Pathophysiology of pneumoperitoneum and complications of laproscopic surgery

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INTRODUCTION
 TILL 1990-LAPROSCOPY, A DIAGNOSTIC TOOL
 1990-LAP CHOLECYSTECTOMY
 1991-LAP NEPHRECTOMY
3
Dept of Urology, GRH and KMC, Chennai.

4. HISTORY
• 1902-KELLING COINED "KOELIOSCOPIE“
• USED FILTERED AIR FOR
PNEUMOPERITONEUM IN DOG
• USED NITZE CYSTOSCOPE
• 1910-JACOBEUS OF STOCKHOLM-FIRST
ENDOSCOPIC ABDOMINAL INSPECTION IN
HUMAN-USED AIR
4
Dept of Urology, GRH and KMC, Chennai.

5. HISTORY
 1920-ORNDOFF –RADIOLOGIST USED OXYGEN AS
INSUFFLANT-USED VALVED CANULA
 1924-ZOLLIKOFER OF SWITZERLAND-CO₂ MORE
PRACTICAL CHOICE
5
Dept of Urology, GRH and KMC, Chennai.

6. CHOICE OF INSUFFLANT
 CO₂ - most commonly used
 Colourless ,non combustible,inexpensive
 Quickly absorbed
 High diffusion coefficient
 Hypercarbia ,hypercapnia ,arrythmias
 Stored in viscera,bone,muscle
6
Dept of Urology, GRH and KMC, Chennai.

7. CHOICE OF INSUFFLANT
 Nitrous oxide
 Less irritating, fewer acid base disturbances
&arrythmias
 Supports combustion
 Helium –inert, non combustible
 Useful in COPD & poor hypercarbia tolerance
 Decrease in tumor cell growth &
inflammatory reaction
7
Dept of Urology, GRH and KMC, Chennai.

8. CHOICE OF INSUFFLANT
 Helium –high risk of gas embolism
 Don’t use in extraperitoneal innsufflation-↑risk
of pneumothorax
 Room air,oxygen-air embolism,combustion, intra
abdominal explosion
8
Dept of Urology, GRH and KMC, Chennai.

9. PHYSIOLOGICAL EFFECTS OF
PNEUMOPERITONEUM
 Cardiovascular effects depends upon
 Intra abdominal pressure
 Patient position
 co₂ absorption
 Intravascular volume status
 Pre existing cardiopulmonary status
 Current medications
9
Dept of Urology, GRH and KMC, Chennai.

10. CARDIO VASCULAR EFFECTS
 At low atrial pressure[normal or hypovolemic
state]→for pneumoperitoneum upto 20mmHg
→venous return is reduced
 At high atrial pressure[hypervolemic state]→ IVC
resists↑IAP→venous return is actually enhanced
 Net effect-↑TPR depressing cardiac function-more
pronounced in hypovolemic individuals
10
Dept of Urology, GRH and KMC, Chennai.

11. CARDIOVASCLAR EFFECTS
 Cardiac index↓ by 50% of pre operative value within
5 minutes of insufflation,stabilises after 10 minutes
as systemic vascular resistance drops
 EUROPEAN ASSOCIATION FOR ENDOSCOPIC
SURGERY PRACTICE GUIDELINES –
 At IAP up to 15mmHg,↓venous return & cardiac output
is minimal without consequence in healthy individuals
11
Dept of Urology, GRH and KMC, Chennai.

12. CARDIOVASCULAR EFFECTS
 Tachycardia,ventricular extrasystole-due to
hypercapnia
 Brady arrythmia-due to peritoneal irritation and
vagal stimulation
 Significance-clinical warning for
pneumothorax,hypoxia,gas embolism
 Unreliability of CVP
12
Dept of Urology, GRH and KMC, Chennai.

13. CVS EFFECTS OF↑IAP[10-
20mmHg]
 Heart rate - unchanged / ↑
 Mean arterial pressure - ↑
 Systemic vascular resistance - ↑
 Central venous pressure - ↑
 Venous return - ↓
 Cardiac output/index - unchanged / ↓
13
Dept of Urology, GRH and KMC, Chennai.

