Effects of Pneumoperitoneum

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Effects Of Pneumoperitoneum

Rohit Gaurav


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Pneumoperitoneum

Pathological

- Hollow viscus perforation

- Traumatic- Gas forming bacteria

Induced


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Background

" I asked myself, how do organsreact to the air introduction? To findthis out, I devised a method to usean endoscope on an unopenedabdominal cavity ( Koelioskopie) inthe following way." George Kelling,

1901

1901- George Kell ing, of Dresden

coined the term "coelioskope" to

describe the technique that used a

cystoscope to examine the abdominal

cavity of dogs.


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Background

Pneumoperitoneum

Gas in the peritoneal cavity

Provide necessary work space by:

- distending the antrolateral abdominal wall

- depressing the hollow organs and soft tissues

Gases used: CO2, N2O, He, Ar


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Background

Ideal insufflating agent

Colorless Nonflammable

Nonirritating/Nontoxic

High blood solubility

Low tissue solubility


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Background

Carbon dioxide insufflation

Colorless Odorless

Readily available

Highly soluble in blood

Highly diffusible

Noncombustible

Disadvantage - Hypercarbia

Acidosis


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Background

Nitrous oxide insufflation

Colorless Soluble in blood

Insignificant change in acid base balance

Decreases pain

Disadvantage - support combustion


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Background

Helium insufflation

Colorless Odorless

Inert gas

Noncombustible

Disadvantage - subcutaneous emphysema

Gas embolism


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Physiology

Mechanical effects of increased intra-

abdominal pressure

Hemodynamic effects of CO2

Effects of positioning


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Pulmonary Effects

Intra abdominal volume and pressure

Diaphragmatic excursion

Compress basilar lung segments, functional residual

capacity and alveolar dead space

Peak airway pressure, pulmonary compliance,

vital capacity


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Pulmonary Effects

Organ System Physiologic Effect Potential Outcome

Pulmonary 1. peak airwaypressure

2. pulm compliance3. Superior

displacement of

diaphragm

4. end-tidal CO2

1. Barotrauma

2. pCO2 or pO2

3. pCO2 or pO2

4. Acidosis


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Pulmonary Effects

Volatile anesthetic and positive pressure ventilation

Ventilation- perfusion mismatch and shunting


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Pulmonary Effects

Systemic acidosis

CO2 absorption from peritoneum

Pco2

delivery of CO2 to lungs

Acidosis


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Pulmonary Effects

High risk patients for acidosis

(FEV1


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Pulmonary Effects

Locoregional acidosis

By impairing microcirculation and organblood flow

Amount of depression duration


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Pulmonary Effects

Laparoscopic vs. Open procedure(postoperative)

Less pain

Less pulmonary embarrassment

Lower incidence of atelectasis


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Circulatory Effects

IAP - CVP, capillary wedge pressure

(preload), mean arterial pressure, SVR

Effect on cardiac output depends on patientvolume status.

venous return

Euvolemic pt peripheral resistance intrathorasic pressure


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Circulatory Effects


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Circulatory Effects

CO2 absorption Hypercarbia

arteriolar dilation and myocardial depression

BP

sympathetic activity

vasopressin reduced diuresis and BP

Renin- angiotensin system BP


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Circulatory Effects

Organ System Physiologic Effect Potential Outcome

Circulatory 1. Direct effects -

CVP, CWP,SVR (afterload),

MAP

2. Indirect effects

arteriolar dilation

and myocardial

depression3. Indirect effects

sympathetics,

renin-angiotensin

1. cardiac work

2. blood pressure3. Blood pressure

and cardiac

output

4. Urine output


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Cardiovascular Effects

IAP

CVP

CO SV HR =

PCWP MAP SVR

Vasopressin

&Catechols

VR

Afterload

CO2


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Circulatory Effects

Effect of patient position

Trendelenburg - CVP, CWP, MAP, CO.

ICT, IOP.

Reverse- Trendelenburg - CO by preload.may cause hypotension
http://www.lhsc.on.ca/transplant/images/kidneytx.jpg


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Renal Effects

Compression of renal parenchyma

Factors CO and renal blood flowImpaired venous return

plasma renin and aldosterone

local vasoconstriction and renal blood flow

Dependant on hydration status
http://www.lhsc.on.ca/transplant/images/kidneytx.jpg


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Intracranial Pressure

vasoactive property of CO2 on

cerebral circulation Etiology

transmission of CVP to ICP

Avoid in head injury patients


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Effects of Coagulation System

Lower extremity venous stasis and increases

the risk for thromboses

May be offset by earlier return to full activity


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Immune Function and Inflammatory

Response

Surgical procedures are immunosuppressive,

but compared to open surgery, laparoscopy

appears to be less so.

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 andTNF- production


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Intestinal Function

Quicker returns of bowel function

Due to blunted sympathetic activity


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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, especially for liver surgery.

Laparofan attached with laparolift after

introduction inside abdominal cavity

Abdolift


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Benefits

Decreased pain

Attenuated stress response Early return to ambulation


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Thank You

Effects of Pneumoperitoneum

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