Start Of Insufflation Research Articles

Tubal Pregnancy with Acute Bleeding Treated by Laparoscopic Surgery: Tips and Case Presentation

Laparoscopic surgery is the standard surgical approach for ectopic pregnancy. However, some surgeons prefer laparotomy for patients with acute bleeding. We evaluated four cases of tubal pregnancy with massive hemoperitoneum (>800 ml) and performed laparoscopic surgery. The patient age ranged from 20 to 37 years, and the gestational age ranged from 5 to 8 weeks. All cases were hemodynamically unstable. Two cases had hemoperitoneum of >2000 mL, which was caused by the rupture of the left isthmus tube. In three cases, surgery could be started within approximately 30 min, and in one case, the start time extended owing to difficulty in anesthesia introduction. Moreover, in three cases, the target lesion was reached within 7 min, and the lesion was excised in approximately 20 min from the start of insufflation, and in one case with a lesion exceeding 7 cm, the time extended. All patients were safely treated via laparoscopic surgery. To initiate surgery without deterioration of the hemodynamic condition, blood transfusion can be started simultaneously with preparation for laparoscopic surgery. Lifting the lesion with a pair of forceps can help immediately stop bleeding, even if it is difficult to secure the visual field owing to massive bleeding. When there is difficulty in anesthesia or a large pregnancy lesion, care should be taken to avoid an increase in the amount of bleeding associated with extension of the perioperative period.

Response to Air Insufflation in Patients with Non-Erosive Gastro-Oesophageal Reflux Disease (NERD)

This study compared changes in intragastric pressure (IGP) in response to a gastric distension stimulus caused by air insufflation in 25 patients with non-erosive gastro-oesophageal reflux disease (NERD) and 34 healthy volunteers (controls). In four NERD patients, IGP responses were also measured before and after oral treatment with 10 mg rabeprazole daily for 2 weeks. The rate of increase in IGP at the start of insufflation was significantly higher in NERD patients than in controls. The time to appearance of symptoms (i.e. time to threshold) was significantly shorter in NERD patients than in controls. Direct measurement of IGP showed that visceral hypersensitivity and impaired fundal relaxation are both characteristic of NERD. Administration of rabeprazole led to a marked prolonging of time to threshold, indicating that treatment could alleviate this hypersensitivity.

Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric technique

Carbon dioxide (CO(2)) is absorbed during pneumoperitoneum and may cause adverse haemodynamic effects. The aim of this study was to measure the elimination of exogenous CO(2) during laparoscopy in children. Ten children [27.6 (56.5) months; mean (SD)] undergoing laparoscopic and nine [24.5 (17.3) months] undergoing open surgery were studied. Breath samples were collected at the line for end-tidal CO(2) and analysed for (13)CO(2)/(12)CO(2) ratio expressed as deltaPDB (difference from standard), by isotope-ratio mass spectrometry. The proportion of absorbed CO(2) was calculated comparing exhaled (13)CO(2)/(12)CO(2) before and during CO(2) pneumoperitoneum. (13)CO(2)/(12)CO(2) in medical CO(2) was -32.7 (2.1) deltaPDB. (13)CO(2)/(12)CO(2) in breath of patients undergoing open procedures was -24.3 (2.4) deltaPDB at the start of operation and did not change during the operation (P > 0.2). (13)CO(2)/(12)CO(2) in breath of patients undergoing laparoscopy was -21.5 (5.4) deltaPDB at the start of insufflation, and decreased during pneumoperitoneum by 2.5 (1.6) deltaPDB, indicating absorption of exogenous CO(2). The percentage of expired CO(2) absorbed rose to 15.5 (7.7)% after 30 min of pneumoperitoneum and decreased rapidly after desufflation. After 10 min of laparoscopy 10-20% of expired CO(2) derives from the exogenous CO(2). CO(2) absorption can be measured using a simple mass spectrometric technique.

Liver blood flow changes during laparoscopic surgery in pigs. A study of hepatic indocyanine green removal.

Physiological effects caused by abdominal insufflation in the course of laparoscopic surgery are partially unknown. The purpose of the present study was to determine if indocyanine green (ICG) pharmacokinetic parameters, as an index of hepatic blood flow, change during laparoscopic surgery in the presence of a CO2 pneumoperitoneum. This effect could cause important alterations in the kinetics of anesthetic drugs. Eighteen female pigs were anaesthetized under constant ventilation and randomly assigned to three groups undergoing insufflation with CO2 (I), laparoscopic oophorectomy with CO2 pneumoperitoneum (LS), or oophorectomy by open surgery (OS). CO2 pneumoperitoneum was performed at 14 mmHg. ICG (1 mg/kg) was injected into a marginal vein on two separate occasions: 30 min before and 30 min after the start of insufflation or surgery. Blood was sampled from the carotid artery at time intervals after the injection of ICG and after pharmacokinetic parameters were obtained by a computer program. The area under the curve (AUC0-infinity) indicated important dysfunctions in ICG availability in all three groups of animals, with significant increases of 104%, 82%, and 48% for groups I, LS, and OS, respectively. The ICG apparent half-life did not significantly change in group OS, but it rose in groups I (+17%) and LS (+28%). ICG clearance was significantly reduced by 32% in group OS and to a larger extent in groups I and LS (-45% and -46%, respectively). These findings confirm the contribution of CO2 pneumoperitoneum to decreased liver blood flow during laparoscopic surgery.

