Onset Of Pneumoperitoneum Research Articles

The effect of different levels of pneumoperitoneum pressures on regional cerebral oxygenation during robotic assisted laparoscopic prostatectomy

Background/aimThis study aimed to evaluate the effect of low- and high-pressure pneumoperitoneum pressures applied during robotic-assisted laparoscopic prostatectomy (RALP) using near-infrared spectroscopy (NIRS) on regional cerebral oxygenation saturation (rSO2). Materials and methodsThe prospective, comparative, and observational study included patients aged 18–80 years, with the American Society of Anesthesiologists (ASA) physical status I-II, who would undergo elective RALP. The patients were divided into two groups (12 mmHg of pneumoperitoneum pressure group, n=22 and 15 mmHg of pneumoperitoneum pressure group, n=23). Patients’ demographic data, durations of anesthesia, surgery, pneumoperitoneum, and Trendelenburg position, intraoperative estimated blood loss, fluid therapy, urine output, hemodynamic and respiratory data, and rSO2 values were recorded at regular intervals.Results The rSO2 values increased significantly during the pneumoperitoneum combined with steep Trendelenburg position (from t 3 to t 6 ) and at the end of the surgery ( t 7 ) in both groups, compared to the values 5 min after the onset of pneumoperitoneum in the supine position ( t 2 ) (P < 0.05), but no statistical significance was observed between the two groups. No cerebral desaturation was observed in any of our patients. Hemodynamic and respiratory parameters were preserved in both groups. The blood lactate levels were significantly higher in patients operated at high-pressure pneumoperitoneum, compared to those with low-pressure pneumoperitoneum (P < 0.05). Conclusion We believe that low-pressure pneumoperitoneum, especially in robotic surgeries, such as robotic-assisted laparoscopic prostatectomy (RALP), can be applied safely.

SEVOFLURANE REQUIREMENT TO ATTENUATE STRESS RESPONSE TO PNEUMOPERITONEUM AND POST-OPERATIVE ANALGESIA DURING LAPAROSCOPIC CHOLECYSTECTOMY: INTRATHECAL DEXMEDETOMIDINE VS. FENTANYL. A PROSPECTIVE RANDOMISED STUDY

Background and aims: Laparoscopic cholecystectomy is considered as the gold standard for cholelithiasis with better preservation of surgical anatomy, early recovery and post-operative analgesia but haemodynamic instability due to pneumo-peritoneum is a concern. This study was contemplated to assess the effect of intrathecal dexmedetomidine or fentanyl on end-tidal inhalation agent concentration requirement as an indirect measure of haemodynamic stress response during the creation of pneumo-peritoneum and on post-operative analgesia. Methods: This prospective, randomized, comparative study was conducted in 75 ASA I and II patients with three groups of 25 each. The patients in group-1 received 10µg of intrathecal dexmedetomidine, group-2 50µg fentanyl and group-3 equal volume of normal saline before administration of general anesthesia. We assessed the vital parameters and end-tidal concentration of sevourane requirement before and 10minutes after creation and immediately after deation of pneumo-peritoneum. Post-operative pain scores were measured using Visual analogue scale(VAS) for 24hrs and rescue analgesia was 0.5µg/kg fentanyl in the immediate post-operative period and paracetamol 15mg/kg if the score was ≥4 in the post-operative period. Results: Demographic data were comparable in all the groups. Systolic blood pressure before onset of pneumo-peritoneum(P=0.03),endtidal inhalation agent concentration to maintain stable haemodynamics post-pneumoperitoneum were signicantly low(P=0.036) in group-1 as compared to group-3. Immediate bolus dose requirement of fentanyl after extubationwas signicantly low, and the duration of post-operative analgesia was prolonged(P=0.009) in group-1.Conclusion: Intrathecal dexmedetomidine may be a safe and effective method in alleviating haemodynamic stress response during pneumo-peritoneum and provides adequate post-operative analgesia in laparoscopic cholecystectomy.

