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ORIGINAL ARTICLE
Year :   |  Volume :   |  Issue :   |  Page :
 

Conjunctival congestion after laparoscopic operation in children: A retrospective case series in a single-centre children's medical centre


1 Department of General Surgery, Women and Children's Hospital, Qingdao University, Qingdao, China
2 Pediatric Intensive Care Unit (PICU), Women and Children's Hospital, Qingdao University, Qingdao, China

Date of Submission15-Mar-2022
Date of Decision13-Apr-2022
Date of Acceptance22-Apr-2022
Date of Web Publication06-Jul-2022

Correspondence Address:
He Wu,
Women and Children's Hospital, Qingdao University, No. 6 Tongfu Road, Qingdao City
China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_97_22

PMID: 35915523

  Abstract 


Objective: In the present study, we report a retrospective analysis of 23 cases of conjunctival congestion after laparoscopic operation in children and try to explore the causes and intervention measures.
Methods and Results: This is a retrospective, single-centre and observational study, and all patients with conjunctival congestion after laparoscopic operation admitted to our institution between August 2021 and December 2021 were included in this study. Records of 23 patients including 16 male patients and 7 female patients were retrospectively analysed. These patients were in the age group of 2–12 years. Their primary symptom was different degrees of conjunctival congestion, and the symptom onset was between 2 and 7 days after laparoscopic operation, including laparoscopic inguinal hernia repair, laparoscopic appendectomies, laparoscopic Meckel's diverticulectomy, laparoscopic removal of foreign body ingestions and laparoscopic choledochal cystectomy, and the duration of operations varies from 20 min to 255 min. The symptom disappeared from 5 to 21 days after the operation, and the duration of the symptom ranged from 2 to 14 days. A total of 1718 operations were performed, of which 461 were laparoscopic and 1257 were general operations, the incidence of conjunctival congestion after laparoscopic surgery was 23/461, and compared with 0/1257 after ordinary surgery, there was a significant difference between them. Of these 23 patients, 5 patients received no treatment and the other 18 patients were intervened with steroid-containing eye drops. Although eye drops containing steroids can significantly relieve eye discomfort, the duration of conjunctival congestion between the two groups (i.e. steroid-containing eye drop treated vs. non-steroid-containing eye drop treated) did not differ significantly. All patients recovered well. In the follow-up till the end of February 2022, no serious complications had occurred.
Conclusion: Conjunctival congestion after laparoscopic operation is extremely rare in children, and the underlying causes are still unclear. We speculate that the pressure of pneumoperitoneum may be the main cause of this phenomenon. Symptoms may be self-limiting, and steroid-containing eye drops can relieve effectively the discomfort.


Keywords: Conjunctival congestion, laparoscopic operation, pneumoperitoneum pressure



How to cite this URL:
Gong HL, Yang N, Zhao QK, Zhao JC, Wu H. Conjunctival congestion after laparoscopic operation in children: A retrospective case series in a single-centre children's medical centre. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=350049





  Introduction Top


In the past 30 years, the laparoscopic approach has become the first-line approach to many general surgical operations.[1] It has been applied to many diseases in paediatric surgery due to its advantages such as reduced post-operative pain, shorter hospital stays and rapid return to normal activities.[2] However, it is undeniable that laparoscopy also has many different degrees of complications during and after the operation including: subcutaneous emphysema, pneumothorax, gas embolisation and bowel or bladder perforation, pain nausea, vomiting and incisional hernia, etc. However, up to now, there has been no report of conjunctival congestion after laparoscopic surgery.


  Case Series Top


This is a retrospective, single-centre and observational study in Qingdao, China. Twenty-three patients visited our institution for different diseases between August 2021 and December 2021. The number of these patients accounted for 1.34% (23/1718) of the patients during the same period. Amongst them, 16 cases were males and 7 were females. Moreover, these patients were in the range of 2–12 years old. All patients were well prepared before the operation and their medical history inquiry, physical check and necessary auxiliary inspection were conducted. All the operations were performed under general anaesthesia which was decided jointly by ophthalmologists, paediatricians and anaesthesiologists, patients were informed in detail about the risks and side effects of anesthesia, and signed an informed consent form. An inhalational anaesthetic, sevoflurane, was used to induce general anaesthesia; propofol, sufentanil and cisatracurium besylate were adopted in the intravenous induction; the intravenous inhalation compound was maintained until the end of the surgeries.

