PURPOSE:We found current robotic positioning devices to be inadequate and cumbersome. Furthermore, we realized there were no premarket well-designed studies to prove their safety and efficacy. In this prospective pilot study, we aimed to investigate the safety and effectiveness of a novel patient-positioning device (SAF-R) to secure the patient in Trendelenburg (T-burg) position for robot-assisted pelvic surgery.PATIENTS AND METHODS:Sixteen patients undergoing robot-assisted pelvic operation in T-burg position were enrolled. Patients were positioned using SAF-R board. Pressure sensor mats were used for real-time monitoring of the contact pressures and contact area on the shoulders and calves throughout the surgery. Data collection included patients' body mass index (BMI), time needed for positioning, total time in the T-burg position, contact pressure and contact area readings from the sensor mats, and the patient shifting distance on the table. Patients were also followed for 1-month postoperatively for any position-related adverse event.RESULTS:The median age of the patients was 56.5 years with median BMI of 27.3. The median positioning time was 6 minutes, duration of T-burg position was 3.5 hours, and patient shift on the table was 1 cm. The contact pressure over the shoulders was in the safe range (< 80 mm Hg) before and at the end of the surgery in all cases (right: 13.12 ± 1.12 vs 20.25 ± 1.56 mm Hg, left: 12.84 ± 1.05 vs 19.60 ± 1.09 mm Hg, p = 0.001). The changes in the mean contact pressure over the calves and the mean contact area for the shoulders and calves during the T-burg position were not significantly different. No significant position-related complication was detected during follow-up.CONCLUSIONS:SAF-R surgical board is a safe, reliable, and timesaving positioning device for patients undergoing robotic pelvic surgery in the T-burg position.

Bony exostoses such as mandibular tori are fairly common.They are asymptomatic, benign cortical bony protuberances occurring along the lingular aspect of the mandible.Large tori may interfere with direct laryngoscopy resulting in difficult intubation.This is a case report about a 66 year old, Caucasian male with a Mallampati class I airway who was un-intubatable initially, due to the presence of bilateral mandibular tori that formed a plate of bone beneath his tongue.He was intubated subsequently with the help of an Eschmann bougie.

A 76-YR-OLD emaciated woman came to the emergency department with a history of increasing shortness of breath. Her medications included atenolol and extended-release nifedipine. A mass was detected on the chest x-ray, and subsequent computer tomography scan (top) revealed a possible large pharmacobezoar that was confirmed by endoscopy (bottom). Two preanesthetic considerations must be taken into account in patients presenting with pharmacobezoar. First, acute intake of large doses of the active component can induce toxic symptoms. Medications reported to form bezoars occasionally include clomipramine, amitriptyline, potassium chloride, procainamide, nifedipine, carbamazepine, meprobamate, iron, verapamil, theophylline, and enteric-coated aspirin. The patient’s medical history and physical examination did not reveal evidence of acute intoxication. Second, risk of aspiration during deep sedation or general anesthesia is increased. There is no evidenced-based guideline for the anesthetic management of such a patient. Therefore, the clinical anesthesiologist needs to decide how best to proceed, based on a risk-benefit analysis. Our patient denied abdominal pain, vomiting, and any alteration in bowel habits. Bezoar fragmentation and endoscopic removal of retained tablets was conducted. Approximately 150 pills, about one-third of the total number of retained pills, were safely removed.

Chondrosarcomas of the larynx are rare tumors, representing less than 0.2% of all head and neck malignancies [1]. In this report, we present an unusual case of an undiagnosed chrondrosarcoma of the larynx presenting as difficult intubation in an otherwise asymptomatic patient. Difficult intubation in an otherwise asymptomatic patient has not been reported as an initial presentation of this tumor. Men are more commonly affected than women (3.6: 1), and the tumors typically present in the fifth or sixth decade of life. Patients may present with dyspnea, dysphagia, hoarseness of the voice, airway obstruction and some may have pain as a result of expansion of this tumor. The tumors almost always arise from hyaline cartilage, with the most common site of involvement the cricoid cartilage (75%), specifically the posterior lamina, with the thyroid cartilage and arytenoid cartilage less frequently involved. Though locally invasive, these tumors are characterized by a low tendency for distant metastasis and the overall prognosis following excision is excellent [2].

A patient undergoing laparoscopic radical prostatectomy developed unilateral periorbital edema and cervical subcutaneous emphysema following carbon dioxide insufflation into the retropubic and retroperitoneal space. He had hypercarbia and acidosis during and after the end of the case and he required hyperventilation in the recovery room for two hours before the hypercarbia subsided and the arterial blood gases returned to normal levels. Despite massive surgical emphysema reaching up to his face, there was no evidence of a pneumothorax or pneumomediastinum in this patient. He had no respiratory distress and his visual examination was normal and the periorbital surgical emphysema subsided gradually within two days. The management of this complication and a review of the literature is presented.

To the Editor: A 56-year-old male patient presented with an enlarged thyroid gland for a subtotal thyroidectomy under general anesthesia. He was 72-in tall, weighed 210 pounds, and had a history of smoking 2 packs of cigarettes a day for over 25 years. He had never had surgery and was not on any medication. He did complain of hoarseness of the voice and some mild dyspnea on exertion. Routine airway examination was unremarkable. He was induced with 2 mg/kg of propofol and 150 μg of fentanyl and, after determining that mask ventilation was easy, he was given 12 mg of cisatracurium for muscle relaxation. Laryngoscopy was attempted with Macintosh size 3 and 4 blades without being able to visualize the larynx. A size 5 laryngeal mask airway (LMA) was passed and ventilation could be performed. A fiberoptic bronchoscope was then inserted through the LMA and the vocal cords appeared to be inflamed and edematous. Two attempts at passing an endotracheal tube through the LMA were unsuccessful. Under direct fiberoptic vision, a gum elastic bougie was passed through the vocal cords and the LMA and fiberoptic bronchoscope were removed and a 7-mm cuffed endotracheal tube was threaded over the gum elastic bougie and the airway was secured. The trachea was ventilated via the LMA between attempts and the oxyhemoglobin saturation never diminished below 90% throughout the procedure. The case proceeded uneventfully thereafter. At the end of the case, the neuromuscular blockade was reversed and the endotracheal tube was removed after the patient was fully awake and was able to follow commands. An otolaryngologist was called in for consultation during the case and he diagnosed Reinke's edema of the vocal cords. These patients usually present with hoarseness of the voice and have a history of heavy smoking. They also have polypoid degeneration of the vocal cords and can pose difficulty with intubation and even positioning of the LMA-like devices (1). Jaydev Sarma, MD Department of Anesthesia Massachusetts General Hospital Boston, MA [email protected]