The direction of surgical expansio...

The direction of surgical expansion during the last 10 years has been toward minimally invasive surgery Splenectomy, adrenalectomy, Nissen fundoplication, and laparoscopy-assisted colectomy are just about of the procedures now being performed laparoscopically. everyday to all of these performances is the need to elevate the patient's abdominal wall from the viscera, which allows the surgical team members to behold the abdominal contents and perform surgery Although mechanical means of elevating the abdominal wall exist, gaseous insufflation of the abdomen (ie, pneumoperitoneum) is standard practice.

Pneumoperitoneum is a compages process that affects many of the body's organ a whole s and, in turn, is influenced by dint of patient position and the insufflating agent. Advanced laparoscopic managements may take several hours, and the results of pneumoperitoneum are cumulative. The perioperative supply with nourishment must be aware that the initiation and maintenance of pneumoperitoneum are responsible for most numerous of the complications of laparoscopic surgery (Table 1)(1)

Table 1 LAPAROSCOPIC COMPLICATIONS AND THEIR INCIDENCE(1)

Complications requiring surgical intervention: 1 in 660 cases, 1 fatality in 2000 cases.

Pneumoperitoneum-related complications 07%

* Hypercarbia

* Acidosis

* Arrhythmias

* Bradycardia

* Subcutaneous emphysema

* Atelectasis

* Pneumothorax

* Pneumomediastinum

Hemorrhage: 06%

* Abdominal wall hemorrhage from trocar insertion

* Major tube injury

Perforation injury: 0.2% to 030%

* Visceral injury (eg small bowel, liver, colon)

Cardiac arrest 003%

* Gas embolism

(1) R W Bailey, J L Flowers, Complications of Laporoscopic Surgery (St Louis: Quality Medical Publishing, Inc, 1995) 31-35; K C Sharma et al, "Laparoscopic surgery and its potential for medical complications," Heart & Lung 26 (January/February 1997) 55-58

HISTORY OF PNEUMOPERITONEUM

George Kelling, a German surgeon is credited with performing the first pneumoperitoneum almost 100 years ago. He inserted a trocar into a live dog, used filtered extent air to create a pneumoperitoneum, then inserted a cystoscope to view the abdominal cavity.(2) A pioneer for other surgeon who would explore this modern field from 1910 to the 1920 Kelling apparently performed what he called a "coelioscopy" in humans in the latter part of 1901(3)

The seasons ventroscopy, organoscopy, peritoneoscopy, coelioscopy, abdominoscopy and laparoscopy were all names for this modern procedure. Physicians used these early laparoscopies for observation (eg to establish a differential diagnosis or to determine if tumors had metastasized, thus ruling revealed resection) because instrumentation was not available that allowed surgical intervention. united British surgeon noted that, unlike an exploratory laparotomy, coelioscopy could be performed in the patient's home(4)

During these early measures the physician used 1% novocaine to locally anesthetize the patient's abdomen, then inserted an 18-gauge spinal needle into the peritoneal cavity. The physician used tubing attached to a bellows lower part pump to inflate the abdomen with apartment air, which was preferred through other gases because it was always available.(5) The medical profession at that time believed that inflation had no import on the abdominal cavity, thus the amount of gas instilled was not considered important.(6) Another German physician had many watercolor sketches made of the abdominal anatomy he observ during laparoscopy, sometimes leaving the full play in the patient two or three hours in like manner the artist could work.(7)

The spring-loaded Verre needle almost unchanged since its invention in 1938 was originally designed to create a pneumothorax to treat tuberculosis.(8) When used in laparoscopic surgery today, the outside obturator retracts when the fascia is being penetrated then shields the needle's point when entering the peritoneal cavity. This note is much safer than the original means in which a spinal needle was blindly inserted into the patient's abdomen.

The idea of controlling the amount of gas instilled originated in the 1960 when a machine was discloseed that allowed gas regulation. Perioperative festers now take for granted an insufflator that automatically

* instills carbon dioxide ([COsub2])

* indicates the rate of flow

* monitors the abdominal pressure

* unimpaireds an alarm when the compressing exceeds preset limits,

* warms the gas, and

* records the amount of gas used. As the physiology of pneumoperitoneum became known, the importance of these parameters has grown

PHYSIOLOGY OF PNEUMOPERITONEUM

Establishing pneumoperitoneum affects the patient's entire dead body Although changes occur in many organ schemes they are not all full understood. In addition, the patient's underlying cardiac and pulmonary status, surgical position (eg Trendelenburg) and the representation of gas used all influence the issues of pneumoperitoneum.

Respiratory general intents Pneumoperitoneum can adversely affect: lung function from causing atelectasis or ventilation/perfusion (V/Q) mismatch. Understanding general pulmonary terms is important when discussing lung function. Table 2 lists definitions of belonging to all pulmonary terms.