14. RESPIRATORY EFFECTS
 ↑IAP→limits diaphragmatic movement →FRC↓,
pulmonary dead space unaffected→average peak
airway pressure needed to keep up constant tidal
volume increases parallel to ↑IAP
 Non pressure related respiratory effects
 Head down position ↓vital capacity
 Pulmonary edema in ↑left atrial pressure
14
Dept of Urology, GRH and KMC, Chennai.

15. PULMONARY EFFECTS
OF↑IAP[10-20 mmHg]
 Peak inspiratory pressure - ↑
 Chest wall mechanical resistance - ↑
 Pulmonary dead space - unchanged
 Pulmonary compliance - ↓
 Functional reserve capacity - ↓
 Vital capacity - ↓
15
Dept of Urology, GRH and KMC, Chennai.

16. RENAL EFFECTS
 Thorington&Schmidt found in dogs that
 IAP>15mmHg - oliguria
 IAP>30mmHg - anuria
 Causes-↑renal vein pressure
 Direct renal compression [Harman & co]
 ?ADH, ?AVP - unclear
16
Dept of Urology, GRH and KMC, Chennai.

17. RENAL EFFECTS
 Renal vein& IVC pressure correlates with IAP
 Renal artery pressure relatively unaffected by IAP
changes
 With ↑IAP,increase in renal vascular resistance far
exceeded systemic vascular resistance
 Direct effects on kidney plays major role
17
Dept of Urology, GRH and KMC, Chennai.

18. RENAL EFFECTS
 In 1994 CHIU et al found that
 Renal cortical blood flow↓ with↑IAP
 Renal medullary blood flow↑upto 20mmHg &↓
>20mmHg
 Low dose dopamine[2μg/kg] can prevent dip in urine
output [PEREZ et al,2002 ]
 Summary-At IAP 10-15mmHg urine output ↓
significantly & associated with↓ RBF
18
Dept of Urology, GRH and KMC, Chennai.

19. INTRACRANIAL PRESSURE
 Monroe –kellie doctrine hypothesis
 Vascular,CSF,osseous,parenchymal
 Este-Mcdonald colleagues
 ↑IAP→↓venous outflow from spinal cord via
lumbar & pelvic plexuses → ↑intracranial
pressure
19
Dept of Urology, GRH and KMC, Chennai.

20. INTRACRANIAL PRESSURE
 Rosenthal & colleagues postulated that ,↑ICP is by
two phase mechanism
 Early passive venous effect
 Late active arterial effect
 Acute elevation of ICP elicits CUSHING REFLEX
 Todate ,no neurological sequelae in normal patients
20
Dept of Urology, GRH and KMC, Chennai.

21. INTRACRANIAL PRESSURE
21
Dept of Urology, GRH and KMC, Chennai.

22. VISCERAL EFFECTS
 Decreased blood flow noted in mesentry,
liver,pancreas,stomach,spleen, small& large intestine
 Increased blood flow in adrenals
 No ↑ incidence of GE reflux/regurgitation
22
Dept of Urology, GRH and KMC, Chennai.

23. ACID BASE METABOLIC
EFFECTS
 Co₂ absorbed from peritoneal membrane in TPL
&preperitoneal adipose& connective tissue in RPL
scopy
 Co₂ absorption is more, during initial 30-60 minutes
of the procedure
 Hypercarbia & respiratory acidosis is more common
 ABG must in-lap >1 hour,COPD,RF,CCF.
23
Dept of Urology, GRH and KMC, Chennai.

24. ACID BASE METABOLIC
EFFECTS
 Ideally End tidal co₂ & o₂ should be monitored using
a capnometer.
 With ↑ in end tidal co₂, adjust the respiratory rate &
tidal volume.
24
Dept of Urology, GRH and KMC, Chennai.

25. HEMODYNAMIC EFFECTS IN RELATION
TO PATIENT POSITION
parameter Head up Head down
Heart Rate
MAP
SVR
CO
ICP
25
Dept of Urology, GRH and KMC, Chennai.

26. HARMONAL & METABOLIC
EFFECTS
 Increase in βendorphin,cortisol,prolactin,
epinephrine,nor epinephrine,dopamine.
 Reduced tissue loss of amino nitrogen in LAP
responsible for rapid convalescense
 Lap procedures generally result in less
immunosuppression
26
Dept of Urology, GRH and KMC, Chennai.