No case was converted to laparotomy, and all the surgeries were successfully completed. As shown in [Graph 1], these cases included laparoscopic inguinal hernia repair (8/23), laparoscopic appendectomies (11/23), laparoscopic Meckel's diverticulectomy (1/23), laparoscopic removal of foreign body ingestions (2/23) and laparoscopic choledochal cystectomy (1/23), which accounted for 4.99% of laparoscopic surgeries (23/461).



In all cases, the eyelids of these patients were closed during the operation to avoid prolonged exposure. The duration of the operation varied from 20 to 255 min. The pneumoperitoneum flow kept constant at 2.5 L/min. The pneumoperitoneum pressure ranged from 7 to 12 mmHg [Table 1]. Unexpectedly, as illustrated in [Figure 1], [Figure 2], [Figure 3], these 23 patients developed different degrees of conjunctival congestion after the operation. The primary symptom was different degrees of conjunctival congestion which varied from mild to severe, including filamentous hyperaemia (20/23) and flaky haemorrhage (3/23) specifically. Meanwhile, the patients also exhibited various degrees of dry eyes (6/23), photophobia and tearing (8/23) and pain and other uncomfortable feelings (8/23). Ten patients did not show any accompanying symptoms (10/23). The symptom appeared from 2 to 7 days after the operation, and the duration of this symptom varied from 2 to 14 days. Then, it gradually subsided within 5 days after the surgery at the earliest and 21 days at the latest [Table 1].
Table 1: Detailed information about the symptom and treatment on the 23 patients

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Figure 1: Different clinical manifestations of patients (filamentous hyperaemia to flaky haemorrhage)

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Figure 2: Different clinical manifestations of patients (filamentous hyperaemia to flaky haemorrhage)

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Figure 3: Different clinical manifestations of patients (filamentous hyperaemia to flaky haemorrhage)

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[Table 2] shows that compared with ordinary surgery, the incidence of conjunctival congestion after laparoscopic surgery was statistically significant (P < 0.01).
Table 2: Comparison of conjunctival congestion incidence after ordinary surgery and laparoscopic surgery

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When the symptom appeared, we immediately held discussions with ophthalmologists and anaesthesiologists. It was found that the underlying causes of this symptom were not clear. First, during the operation, patients' eyes were covered to avoid prolonged exposure of the conjunctiva. Meanwhile, the anaesthetics we used on patients produced no related side effects. Moreover, medical carbon dioxide was used in artificial pneumoperitoneum. Finally, there was no regional outbreaks of epidemic haemorrhagic conjunctivitis. Therefore, before we attempted to clarify the reasons, we first obtained consent of the patients' guardian, and then, we used steroid-containing eye drops for treatment. Specifically, if the patient only showed conjunctival congestion with no other accompanying symptoms, we just kept observing unless the parent strongly requested for the eye drop treatment; if the patient exhibited conjunctival congestion accompanied by other discomforts, steroid-containing eye drop is needed expect the parents disagreed. Finally, five patients chose the method of observation although one of them had dry eyes; 18 patients were given steroid-containing eye drops to relieve their discomfort and six of them had no accompanying symptoms

We observed that the eye discomfort could be relieved after the drug use. However, drug use did not speed up the disappearance of symptoms. In other words, there had been no significant difference in duration of symptoms between the medicated group and the unmedicated group [Table 3]. Fortunately, despite the symptom duration, all patients had no vision changes or other serious complications.
Table 3: Comparison of the duration of conjunctival congestion between the medicated group and the non-medicated group

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  Discussion and Conclusion Top


The underlying causes of conjunctival congestion after paediatric laparoscopic surgery are still unclear. Although the similar phenomenon after endoscopy was also reported in other studies, no detailed explanation was provided.[3],[4] We investigated all cases of ordinary surgery during the same period and found that none of them had conjunctival congestion. In addition, there appeared a significant difference in the incidence of conjunctival congestion. Therefore, it was concluded that the occurrence of this phenomenon should be closely related to laparoscopic surgery. Why did this happen? We could not propose a definite answer. As suggested in relevant literature, the most common causes of conjunctival congestion include hypertension, acute inflammation, trauma and contact lens wearers.[5],[6] Obviously, the above causes could be excluded on the situation of the 23 patients in this study.

