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Pneumoperitoneum in
Laparoscopic Surgery
SURG5031 – Surgical Skills and
Practical Professionalism
Presented by
Dr. Chris Nahm BSc (Med) MBBS(Hons) FRACS
Fellow – HPB Surgical Unit, Royal North Shore Hospital
Clinical Lecturer – The University of Sydney
Faculty - Sydney Clinical Skills and Simulation Centre

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Pneumoperitoneum in Laparoscopic Surgery

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 Outline
–  Why do we need pneumoperitoneum
–  Establishing pneumoperitoneum
–  Gas selection
–  Pressures and pain
–  Physiological effects of pneumoperitoneum
–  Troubleshooting
–  Cardiac
–  Respiratory
–  The beeping machine
•  No gas
•  The waking patient
•  Obstruction to flow
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 Why do we need pneumoperitoneum?

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 Establishing Pneumoperitoneum

Laparoscopic gas tubing

Pressure Flow Volume
insufflated

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 Gas Selection

–  CO2 most common

–  Non-combustible, rapidly soluble in blood, quickly excreted, relatively
inexpensive.
–  Nitrous oxide popular in 1970s but combustibility à unpopular.
–  Less post-op pain and pneumoperitoneum-associated oxidative stress.
–  Helium
–  More subcutaneous emphysema.
–  Fewer cardiopulmonary changes

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 Pressures and Pain

–  Higher pressures ! more post-op pain

–  (Bogani, Martinelli et al. 2015)
–  (Hua, Gong et al. 2014)
–  Lower pressures, low insufflation rate, and active gas aspiration ! less
shoulder tip pain after lap chole.
–  Systematic review
–  (Donatsky, Bjerrum et al. 2013)

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Respiratory effects
–  Diaphragmatic splinting à Decreased FRC, increased alveolar dead space à
Atelectasis à Reduced post-op FEV1, peak expiratory flow, and FVC.
–  High airway pressures à barotrauma
–  Gas embolism
–  Serious but rare. 28% mortality
–  Causes: Veress needle into vessel; Injury to any substantial vessel; Hypovolaemia is a risk
–  Presentation – profound hypotension, cyanosis, arrhythmia +/- asystole, grinding murmur, end-
tidal CO2 sudden increase.
–  Rx:
•  Immediately deflate
•  Left-lateral head-down position
•  Increase minute ventilation
•  100% FiO2
•  CVC to aspirate gas
•  CPR
•  Hyperbaric O2 if available.
–  Pneumothorax – usually with high pressures
–  Subcutaneous emphysema
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 Respiratory Effects
–  Changes are not clinically significant in most healthy people.
–  Clinically significant in patients with:
–  Underlying lung disease
–  High BMI
–  Positioning
–  Reverse Trendelenburg à improved respiratory mechanics
–  Trendelenburg à worsened respiratory mechanics.

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 Cardiovascular Effects
–  Increased IAP
–  à Increased systemic vascular resistance à Increased afterload
–  à Decreased venous return à Decreased preload
–  à Decrease in cardiac output
–  Increased pCO2
–  Myocardial depression
–  Vasodilatation
–  Counteracting sympathetic nervous system à tachycardia and
systemic vasoconstriction.
–  Positioning
–  Reverse Trendelenburg à reduced venous return à reduced preload
à Reduced cardiac output.
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 Cardiovascular Effects

–  Patients with underlying cardiac disease need special attention

–  Increased heart rate + afterload + total peripheral resistance à
increased ventricular wall tension à myocardial ischaemia.
–  IAP of 15mmHg in ASA III or IV patients à significant reduction in
cardiac output
•  (Safran and Orlando 1994)
–  Profound bradycardia may result from vagal stimulation due to acute
peritoneal stretch.
–  (Henny and Hofland 2005)
–  Reduced femoral venous flow à ?DVT
–  Despite theoretical risk, not definitively demonstrated clinically.
–  Sequential pneumatic compression devices recommended.

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Gastrointestinal Effects
–  Usual laparoscopy pressures of 12-15mmHg are above portal venous
pressure of 7-10mmHg à venous mesenteric ischaemia
–  Splanchnic vasoconstriction due to vasopressin produced in response to
increased IAP.
–  Dry and cold CO2 à desiccating and cooling effect à visible structural,
morphological and biochemical changes in peritoneum. (Binda 2015)
–  But probably minimal benefit on acute patient outcomes.
•  Cochrane Review: Heated vs. cold CO2 insufflation. 16 studies. No
effect on post-op pain, changes in core temp, morphine consumption,
length of stay, lens fogging, length of operation, or recovery room
stay. (Birch, Manouchehri et al. 2011)
•  Long-term outcomes unclear.

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 Renal effects
–  Pneumoperitoneum causes decreased renal function.
–  Decreased urine output
–  Decreased GFR
–  Decreased renal blood flow
–  Increased creatinine
–  Increased vasopressin
–  (Demyttenaere, Feldman et al. 2007) – Systematic review.

–  Multifactorial
–  Vascular and parenchymal compression
–  Increased vasopressin levels

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 Metabolic effects
–  CO2 insufflation à peritoneal acidosis à metabolic acidosis
–  à decreased cardiac output
–  à predisposition to arrhythmias
–  à resistance to infused catecholamines
–  à suppression of lymphocyte function
–  à impaired cellular energy production
–  CO2 à dissolved in blood à expired via lungs
–  Most healthy patients à able to adapt via intracellular and plasma buffers
–  Those with decreased lung function, reduced cardiac output, or septic patients
à less homeostatic reserve à unable to tolerate the increased CO2 load.
–  Require strict end-tidal CO2 and arterial pH monitoring.

