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Effects Of Pneumoperitoneum

Rohit Gaurav

Pneumoperitoneum

Pathological - Hollow viscus perforation - Traumatic - Gas forming bacteria Induced

Background

1901- George Kelling, of Dresden coined the term "coelioskope" to describe the technique that used a cystoscope to examine the abdominal cavity of dogs.
" I asked myself, how do organs react to the air introduction? To find this out, I devised a method to use an endoscope on an unopened abdominal cavity ( Koelioskopie) in the following way." George Kelling, 1901

He.Background “Pneumoperitoneum”   Gas in the peritoneal cavity Provide necessary work space by: . Ar  .depressing the hollow organs and soft tissues Gases used: CO2. N2O.distending the antrolateral abdominal wall .

Background Ideal insufflating agent      Colorless Nonflammable Nonirritating/Nontoxic High blood solubility Low tissue solubility .

Hypercarbia Acidosis .Background Carbon dioxide insufflation        Colorless Odorless Readily available Highly soluble in blood Highly diffusible Noncombustible Disadvantage .

support combustion .Background Nitrous oxide insufflation      Colorless Soluble in blood Insignificant change in acid base balance Decreases pain Disadvantage .

Background Helium insufflation      Colorless Odorless Inert gas Noncombustible Disadvantage .subcutaneous emphysema Gas embolism .

Physiology    Mechanical effects of increased intraabdominal pressure Hemodynamic effects of CO2 Effects of positioning .

↓ pulmonary compliance. ↓ functional residual capacity and ↑ alveolar dead space ↑ Peak airway pressure.Pulmonary Effects  ↑ Intra abdominal volume and pressure ↓ Diaphragmatic excursion  Compress basilar lung segments. ↓ vital capacity  .

3. 2.Pulmonary Effects Organ System Pulmonary Physiologic Effect 1. 4. Barotrauma ⇧ pCO2 or ⇩pO2 ⇧ pCO2 or ⇩pO2 Acidosis 4. 3. ⇧peak airway pressure ⇩pulm compliance Superior displacement of diaphragm ⇧end-tidal CO2 2. Potential Outcome 1. .

perfusion mismatch and shunting .Pulmonary Effects Volatile anesthetic and positive pressure ventilation Ventilation.

Pulmonary Effects Systemic acidosis CO2 absorption from peritoneum ↑ Pco2 ↑ delivery of CO2 to lungs Acidosis .

Pulmonary Effects High risk patients for acidosis      (FEV1<70% and DLCO<80%) Septic patients COPD Diabetes Renal failure Poor cardiac output Monitored by End tidal CO2 and ABG .

Pulmonary Effects Locoregional acidosis   By impairing microcirculation and ↓ organ blood flow Amount of depression ∞ duration .

Open procedure (postoperative)    Less pain Less pulmonary embarrassment Lower incidence of atelectasis .Pulmonary Effects Laparoscopic vs.

↑ capillary wedge pressure (preload). ↑ SVR Effect on cardiac output depends on patient volume status. ↑ mean arterial pressure. ↓ venous return Euvolemic pt ↑ peripheral resistance ↑ intrathorasic pressure .↑ CVP.Circulatory Effects    ↑ IAP .

Circulatory Effects .

Circulatory Effects     CO2 absorption → Hypercarbia → arteriolar dilation and myocardial depression → ↓ BP ↑ sympathetic activity ↑ vasopressin → reduced diuresis and ↑ BP ↑ Renin.angiotensin system → ↑ BP .

3. renin-angiotensin 1. MAP Indirect effects – arteriolar dilation and myocardial depression Indirect effects – sympathetics. 2. Direct effects ⇧CVP. 3. 2. ⇧cardiac work ⇩blood pressure ⇧ Blood pressure and cardiac output ⇩ Urine output .Circulatory Effects Organ System Physiologic Effect Potential Outcome Circulatory 1. 4. CWP. SVR ⇧ (afterload).

Cardiovascular Effects ↑ IAP ↑ CO2 ↑ Vasopressin &Catechols ↑ CVP ↑PCWP ↑MAP ↑SVR ↓ VR ↑ Afterload ↓ CO ↓ SV × HR = .

 Reverse. CWP.Circulatory Effects Effect of patient position  Trendelenburg - ↑ CVP.↓ CO by ↓ preload. may cause hypotension .Trendelenburg . CO. ↑ IOP. ↑ ICT. MAP.

Renal Effects Compression of renal parenchyma Factors ↓ CO and renal blood flow Impaired venous return ↑ plasma renin and aldosterone local vasoconstriction and ↓ renal blood flow    Dependant on hydration status .

Intracranial Pressure vasoactive property of CO2 on cerebral circulation  Etiology transmission of ↑ CVP to ICP  Avoid in head injury patients .

Effects of Coagulation System  Lower extremity venous stasis and increases the risk for thromboses  May be offset by earlier return to full activity .

Degree of immunosuppression is related to the length of the abdominal incision and the amount of abdominal wall trauma High CO2 results in less interleukin-1 and TNF-α production . but compared to open surgery.Immune Function and Inflammatory Response    Surgical procedures are immunosuppressive. laparoscopy appears to be less so.

Intestinal Function  Quicker returns of bowel function Due to blunted sympathetic activity  .

especially for liver surgery. Laparofan attached with laparolift after introduction inside abdominal cavity Abdolift .Gasless/abdominal wall lift techniques abdominal wall lift permits the conduct of laparoscopic procedures at an intra-abdominal pressure of only 6-8 mmHg benefits patients with pre-existing cardiac disease and chronic bronchitis.

Benefits    Decreased pain Attenuated stress response Early return to ambulation .

Thank You .