Hemodynamic changes during prolonged laparoscopic surgery.

7 healthy pigs, anesthetized with ketamine/azaperon/thiopentone and ventilated with O2/N2O by volume control, underwent anterior resection of the descending colon by laparoscopic view. During operation of pneumoperitoneum by inflating CO2 to an abdominal pressure of 14 mm Hg was installed. Immediately (+2 min) after the onset of insufflation, both systemic and pulmonary arterial pressure increased. However, pulmonary artery pressure started to decrease after 10 min, whereas systemic arterial pressure remained elevated until the end of the experimental protocol. Left ventricular (LV) pressure and LV dp/dt increased in parallel with the systemic arterial pressure. Peak inspiratory pressure and central venous pressure increased in parallel with the abdominal pressure. Blood gas analysis of arterial and pulmonary blood demonstrated increased pCO2 associated with mild acidosis. Arterial pO2 did not change significantly indicating that the decreased pulmonary distensibility did not endanger the oxygenation. Pulmonary pO2 and pulmonary O2 saturation increased early (+10 min) after start of insufflation and were stable during the 2 h of observation indicating either increased cardiac output or decreased O2 extraction. We conclude that the sharp initial rise of both arterial pressures could be the effect of a mechanical action, whereas sustained hemodynamic alterations would involve complex regulatory mechanisms like an increase of sympathetic activity, baroreceptor control, or a response to acidosis. The acute and, in the systemic circulation, stable increase of ventricular afterload should be considered in patients with underlying cardiac diseases such as ischemic heart disease or valvular dysfunction or in patients taking drugs which interfere with normal compensatory processes.

Changes in the Cardiovascular and Respiratory Systems During Laparoscopic Cholecystectomy

The effects of peritoneal insufflation on the cardiovascular and respiratory systems were investigated in eight patients who underwent laparoscopic cholecystectomy. During the operation, intraabdominal pressure was maintained at a constant 12 mm Hg with carbon dioxide. The cardiac index had increased significantly at 20 and 40 min after the start of insufflation (3.6 +/- 0.6, 3.9 +/- 0.8 mL/min, respectively) and after evacuation (4.2 +/- 0.6 mL/min) compared with the control value (3.2 +/- 0.6 mL/min). Mean arterial pressure was significantly increased at 20 min after the start of insufflation (94.6 +/- 11.2 mm Hg) relative to the control value (79.9 +/- 11.1 mm Hg) and remained high after evacuation (101.5 +/- 11.9 mm Hg). Central and femoral venous pressure rose significantly during the operation from baseline values (12 +/- 6 and 4 +/- 4 mm Hg, respectively) to 18 +/- 10 and 11 +/- 6 mm Hg, respectively, at 20 min, and to 18 +/- 10 and 19 +/- 8 mm Hg, respectively, at 40 min after the start of insufflation. These parameters returned to control levels immediately after evacuation. Dynamic lung compliance decreased by 25% as a result of the elevated intraabdominal pressure. These findings demonstrate that some cardiopulmonary changes occur even at an intraabdominal pressure of 12 mm Hg, which up to now has been considered a safe level.

Gasembolie mit Kreislaufstillstand bei Hysteroskopien: Fallberichte von drei Patientinnen

Hysteroscopy and laparoscopy are relatively non-invasive methods routinely employed in the investigation of infertility. The danger of air embolism during these procedures was recognized early, and carbon dioxide was substituted for air since it is more readily soluble in blood. In this report we describe 3 cases of circulatory collapse and cardiac arrest in healthy young women during routine hysteroscopy (out of a total of 62 patients during the period 1989-1990) which were most probably caused by massive carbon dioxide embolism. Premedication was with oral diazepam 10 mg. Anesthesia was induced with 0.1 mg fentanyl, 2.5 mg droperidol and 100 mg methohexital (100 mg propofol in one case). Intubation was facilitated with 2 mg pancuronium and 50-100mg succinylcholine. Anesthesia was maintained with nitrous oxide 66% and halothane. Ventilation was controlled with a tidal volume of 10 ml per kilogram body weight at a rate of 10 per minute. Monitoring included ECG, automated non-invasive blood pressure, capnometry, pulse oximetry and body temperature. Anesthesia was uneventful prior to insufflation. In each case the signs and symptoms began approximately 5-8 minutes after the start of insufflation and consisted of an initial tachycardia rapidly followed by ventricular dysrhythmias, bradycardia and cardiac arrest. The end-tidal CO2 decreased during the tachycardic phase and prior to asystole. The patients were cyanotic with engorged jugular veins. Resuscitation with closed chest heart massage and intravenous epinephrine or orciprenaline was successful in every case. The typical "mill wheel phenomenon" of gas embolism was audible on auscultation after heart activity had returned, but disappeared after about 5 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)