Changes of cerebral regional oxygen saturation during pneumoperitoneum and Trendelenburg position under propofol anesthesia: a prospective observational study

BackgroundWe evaluated the change of cerebral regional tissue oxygen saturation (rSO2) along with the pneumoperitoneum and the Trendelenburg position. We also assessed the relationship between the change of rSO2 and the changes of mean arterial blood pressure (MAP), heart rate (HR), arterial carbon dioxide tension (PaCO2), arterial oxygen tension (PaO2), or arterial oxygen saturation (SaO2).MethodsForty-one adult patients who underwent a robotic assisted endoscopic prostatic surgery under propofol and remifentanil anesthesia were involved in this study. During the surgery, a pneumoperitoneum was established using carbon dioxide. Measurements of rSO2, MAP, HR, PaCO2, PaO2, and SaO2 were performed before the pneumoperitoneum (baseline), every 5 min after the onset of pneumoperitoneum, before the Trendelenburg position. After the onset of the Trendelenburg position, rSO2, MAP, HR were recorded at 5, 10, 20, 30, 45, and 60 min, and PaCO2, PaO2, and SaO2 were measured at 10, 30, and 60 min.ResultsBefore the pneumoperitoneum, left and right rSO2 were 67.9 ± 6.3% and 68.5 ± 7.0%. Ten minutes after the onset of pneumoperitoneum, significant increase in the rSO2 was observed (left: 69.6 ± 5.9%, right: 70.6 ± 7.4%). During the Trendelenburg position, the rSO2 increased initially and peaked at 5 min (left: 72.2 ± 6.5%, right: 73.1 ± 7.6%), then decreased. Multiple regression analysis showed that change of rSO2 correlated with MAP and PaCO2.ConclusionsPneumoperitoneum and the Trendelenburg position in robotic-assisted endoscopic prostatic surgery did not worsen cerebral oxygenation. Arterial blood pressure is the critical factor in cerebral oxygenation.Trial registrationJapan Primary Registries Network (JPRN); UMIN-CTR ID; UMIN000026227 (retrospectively registered).

Repeated alveolar recruitment maneuvers with and without positive end-expiratory pressure during bariatric surgery: a randomized trial.

Positive end-expiratory pressure (PEEP) is considered essential in protective ventilation, while it may lead to hemodynamic impairment. In the present study, we investigated the effect of repeated alveolar recruitment maneuvers (ARMs) with or without additional PEEP on the arterial oxygenation of obese patients who were undergoing bariatric surgery. Thirty-six obese adult patients with Body Mass Index >40 kg/m2 who were scheduled for laparoscopic sleeve gastrectomy were randomly allocated into three groups: 1) control group, no intraoperative ARMs; 2) ARM+ZEEP group, repeated ARMs every 30 minutes without extra PEEP; or 3) ARM+PEEP group, ARMs followed by 8 cmH2O of PEEP from the onset of pneumoperitoneum. Arterial oxygenation, respiratory mechanics, hemodynamics, and postoperative outcomes were investigated. Patients in the ARM+PEEP group had significantly higher peak and plateau airway pressures during pneumoperitoneum, and more subjects required treatment with vasoconstrictors intraoperatively compared to patients in the other groups. Patients in the two ARMs treated groups had lower driving pressure during pneumoperitoneum and better arterial oxygenation in the emergence stage compared to patients in the control group. The PaO2/FiO2 ratio was 299±30, 315±39 and 245±43 mmHg in the ARM+ZEEP, ARM+PEEP, and control group, respectively (P<0.05 compared to control). There were no significant differences in the postoperative recovery variables between the groups. Repeated ARMs, either with or without PEEP, improve early postoperative oxygenation and shorten time to extubation. ARMs without PEEP result in lower airway pressure and less hemodynamic impairment in patients who were undergoing bariatric surgery.

Effect of positive end-expiratory pressure on intraoperative pulmonary function in patients undergoing urological retroperitoneal laparoscopic surgery in mode of protective ventilation

Objective To evaluate the effect of positive end-expiratory pressure (PEEP) on intraoperative pulmonary function in the patients undergoing urological retroperitoneal laparoscopic surgery in the mode of protective ventilation. Methods Forty patients of both sexes, aged 30-64 yr, with body mass index of 16-29 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective retroperitoneal laparoscopic ureterolithotomy, were randomly divided into 2 groups (n=20 each) using a random number table: control group (group C) and PEEP group (group P). After induction of general anesthesia, the patients were endotracheally intubated.Intermittent positive pressure ventilation (tidal volume [VT] 6 ml/kg, respiratory rate [RR] 12 breaths/min, inspiratory/expiratory ratio [I∶E] 1∶2, fraction of inspired oxygen 50%) was performed from the end of intubation until the onset of pneumoperitoneum.After the onset of pneumoperitoneum, the patients were ventilated (VT 6 ml/kg, RR 22 breaths/min, I∶E 1.0∶1.5), and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg in group C. After the onset of pneumoperitoneum, the patients were ventilated (VT 6 ml/kg, RR 22 breaths/min, I∶E 1.0∶1.5, PEEP 5 cmH2O), and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg in group P. At 5 min before pneumoperitoneum (T1), at 10, 30 and 60 min of pneumoperitoneum (T2-4), immediately after the end of pneumoperitoneum (T5), and at 5 min before extubation (T6), arterial blood samples were collected for blood gas analysis.Peak airway pressure and mean airway pressure were also recorded.Dynamic lung compliance, oxygenation index, respiratory index, dead space fraction and alveolar-arterial oxygen gradient were calculated. Results Compared with group C, mean airway pressure was significantly higher at T2-4, oxygenation index was significantly higher at T3, alveolar-arterial oxygen gradient difference was significantly lower at T3 and T6, and respiratory index was significantly lower at T6 (P 0.05). Conclusion PEEP (5 cmH2O) can improve the intraoperative pulmonary function in the patients undergoing urological retroperitoneal laparoscopic surgery in the mode of protective ventilation. Key words: Positive-pressure respiration; Respiratory function tests; Laparoscopy; Urologic surgical procedures