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 Intracranial effects
–  Pneumoperitoneum à measurable increase in ICP
–  Mostly animal studies
–  Exact mechanism unknown
–  No clinical consequence in healthy patients
–  Beware patients with recent intracranial haemorrhage, head trauma,
tumour, etc.
–  Worsened with Trendelenburg, but not made better with reverse
Trendelenburg
•  (Grabowski and Talamini 2009)
•  (Halverson, Buchanan et al. 1998)
•  (Josephs, Este-McDonald et al. 1994)

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Immune/Oxidative Stress Effects
–  Pneumoperitoneum à reduced splanchnic blood flow à reperfusion à
oxidative stress.
–  (Sammour, Mittal et al. 2009) – Systematic review
–  Less oxidative stress with helium and N2O but:
–  Helium less soluble à higher theoretical risk of gas embolus and
pneumothorax
–  N2O combustible.
–  Down-regulation of inflammatory response with CO2 insufflation (lower TNF-
a, IL-6, pro-inflammatory cytokines)
–  (Grabowski and Talamini 2009)
–  Unclear clinical significance.
•  Abdominal sepsis
•  Cancer surgery

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 Practical points
–  Listen to your anaesthetist.
–  Most patients can tolerate 15mmHg CO2 insufflation at high flow.
–  A euvolaemic patient will better tolerate laparoscopy.
–  Lower pressures (e.g. 10-12mmHg) will help the patient with
–  Cardiac failure
–  Respiratory disease
–  Reverse Trendelenburg (i.e. head up) is
–  good for the patient with respiratory disease
–  but can decrease cardiac output on the patient who is hypovolaemic, septic,
or has cardiac failure.
–  Trendelenburg (i.e. head down) may be poorly tolerated by the patient with
–  Obesity
–  Underlying respiratory disease.
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 Practical points
–  Check there is adequate gas in the tank before you start
–  Losing pneumoperitoneum? Check the following:
–  Are any of the taps on the working ports open?
–  Is there a leak around any of your ports esp. the Hasson?
–  Is the patient not relaxed? (check for abdominal muscle
contractions, high pressure readings on laparoscopy tower, and
ask anaesthetist)
–  Is there an obstruction in the gas tubing and is the tap open?
–  Are you running out of gas?

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References
Binda, M. M. (2015). "Humidification during laparoscopic surgery: overview of the clinical benefits of using humidified gas during laparoscopic surgery." Arch
Gynecol Obstet 292(5): 955-971.
Birch, D. W., N. Manouchehri, X. Shi, G. Hadi and S. Karmali (2011). "Heated CO(2) with or without humidification for minimally invasive abdominal surgery."
Cochrane Database Syst Rev(1): Cd007821.
Bogani, G., F. Martinelli, A. Ditto, V. Chiappa, D. Lorusso, F. Ghezzi and F. Raspagliesi (2015). "Pneumoperitoneum pressures during pelvic laparoscopic surgery:
a systematic review and meta-analysis." Eur J Obstet Gynecol Reprod Biol 195: 1-6.
Demyttenaere, S., L. S. Feldman and G. M. Fried (2007). "Effect of pneumoperitoneum on renal perfusion and function: a systematic review." Surg Endosc 21(2):
152-160.
Donatsky, A. M., F. Bjerrum and I. Gogenur (2013). "Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review."
Surg Endosc 27(7): 2275-2282.
Grabowski, J. E. and M. A. Talamini (2009). "Physiological effects of pneumoperitoneum." J Gastrointest Surg 13(5): 1009-1016.
Gurusamy, K. S., J. Vaughan and B. R. Davidson (2014). "Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy." Cochrane
Database Syst Rev 3: Cd006930.
Halverson, A., R. Buchanan, L. Jacobs, V. Shayani, T. Hunt, C. Riedel and J. Sackier (1998). "Evaluation of mechanism of increased intracranial pressure with
insufflation." Surg Endosc 12(3): 266-269.
Henny, C. P. and J. Hofland (2005). "Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum." Surg Endosc 19(9): 1163-1171.
Josephs, L. G., J. R. Este-McDonald, D. H. Birkett and E. F. Hirsch (1994). "Diagnostic laparoscopy increases intracranial pressure." J Trauma 36(6): 815-818;
discussion 818-819.
Safran, D. B. and R. Orlando, 3rd (1994). "Physiologic effects of pneumoperitoneum." Am J Surg 167(2): 281-286.
Sammour, T., A. Mittal, B. P. Loveday, A. Kahokehr, A. R. Phillips, J. A. Windsor and A. G. Hill (2009). "Systematic review of oxidative stress associated with
pneumoperitoneum." Br J Surg 96(8): 836-850.
Valenza, F., G. Chevallard, T. Fossali, V. Salice, M. Pizzocri and L. Gattinoni (2010). "Management of mechanical ventilation during laparoscopic surgery." Best
Pract Res Clin Anaesthesiol 24(2): 227-241.

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 COMMONWEALTH OF AUSTRALIA
Copyright Regulation
WARNING
This material has been reproduced and communicated to you by or on behalf of the
University of Sydney pursuant to Part VB of the Copyright Act 1968 (the Act).
The material in this communication may be subject to copyright under the Act. Any
further reproduction or communication of this material by you may be the subject of
copyright protection under the Act.
Do not remove this notice

The University of Sydney Page 21