27. COMPLICATIONS WITH VERESS
NEEDLE PLACEMENT
 Pre peritoneal placement
 Steep pressure rise
 Unequal abdominal distension
 Check –signs of proper entry
 Negative aspiration
 Easy irrigation of saline
 Negative aspiration of saline
 Positive drop test, normal advancement test
27
Dept of Urology, GRH and KMC, Chennai.

28. VASCULAR INJURIES
 First sign-blood appearing at hub of the needle
 Prevention-direct needle towards hollow of pelvis
 Blunt subcutaneous fat separation, grasp & stabilise
anterior fascia before puncture
 Non umbilical site of entry
 Use of blunt trochars
28
Dept of Urology, GRH and KMC, Chennai.

29. VISCERAL INJURIES
 Initial sign-aspiration of blood, urine, bowel
contents/high pressure on insufflations
 Management-reintroduce at different site
 Bleeding from liver/spleen need argon beam
coagulator or apply surgical hemostat[fibrin
glue]
 Bowel/bladder entry needs only needle
withdrawal
29
Dept of Urology, GRH and KMC, Chennai.

30. VISCERAL INJURIES
 Prevention-NG tube
Foley catheter
Stabilize abdominal wall fascia
Check proper signs of peritoneal entry
30
Dept of Urology, GRH and KMC, Chennai.

31. COMPLICATIONS OF
INSUFFLATION
 Bowel insufflations
 Gas embolism-mc cause is puncture of blood
vessel/organ
 first sign-acute cardiovascular collapse
 Dysrhythmias, tachycardia, cyanosis,
pulmonary edema
 Millwheel precordial murmur
31
Dept of Urology, GRH and KMC, Chennai.

32. COMPLICATIONS OF
INSUFFLATION
 Management of gas embolism
 Cessation of insufflations
 Desufflate peritoneal cavity
 Turn pt in left lateral decubitus position
 Hyperventilate with 100% oxygen
 Advance central line into Rt heart & aspirate gas
32
Dept of Urology, GRH and KMC, Chennai.

33. COMPLICATION OF
INSUFFLATION
 Barotrauma-prolonged elevated pressure [>15mm hg]
 Cause-malfunction of insufflator
 Insufficient pressure monitoring
 PEEP ventilation –rupture of pulmonary bulla
 Initial sign- hypotension-↓ venous return from IVC
compression
33
Dept of Urology, GRH and KMC, Chennai.

34. BAROTRAUMA
 Management- desufflate the abdomen
 Replace malfunctioning insufflator
 Reinitiate pneumoperitoneum
 Subcutaneous emphysema-cause
 Improper veress needle placement
 Leakage of co₂ around ports
 Problem resolves in 2 to 3 post op days
34
Dept of Urology, GRH and KMC, Chennai.

35. PNEUMOPERICARDIUM
 Cause-gas leak along major blood vessels,through
congenital defects
 Incidence-0.8%
 Diagnosis rarely made during procedure, usually
made in recovery room with CXR
 Treatment-interrupt procedure
 Desufflate abdomen
 pericardiocentesis
35
Dept of Urology, GRH and KMC, Chennai.

36. PNEUMOTHORAX
 Incidence-1.6% [90%RPL,10%TPL]
 Earliest signs-subcutaneous emphysema in
neck&chest
 Ominous sign-hypotension,↓breath sounds, ↑
ventilatory pressure-tension pneumothorax
 CXR confirm diagnosis
 Pass 16G needle via 2nd 0r 3rd ICS-midclavicular
line,tube thoracostomy
36
Dept of Urology, GRH and KMC, Chennai.

37. Complications of blind
placement of first trochar
 Injury to GI organs-small/large intestine injury
 Injury to intra abdominal vessels-0.11%-2%
 More common in retroperitoneoscopy
 Aorta & common iliac vessels-mc
 In intestinal adhesions- mesentric vessel of
fixed loop, may be injured
 First sign-hypotension, tachycardia
 Treatment-emergency laporotomy
37
Dept of Urology, GRH and KMC, Chennai.

38. COMPLICATIONS
 Prevention-special care in children
 Look for CT scan if available
 IAP may be temporarilyraisedto25mmHG
 Avoid trochar through scar
 treatment-vascular repair
38
Dept of Urology, GRH and KMC, Chennai.

