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
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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
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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