Comparison of the post-operative ultrasonographic assessment of diaphragmatic function in robotic assisted laparoscopic surgeries and laparotomies-a prospective observational study

Patient will be assessed preoperatively before induction using a GE Healthcare  ultrasound (M-mode) to examine the DE and TF of both hemidiaphragms respectively in a semi recumbent position with the head of the bed tilted at 45 degrees. The diaphragm excursion refers to the movement of diaphragm during breathing assessed by ultrasound by placing a linear probe over the lower intercostals space in the anterior axillary line measured during a quiet breathing. The ultrasound beam was directed to the diaphragm domes at an angle greater than 70 degrees and M-mode tracing was initiated. DE is measured as the vertical distance from the baseline to the highest point of inspiration at quiet breathing. Six measurements from both the hemidiaphragms will be obtained and their mean will be used in data analysis. Where as The diaphragm thickness is measured (in the zone of apposition of the diaphragm and rib cage) in the mid-axiallary line (longitudinally) between the eighth and tenth intercostals space, using a  high frequency linear probe. the diaphragm will be viewed as a three layered structure sandwiched between  the two ecogenic layer of pleura and peritoneum. Using the M-mode function, the thickness of the diaphragm at end inspiration (DTI) and end expiration (DTE) will be measured. TF is given by the formula:

TF  = DTI – DTE / DTE   * 100

TF of both the hemidiaphragm was taken into account and there mean was used for data analysis. Intra-operative neuromuscular monitoring with NMT for TOF ratio will be monitored and only when TOF >0.9 patient will be extubated so as no neuromuscular residual blockade persist due to general anaesthesia.

Post operatively patient will be examined in PACU after one hour of successful extubation and same technique will be used as described above for post operative DE and TF measurement and their findings will be compared and analyzed for any residual paralysis or dysfunction of diaphragm post RALS and laparotomies.