting malignant disease was not among the co-variates (hazard ratio [HR] 113 [1.01-1.27] and 1.18 [1.08-1.29], respectively). Further exploration confined the significant relation between postoperative mortality and T-BIS &lt;45 to Patients with preexisting malignant diagnoses associated with extensive Surgery and less favorable prognosis. The most powerful predictors of 2-yr mortality in the model, including preexisting malignancy, were ASA physical score class IV (HR 19.3 [7.31-51.1]), age &gt;80 yr (HR 2.93 [1.79-4.79]), and preexisting malignancy associated with less favorable prognosis (HR 9.30 [6.60-13.1]). When the initial multivariate regression was repeated using preexisting malignancy status among the co-variates in the model, the previously significant relation between 1, and 2-yr mortality and T-BIS &lt;45 did not reach statistical significance.

CONCLUSION: Using a similar set of co-variates as in previous work, we confirmed the statistical relation between 1-yr mortality and T-BIS &lt;45, and we extended this observation to 2-yr mortality. However, this relation is sensitive to the selection of co-variates in the statistical model, and a randomized study is required to demonstrate that there really is a causal impact from and T-BIS (&lt;45) on postoperative mortality and, if it does, the effect is probably very weak in comparison with co-morbidity as assessed by ASA physical score, the preexisting malignancy status at surgery and age.

Intraoperative awareness with subsequent recall is a rare but serious complication with an incidence of 0.1-0.2%. In approximately one third of the patients who have experienced awareness, late severe psychiatric sequelae may develop. The psychiatric symptoms in these patients fulfil the diagnostic criteria for post traumatic stress disorder. To prevent awareness as a negative outcome after anaesthesia, a thorough perioperative management of anaesthesia is necessary. The definite risk for post traumatic stress disorder following awareness indicates the necessity of postoperative clinical routines to identify awareness patients. The problem must be acknowledged. Professional psychiatric assessment and follow up should constitute standard practice. The treatments of choice are Eye Movement Desensitisation Reprocessing and Cognitive Behaviour Therapy. © 2007 Elsevier Ltd. All rights reserved.

Background: Explicit recall (ER) is evident in approximately 0.2% of patients given general anaesthesia including muscle relaxants. This prospective study was performed to evaluate if cerebral monitoring using BIS to guide the conduction of anaesthesia could reduce this incidence significantly. Patients and methods: A prospective cohort of 4945 consecutive surgical patients requiring muscle relaxants and/or intubation were monitored with BIS and subsequently interviewed for ER on three occasions. BIS values between 40 and 60 were recommended. The results from the BIS-monitored group of patients was compared with a historical group of 7826 similar cases in a previous study when no cerebral monitoring was used. Results: Two patients in the BIS-monitored group, 0.04%, had ER as compared with 0.18% in the control group (P < 0.038). Both BIS-monitored patients with ER were aware during intubation when they had high BIS values (>60) for 4 min and more than 10 min, respectively. However, periods with high BIS = 4 min were also evident in other patients with no ER. Episodes with high BIS, 4 min or more, were found in 19% of the monitored patients during induction, and in 8% of cases during maintenance. Conclusions: The use of BIS monitoring during general anaesthesia requiring endotracheal intubation and/or muscle relaxants was associated with a significantly reduced incidence of awareness as compared with a historical control population.