Prolonged inspiratory time produces better gas exchange in patients undergoing laparoscopic surgery: A randomised trial

Laparoscopic surgery performed with a patient in the Trendelenburg position is known to have adverse effects on pulmonary gas exchange and respiratory mechanics. We supposed that prolonged inspiratory time can improve gas exchange at lower airway pressure. One hundred patients undergoing gynaecologic laparoscopic surgery were randomly assigned to one of four groups: conventional inspiratory-to-expiratory (I : E) ratio (Group 1 : 2), I : E ratio of 1 : 1 (Group 1 : 1), 2 : 1 (Group 2 : 1), or 1 : 2 with external positive end-expiratory pressure (PEEP) of 5 cmH2 O (Group 1 : 2 PEEP). Tidal volume was set to 6 ml/kg, and I : E ratio was adjusted at the onset of pneumoperitoneum. Arterial blood gas analysis with measurements of partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2 /FiO2 ), and physiologic dead space-to-tidal volume ratio (VD /VT ) was performed 15 min after anaesthetic induction (T1), and 30 (T2) and 60 min (T3) after onset of CO2 insufflation. PaO2 /FiO2 at T3 in Groups 1 : 1, 2 : 1, and 1 : 2 PEEP were higher than Group 1 : 2. The partial pressure of arterial carbon dioxide at T3 in Group 2 : 1 was lower than the other groups. The VD /VT at T2 and T3 were lower in Groups 1 : 1 and 2 : 1 than Groups 1 : 2 and 1 : 2 PEEP. Peak or plateau airway pressure was higher in Group 1 : 2 PEEP than the other groups. A prolonged inspiratory time demonstrated a beneficial effect on oxygenation. Furthermore, it showed better CO2 elimination without elevating the peak or plateau airway pressure compared with applying external PEEP. In terms of gas exchange and respiratory mechanics, a prolonged inspiratory time appears to be superior to applying external PEEP in patients undergoing laparoscopic surgery in the Trendelenburg position.

The hemodynamic effects of a reversed Trendelenburg in elderly patients with increased cardiac risk during laparoscopic cholecystectomy.

We studied the hemodynamic changes induced by pneumoperitoneum and a reversed Trendelenburg in elderly patients with increased cardiac risk (ASA class III; n = 30; age 70.8 +/- 4.9 years, mean +/- SD) and compared the results with elderly patients at normal risk (ASA class II; n = 30; age 69.2 +/- 4.1 years) during laparoscopic cholecystectomy. The transesophageal Doppler monitor was performed after induction of general anesthesia (pre-incision), after onset of pneumoperitoneum (insufflation), after head-up (20degrees) and a left lateral tilt (15degrees) (reversed Trendelenburg) and after deflation and horizontal position (desufflation). Mean arterial pressure (MAP), heart rate, cardiac index (CI) and systemic vascular resistance (SVR) were measured, respectively. Induction of pneumoperitoneum and head-up tilt in patients with cardiac risk resulted significantly in a decrease in CI and an increase in SVR compared with patients with normal risk (P < 0.05), and that remained until deflation, but no interval changes in MAP and heart rate. The CI, MAP and heart rate decreased and SVR increased significantly in patients with cardiac risk compared with patients with normal risk before incision (P < 0.05). No complications occurred. The results indicate that pneumoperitoneum and a reversed Trendelenburg are associated with significant but relatively benign hemodynamic changes. Anesthesia for laparoscopic cholecystectomy in elderly patients with increased cardiac risk should be performed with an adequate hemodynamic monitoring.

