DR MAJID MUSHTAQUEMBBS, MS, FICLS, FMASMINIMAL ACCESS SURGEON ; MAMC NEW DELHI

PNEUMOPERITONEUM

Definition :

Pneumoperitoneum

Laparoscopic space

CREATION OF PNEUMOPERITONEUM

Closed veress needle technique

Open technique

Direct trocar insertion

CLOSED VERESS NEEDLE TECHNIQUE

VERESS NEEDLE TECHNIQUE - Palpate Abd , Empty bladder , NG tube - Position of the patient - Site for insertion - Lift the Abd-wall & hold veress like dart - Angle of insertion - Spring test

Veress Needle

Stab incision

Veress needle insertion

CLOSED VERESS NEEDLE TECHNIQUE

CONFIRMATION OF NEEDLE POSITION - Hiss test - Aspiration test - Drop test - Piston test - Percussion test - Readings on the insufflator - Volume test

Aspiration test

CLOSED VERESS NEEDLE TECHNIQUE

ALTERNATE PUNCTURE SITES

- Palmers point - Right subcostal - Right lower quadrant

Palmers point ..

OPEN ACCESS TECHNIQUE

HASSONS TECHNIQUE ( 1971 ) - Hasson canula - Technique

USING UMBLICAL CICATRIX TUBE - MAMC Technique - Moberg et al

Access using umbilical cicatrix tube

Access using umbilical cicatrix tube

IDEAL GAS FOR INSUFFLATION

Limited systemic absorption across peritoneum

Limited systemic effects if absorbed Rapid excretion if absorbed High solubility in blood Should not support combustion Limited effects with intravascular embolism Colorless , inert , non-explosive Ready available , non-expensive , non-toxic

CARBON DIOXIDE [ CO2 ]

ADVANTAGES - Does not support combustion - High solubility - Eliminated by lungs - Low risk of gas embolism - Readily available - Less expensive

CO2

DISADVANTAGES : - Hypercarbia and acidosis - Stored Co2 may take hours to be eliminated - Direct effects of acidosis ( Cardio

depressant ,Pul – HTN , Syst – vasodilatation ) - Sympathetic + ( Tachycardia ; Increase in

CVP , MAP , Pul A pressure & Vas-resistance)

NITROUS OXIDE

ADVANTAGES - Biologically inert / colorless - Highly soluble - Insignificant changes in AB balance - Less pain

DISADVANTAGES - Supports combustion - Hazardous for operating team

HELIUM

ADVANTAGES : - Neither combustible nor supports

combustion - Minimal effect on acid-base balance - Absence of hypercarbia and acidosis DISADVANTAGES : - Risk of venous gas embolism ( less soluble ) - More diffusible ( low density gas ) - Post operative emphysema takes days to get absorbed .

ARGON

ADVANTAGES : - Non- combustible - Chemically nonreactive - Maintains stable AB-balance

DISADVANTAGE : - Cardiac depressant

PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY

PNEUMOPERITONEUM

POSITION OF THE PATIENT

ANAESTHESIA

EFFECTS OF PNEUMOPERITONEUM ON RESPIRATORY SYSTEM :

Increased PaCO2 [ and ѴCo2 ] Splinting of the diaphragm Decreased lung volumes and capacities

( FRC ; TLV ; Compliance ) Increased airway resistance V / Q mismatch --- Co2[ (a – A) D Co2 ] Endobronchial movement of ETT Hypoxia and hypercarbia

EFFECTS OF PNEUMOPERITONEUM ON CARDIOVASCULAR SYSTEM :

Hypercarbia and Sympathetic stimulation. Tachycardia , Arrhythmias , HTN . Decreased cardiac output . Increased CVP [Decreased venous return]. Increased SVR . Humoral factors . Decreased splanchnic blood flow . No change in coronary blood flow .

EFFECTS OF PNEUMOPERITONEUM ON KIDNEYS :

Decreased renal blood flow .

Decreased GFR and urine output.

OTHER EFFECTS OF PNEUMOPERITONEUM

Regurgitation and aspiration .

Hypothermia .

Increased IOP .

Increased ICP .

PHYSIOLOGICAL EFFECTS DUE TO POSITION OF THE PATIENT :

RESPIRATORY SYSTEM :[Trendelenberg position] - Decreased capacities & compliance - ET shift CVS : Trendelenberg position -- - Increased Venous return , CVP , C.O. - Increased IOP and ICP . [ No change in BP due to reflux vasodilatation

and bradycardia . ]

POSITION OF THE PATIENT :

Reverse Trendelenberg ..

- Pooling of blood in peripheral vessels [ Decreased venous return , CO , BP ] - Venous stasis [ DVT and Pul-Emb ]

EFFECTS DUE TO ANAESTHESIA

Local / Regional : No change in PaCo2

- Minute ventilation increased - Absence of ventilatory depressant effect of G.A

G.A with spontaneous breathing : - Increased minute ventilation not sufficient to keep PaCO2 within normal range ( due to ventilatory depressant effect of G.A )

EFFECTS DUE TO ANAESTHESIA

Mechanical ventilation under G.A : - PaCO2 increases , plateaus after 15-20 minutes . - Minute volume to be adjusted on ventilator.

