Reply

Abstract

To the Editors:I appreciate the comments by Pelosi and Pelosi. However, I strongly disagree with the postulated explanation of my case as a chemical or mechanical pressure effect of carbon dioxide. I may accept the carbon dioxide pneumoperitoneum as a minor contributing additional factor. My patient underwent a diagnostic laparoscopy, and the carbon dioxide pneumoperitoneum lasted only for <20 minutes. The patient was obese and was in supine position (before and after the operation) for >3 hours. She did not have any predisposing factors for thromboembolism. I strongly propose or postulate the pressure mechanism, in certain cases involving a vulnerable position of the fibroma on the mesenteric blood vessel, as a cause of intestinal gangrene.The cited literature clearly presents cases of operative laparoscopic procedures of longer duration. In these cases mechanical pressure and a chemical effect of carbon dioxide (through transperitoneal absorption) may be reasonably postulated.I would add that during prolonged laparoscopic procedures tilting of the table and decreasing insufflation gas pressure every 20 to 30 minutes will help to prevent this complication. To eliminate the chemical effect of carbon dioxide, the use of nitrous oxide alone or alternating with carbon dioxide should be considered in prolonged endoscopic procedures.In cases of acute abdomen after an endoscopic operation, plain abdominal radiographs to detect air-fluid levels in the intestine should be considered to rule out this rare complication of bowel gangrene. To the Editors:I appreciate the comments by Pelosi and Pelosi. However, I strongly disagree with the postulated explanation of my case as a chemical or mechanical pressure effect of carbon dioxide. I may accept the carbon dioxide pneumoperitoneum as a minor contributing additional factor. My patient underwent a diagnostic laparoscopy, and the carbon dioxide pneumoperitoneum lasted only for <20 minutes. The patient was obese and was in supine position (before and after the operation) for >3 hours. She did not have any predisposing factors for thromboembolism. I strongly propose or postulate the pressure mechanism, in certain cases involving a vulnerable position of the fibroma on the mesenteric blood vessel, as a cause of intestinal gangrene.The cited literature clearly presents cases of operative laparoscopic procedures of longer duration. In these cases mechanical pressure and a chemical effect of carbon dioxide (through transperitoneal absorption) may be reasonably postulated.I would add that during prolonged laparoscopic procedures tilting of the table and decreasing insufflation gas pressure every 20 to 30 minutes will help to prevent this complication. To eliminate the chemical effect of carbon dioxide, the use of nitrous oxide alone or alternating with carbon dioxide should be considered in prolonged endoscopic procedures.In cases of acute abdomen after an endoscopic operation, plain abdominal radiographs to detect air-fluid levels in the intestine should be considered to rule out this rare complication of bowel gangrene. I appreciate the comments by Pelosi and Pelosi. However, I strongly disagree with the postulated explanation of my case as a chemical or mechanical pressure effect of carbon dioxide. I may accept the carbon dioxide pneumoperitoneum as a minor contributing additional factor. My patient underwent a diagnostic laparoscopy, and the carbon dioxide pneumoperitoneum lasted only for <20 minutes. The patient was obese and was in supine position (before and after the operation) for >3 hours. She did not have any predisposing factors for thromboembolism. I strongly propose or postulate the pressure mechanism, in certain cases involving a vulnerable position of the fibroma on the mesenteric blood vessel, as a cause of intestinal gangrene. The cited literature clearly presents cases of operative laparoscopic procedures of longer duration. In these cases mechanical pressure and a chemical effect of carbon dioxide (through transperitoneal absorption) may be reasonably postulated. I would add that during prolonged laparoscopic procedures tilting of the table and decreasing insufflation gas pressure every 20 to 30 minutes will help to prevent this complication. To eliminate the chemical effect of carbon dioxide, the use of nitrous oxide alone or alternating with carbon dioxide should be considered in prolonged endoscopic procedures. In cases of acute abdomen after an endoscopic operation, plain abdominal radiographs to detect air-fluid levels in the intestine should be considered to rule out this rare complication of bowel gangrene.