39. INJURY TO URINARY TRACT
 Mc with trochar passage
 Incidence-0.02% to8.3%
 Mc-bladder injury
 Sign-pnematuria, macroscopic haematuria
 Confirm-intra vesical installation of indigo carmine
 Treatment-lap/open surgical repair[don’t allow to
heal on their own]
39
Dept of Urology, GRH and KMC, Chennai.

40. COMPLICATIONS OF SECONDARY
TROCHAR PLACEMENT
Bleeding at cannula site
Position related problems,
crossing swords & striking
handles
40
Dept of Urology, GRH and KMC, Chennai.

41. COMPLICATIONS OF GA
 Cardiac arrythmias & cardiac arrest
 MC - sinus tachycardia, bradyarrythmias
 Causes- CO₂ insufflation, ↑ vagal tone
 Changes in BP
 Aspiration of gastric contents
 Hypothermia [0.3⁰c for each 50L of co₂ insufflated]
 ↑bleeding tendency, ↑adrenergic response,
prolonged recoverytime, ↑early post op MI.
41
Dept of Urology, GRH and KMC, Chennai.

42. Complications of lap surgery
 Bowel injury-Electro surgical etiology
 Inappropriate direct activation
 Coupling to another instrument
 Capacitative coupling
 Insulation failure
42
Dept of Urology, GRH and KMC, Chennai.

43. Bowel injury-management
 Intra op – looks as white spots in serosa
 Full extent of bowel necrosis-takes 18 days
 Intraperitoneal free air unreliable
 Early or late
 Monopolar thermal injury/bipolar thermal injury
 Preventive measures
43
Dept of Urology, GRH and KMC, Chennai.

44. BLADDER INJURY
 Predisposing factors-prior pelvic/bladder surgery,
prior RT, endometriosis, bladder diverticula,
amyloidosis
 Management- intra op or post op diagnosis
 In post op- extraperitoneal or intraperitoneal
44
Dept of Urology, GRH and KMC, Chennai.

45. URETERAL INJURY
 As a result of monopolar cautery around ureter
 Common in lap hysterectomy-1%,lap endometrial
ablation,pelvic lymphadenectomy,lap radical
prostatectomy
 Management-intra op or post op.
45
Dept of Urology, GRH and KMC, Chennai.

46. NERVE INJURIES
 Invariably due to patient positioning
 Brachial plexus appears to be at high risk
 Schiatic nerve –stretching along superior leg when pt
in lateral decubitus position
 Femoral nerve-lateral rotation& abduction of hip
46
Dept of Urology, GRH and KMC, Chennai.

47. EARLY POST OP
COMPLICATIONS
 Acute hydrocele
 Scrotal&abdominal ecchymosis
 Pain
 Incisional hernia->10mm port –in adults
 Wound infection
 DVT
 rhabdomyolysis
47
Dept of Urology, GRH and KMC, Chennai.

48. DEEP VEIN THROMBOSIS
 Immediate heparin anticoagulation
 Pneumatic sequential compression devices
 Unfractionated heparin 5000 units ,2 hours pre op
and 12th hourly post op
48
Dept of Urology, GRH and KMC, Chennai.

49. RHABDOMYOLYSIS
 Mc after RPL procedures
 Incidence -1%
 Mc in male –LAP renal procedures>5hrs
 Severe pain in downside hip area, brown urine,
CPK>5000units/dl
 Hydration & alkalinisation, extended physiotheraphy.
 Avoid kidney rest, hypotension ,gel/fluid pad.
49
Dept of Urology, GRH and KMC, Chennai.

50. LATE POST OP COMPLICATIONS
 Lymphocele – mc after pelvic procedures, take
weeks to develop, present as mass/pressure effect –
CT- Percutaneous drainage/lap marsupialization.
 Chylous ascites- mc after left sided retroperitoneal
surgeries,-abdominal distension-low fat medium
chain triglyceride diet-observe. CT scan reveal
ascites, tap & analyse.
 Treatment- somatostatin, suturig of leaky lymphatic
channel.
50
Dept of Urology, GRH and KMC, Chennai.

51. PNEUMORETROPERITONEUM
 Higher chance of subcutaneous emphysema,
pnemothorax and pneumomediastinum[7%],
vascular injuries
 Less chance of intraperitoneal visceral injury, port
site hernia.
51
Dept of Urology, GRH and KMC, Chennai.