title: Hand pain during hand assisted laparoscopic nephrectomy--an ischemic event?
abstract: OBJECTIVE
  The etiology of hand discomfort during hand assisted laparoscopic nephrectomy may be ischemic in nature. We determined if pneumoperitoneal pressure sustained to the hand during hand assisted laparoscopic nephrectomy poses an occupational risk, contributing to local hand hypoxia and resultant extremity pain.
  
  
  METHODS
  A total of 442 measurements of hand oxygen saturation were made during hand assisted laparoscopic nephrectomy. A Nellcor OxiMax Max-1 oxygen sensor was attached to the left index finger of each surgeon and hand assisted laparoscopic nephrectomy was performed using a LapDisc at 15 mm Hg pneumoperitoneal pressures. Local hand oximetry readings and a numerical pain distress scale (range 0 to 10) were recorded every 2 minutes. To control for motion artifact oximetry readings were taken during hand motion and at rest. The Student t test was used to compare differences in local hand oxygen saturation and hand pain in and between study groups.
  
  
  RESULTS
  A history of hand pain during hand assisted laparoscopic nephrectomy was significantly associated with local hypoxia during operative motion and at rest (p = 0.023 and 0.012, respectively), even with an adequate fascial incision and standard pneumoperitoneal pressures. During hand assisted laparoscopic nephrectomy hand pain was most significantly associated with local hypoxia after 24 minutes (p = 0.0002), when local oxygen saturation was 56% to 88%.
  
  
  CONCLUSIONS
  A cohort of urologists is predisposed to ischemic hand pain during hand assisted laparoscopic nephrectomy. The etiology of this pain may be hypoxic in nature, attributable to pneumoperitoneal pressure decreasing perfusion and causing venous congestion or regional local ischemia. Circumferential antebrachial constriction from the LapDisc does not seem to be a significant contributing factor in the presence of an adequate fascial incision. Hand pain secondary to ischemia is most significant after 24 minutes at 15 mm Hg. Future studies in more subjects are called for to validate these findings to elucidate which surgeons are predisposed to this potential occupational hazard and what perioperative measures can be taken to avoid hand pain during hand assisted laparoscopic nephrectomy.
authors.affiliation: Department of Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Ost
authors.forename: Brian A
authors.initials: BA
authors.lastname: VanderBrink
authors.forename: Ardeshir R
authors.initials: AR
authors.lastname: Rastinehad
authors.forename: Arthur D
authors.initials: AD
authors.lastname: Smith
authors.forename: Benjamin R
authors.initials: BR
authors.lastname: Lee
mesh_terms: D000328:Adult; D000818:Animals; D005260:Female; D006225:Hand / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000097:blood / Q000209:etiology*; D010535:Laparoscopy; D008297:Male; D009392:Nephrectomy; D009784:Occupational Diseases / Q000209:etiology*; D010100:Oxygen / Q000097:blood; D010146:Pain / Q000209:etiology*; D011028:Pneumoperitoneum, Artificial; D013552:Swine; D014572:Urology
chemical_list: D010100:Oxygen