We further analysed the detailed information of these 23 patients. Compared with other patients undergoing laparoscopic surgery, there was no significant difference in the general condition of the patients, such as disease type, anaesthesia method and duration of the operation and post-operative treatment. Through observation, we found that higher pressure artificial pneumoperitoneum was often used on patients with conjunctival congestion during surgery. That is to say, the higher the peak pressure of the pneumoperitoneum, the more obvious the probability and severity of symptoms after surgery. Therefore, we conjectured that this phenomenon should be attributed to artificial pneumoperitoneum. During the operation, pneumoperitoneum was achieved by infusing CO2 into the peritoneal cavity, which leads to high intra-abdominal pressure.[7] In addition, the position needs to be adjusted to facilitate the operation, for example, the Trendelenburg position. The abdominal cavity of patients should be cleaned. These factors are supposed to be reasons for the increased pressure in patients' abdominal cavity which in turn leads to an increased intrathoracic pressure, central venous pressure and mean arterial pressure. Moreover, this can cause damage to the capillaries as well and this process similar to traumatic asphyxia unfolds as follows: when the pressure in the thoracic cavity increases, the upper body would be in a state of congestion and the blood vessels would be damaged due to high pressure. It manifests with facial and upper chest petechiae, subconjunctival haemorrhages, cervical cyanosis and occasionally neurological symptoms.[8] Since the conjunctiva is very rich in blood vessels and loose tissue, it is easy to observe conjunctival congestion. In addition, as the capillary of children is more fragile than that of adults, the proportion of children with conjunctival congestion is relatively large. Of course, this is only an inference that we have obtained through observation, and there is no direct evidence to verify it. Therefore, we have adopted some measures to avoid this situation, such as reducing the pressure of artificial pneumoperitoneum and avoiding violent puncture during the operation. When flushing the abdominal cavity, we avoid flushing it with a large amount of liquid at one time. Positioning during the operation is also very important; thus, if possible, we avoided head-down and high-foot positions. After the above improvements, we found that the incidence of conjunctival congestion after laparoscopic surgery had decreased significantly to zero.

For the treatment of conjunctival congestion after laparoscopic surgery, we currently believe that those with unobvious symptoms do not need special treatment unless it is strongly requested by the parents. For those with obvious clinical symptoms, we use steroid-containing eye drops for treatment. Although the eye discomfort was significantly relieved after the use of eye drops, the duration of conjunctival congestion did not seem to be significantly shortened. There was no significant difference in the symptom duration of the medicated group and the non-medicated group. Hence, we infer that conjunctival congestion is very likely to be self-limiting.

Therefore, we believe that the occurrence of conjunctival congestion after laparoscopic surgery is extremely rare, and there have been no relevant reports. The analysis is directly related to the artificial pneumoperitoneum pressure, and the symptoms are self-limiting. For those with obvious eye discomfort, steroid-containing eye drops can show good results.

This conclusion is only derived from short-term data from a single centre.

Since then, we informed the possibility of this symptom in the informed consent form, on one hand, this can effectively alleviate the anxiety of parents after symptom appeared, on the other hand, data collection and further analysis can be done with parental consent. Thus, we hope we can attract widespread attention and obtain more data from multiple centres in our future research.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levy B, Mobasheri M. Principles of safe laparoscopic surgery. Surgery (Oxford) 2017;35:216-9.  Back to cited text no. 1
    
2.
Joshi GP. Complications of laparoscopy. Anesthesiol Clin North Am 2001;19:89-105.  Back to cited text no. 2
    
3.
Rajvanshi P, McDonald GB. Subconjunctival hemorrhage as a complication of endoscopy. Gastrointest Endosc 2001;53:251-3.  Back to cited text no. 3
    
4.
Pappas D, Romeu J, Messer J, Dave PB. Postendoscopy subconjunctival hemorrhage. Gastrointest Endosc 1984;30:375.  Back to cited text no. 4
    
5.
Mimura T, Usui T, Yamagami S, Funatsu H, Noma H, Honda N, et al. Recent causes of subconjunctival hemorrhage. Ophthalmologica 2010;224:133-7.  Back to cited text no. 5
    
6.
Fukuyama J, Hayasaka S, Yamada K, Setogawa T. Causes of subconjunctival hemorrhage. Ophthalmologica 1990;200:63-7.  Back to cited text no. 6
    
7.
Wadlund DL. Laparoscopy: Risks, benefits and complications. Nurs Clin North Am 2006;41:219-29, vi.  Back to cited text no. 7
    
8.
Karamustafaoglu YA, Yavasman I, Tiryaki S, Yoruk Y. Traumatic asphyxia. Int J Emerg Med 2010;3:379-80.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04