Carbon dioxide pneumoperitoneum causes severe peritoneal acidosis, unaltered by heating, humidification, or bicarbonate in a porcine model

Carbon dioxide (CO(2)) is the most common gas used for insufflation in laparoscopy, but its effects on peritoneal physiology are poorly understood. This study looks at the changes in peritoneal and bowel serosal pH during CO(2) pneumoperitoneum, and whether heating and humidification with or without bicarbonate alters the outcomes. Twenty-one pigs divided into four groups as follows: (1) standard (STD) laparoscopy (n = 5); (2) heated and humidified (HH) laparoscopy (n = 6); (3) heated and humidified with bicarbonate (HHBI) laparoscopy (n = 5); and (4) laparotomy (n = 5). Peritoneal pH, bowel serosal pH, and arterial blood gas (ABG) were obtained at 15-min intervals for 3 h. Severe peritoneal acidosis (pH range 6.59-6.74) was observed in all laparoscopy groups, and this was unaltered by heating and humidification or the addition of bicarbonate. Bowel serosal acidosis was observed in all laparoscopy groups with onset of pneumoperitoneum, but it recovered after 45 minutes. No significant changes in peritoneal or bowel serosal pH were observed in the laparotomy group. CO(2) pneumoperitoneum resulted in severe peritoneal acidosis that was unaltered by heating and humidification with or without bicarbonate. Alteration in peritoneal pH may conceivably be responsible for providing an environment favorable for tumor-cell implantation during laparoscopy.

Left ventricular loading modifications induced by pneumoperitoneum: a time course echocardiographic study.

The intraperitoneal insufflation of carbon dioxide during laparoscopic procedures is associated with an increase in mean arterial pressure and systemic vascular resistance. To evaluate the time course of the circulatory changes related to intraabdominal pressure variation, we used transesophageal echocardiography in 10 patients anesthetized for laparoscopic cholecystectomy. Left ventricular dimensions, fractional area shortening (FAS), and left ventricular afterload assessed by the left ventricular end-systolic wall stress (LVESWS) were measured from echocardiographic data before insufflation, during pneumoperitoneum, and during exsufflation. Three minutes after the onset of pneumoperitoneum, we observed a 25.7% +/- 10.5% (mean +/- SD) increase in mean arterial pressure, a 49.1% +/- 14.4% increase in LVESWS, and a 17.0% +/- 16.2% decrease in FAS. All measured variables returned to preinsufflation values after 30 min of pneumoperitoneum and thereafter were no longer significantly affected by postural changes (10 degrees head-up position) or pneumoperitoneum exsufflation. We conclude that the circulatory changes associated with pneumoperitoneum are transient and are probably mediated by factors other than intraabdominal pressure variations. Insufflation of gas into the abdominal cavity results in hemodynamic changes during laparoscopic procedures. We found that echocardiographic and blood pressure effects associated with gas insufflation were transient, indicating mediation by factors besides intraabdominal pressure.

Left Ventricular Loading Modifications Induced by Pneumoperitoneum

The intraperitoneal insufflation of carbon dioxide during laparoscopic procedures is associated with an increase in mean arterial pressure and systemic vascular resistance.To evaluate the time course of the circulatory changes related to intraabdominal pressure variation, we used transesophageal echocardiography in 10 patients anesthetized for laparoscopic cholecystectomy. Left ventricular dimensions, fractional area shortening (FAS), and left ventricular afterload assessed by the left ventricular end-systolic wall stress (LVESWS) were measured from echocardiographic data before insufflation, during pneumoperitoneum, and during exsufflation. Three minutes after the onset of pneumoperitoneum, we observed a 25.7% +/- 10.5% (mean +/- SD) increase in mean arterial pressure, a 49.1% +/- 14.4% increase in LVESWS, and a 17.0% +/- 16.2% decrease in FAS. All measured variables returned to preinsufflation values after 30 min of pneumoperitoneum and thereafter were no longer significantly affected by postural changes (10[degree sign] head-up position) or pneumoperitoneum exsufflation. We conclude that the circulatory changes associated with pneumoperitoneum are transient and are probably mediated by factors other than intraabdominal pressure variations. Implications: Insufflation of gas into the abdominal cavity results in hemodynamic changes during laparoscopic procedures. We found that echocardiographic and blood pressure effects associated with gas insufflation were transient, indicating mediation by factors besides intraabdominal pressure. (Anesth Analg 1998;86:482-7)

Massive pneumoperitoneum during gastroscopy treated by needle puncture of the abdomen.

GASTROSCOPY with the flexible, finger-tip instrument is, as a rule, an innocuous diagnostic procedure. The sudden onset of pneumoperitoneum during the course of this examination, however, is a comp...