COMPLICATIONS :

TRAUMATIC COMPLICATIONS :

- Bleeding from abdominal wall

- Visceral injury

- Major vascular injury

Injuries caused by the Veress needle ( % of cases )

696,519 cases of abdominopelvic laparoscopic procedures [55 articles ].

Total of 1,575 injuries [ 0.23% ] Major vascular injuries (0.006%) Major injury to hollow viscera ( 0.0025% )

[ Small gut was most common ] Minor injuries to hollow viscera ( 0.0016 )

[ Stomach was most common ]

Incidence of injuries

One large meta-analysis showed an incidence of vascular injury to be 0.44% in the closed cases compared to 0% in the open cases. They found a bowel injury rate of 0.7% to 0.5% respectively as well.

COMPLICATIONS

RESPIRATORY : - Subcutaneous emphysema

- Pneumothorax

- Pneumomediastinum

- Pneumopericardium

Pneumothorax

Causes : - Potential channels may open - Defects in diaphragm - Weak points in aortic/esophageal hiatus - Pleural tear during surgery at GE junction - Rupture of pulmonary bullae

Pneumothorax

C/F : - Sudden/progressive hypoxemia - Increased peak airway pressure - Subcutaneous emphysema - Auscultation - Decreased movement of one hemi diaphragm.

Pneumothorax

Management : - Avoid ICCT - Increase FiO2 (ventilator setting) - Stop NO2 - Reduce IAP - PEEP (if no pulmonary trauma) - Needle drainage ( If spontaneous resolution does not occur after 1 hour of exsufflation ).

COMPLICATIONS:

GAS EMBOLISM :C/F : - Gas lock in vena cava/right atrium - Tachycardia, Hypotension, Hypoxia - Increased CVP, Arrhythmias , ECG changes - Circulatory collapse - B/L Mydriasis - Delayed recovery , coma, fits , paresis ….

Gas embolism

Diagnosis : - Mill wheel murmur - Aspiration of gas through CV catheter - Precordial / Esophageal Doppler - Capnometry [ Biphasic P ET CO2 ]

Gas embolism

Management : - Stop insufflation & release pneumoperito. - Steep head down and L-lateral position - Increase FiO2 and stop NO2 - Hyperventilation - Aspirate gas through CV catheter - CPR

COMPLICATIONS ( Cont..)

CARDIOVASCULAR : - Arrhythmias - Changes in heart rate - Changes in BP - Circulatory collapse

cvs

Prevention/Management : - Treat CVS problems preoperatively - Avoid excessive IAP - Correct hypoxia and hypercarbia - Slow insufflation / exsufflation - Correct hypovolemia - Slow gradual change in position - Avoid halothane - Drugs -- Atropine , Inotropes , Beta blockers, Nitroglycerin .

COMPLICATIONS :

ASPIRATION

HYPOTHERMIA

REFERENCES :

Hasson HM: A modified instrument and method for laparoscopy.Am J Obstet Gynecol 1971;110:886–887.

Art of Laparoscopic Surgery ; Text book and atlas . C.Palanivelu : First edition ; Volume 1 .

Pawanindra L, Sharma R, Chander J, Ramteke VK: A technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube. Surg Endosc 2002;16:1366–1370

An open Access technique to create pneumoperitoneum in laparoscopic surgery . A.-c. moberg, u. petersson, A. montgomery ; Scandinavian Journal of Surgery 96: 297–300, 2007.

P . Lal , A .Vindal , R. Sharma , J .Chander , V.K.Ramteke . Safety of open technique for first trocar placement in laparoscopic surgery: a series of 6000 cases. . Surg Endosc . 2011

REFERENCES :

Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1–5.

Dingfelder JR. Direct laparoscopic trocar insertion without prior

pneumoperitoneum. J Reprod Med 1978;21:45–7.

Munro MG. Laparoscopic access: complications, technologies and

techniques. Curr Opin Obstet Gynecol 2002;14:365–74. George A. Vilos, MD, Artin Ternamian, Jeffrey Dempster, Philippe Y. Laberge

Laparoscopic Entry: A Review of Techniques, Technologies, and Complications SOGC Clinical practice guideline . JOGC , No. 193, May 2007 , Page 433 -447.

Batra MS , Discoll JJ et al . Evanescent NO2 pneumothorax after laparoscopy . Anaesth-Analg 1983 ;62 : 1121-23.

REF….

Shulman D , Aronson AB . Capnography in early diagnosis of Co2 embolism in laparoscopy . Can J Anaest 1984 ; 31 : 455-59.

Joris JL , Noirot DP , Legrand MJ et al . Haemodynamic changes during laparoscopic cholecystectomy . Anaesth Analg 1993 ; 76 : 1067-71 .

Neumann GG , Sidebotham G et al . Laparoscopy explosion hazards with nitrous oxide . Anaesthesiology 1993 ; 78 : 875-79 .

Yacoub OF , Cardona I et al . Co2 embolism during laparoscopy . Anaesthesiology 1982 ; 57 : 533-35 .

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