Laparoscopic surgery involves inflating the abdominal cavity with gas to lift the abdominal wall away from internal organs. Two common gases used are carbon dioxide and nitrous oxide. Carbon dioxide is rapidly absorbed and can cause respiratory acidosis, while nitrous oxide is physiologically inert but its effects on cancer and pregnancy are unknown. The increased abdominal pressure from insufflation can affect cardiovascular and respiratory physiology by decreasing venous return and increasing intrathoracic pressure. It also decreases renal blood flow. Alternative methods to insufflation include abdominal lifting devices or performing surgery without insufflation, but these provide inferior exposure compared to pneumoperitoneum.
Surgical procedures have been improved to reduce trauma to the pt, morbidity, mortality and hospital stay with consequent reduction in health care cost.
Many painful operations that once required prolonged hospitalizations are now being performed on an out Pt or short stay basis.
the implications for anesthesiologist are to use the technique that not only allows for optimal surgical conditions, but intraoperative Pt comfort and safety, and a rapid anesthetic recovery
The development of better equipment and facilities, along with increased knowledge and understanding of anatomy and pathology have allowed the development of endoscopy for diagnostic and operative procedure. Starting from 1970 used various pathologic gynecological conditions have been diagnosed and treated with laparoscope.
Surgical procedures have been improved to reduce trauma to the pt, morbidity, mortality and hospital stay with consequent reduction in health care cost.
Many painful operations that once required prolonged hospitalizations are now being performed on an out Pt or short stay basis.
the implications for anesthesiologist are to use the technique that not only allows for optimal surgical conditions, but intraoperative Pt comfort and safety, and a rapid anesthetic recovery
The development of better equipment and facilities, along with increased knowledge and understanding of anatomy and pathology have allowed the development of endoscopy for diagnostic and operative procedure. Starting from 1970 used various pathologic gynecological conditions have been diagnosed and treated with laparoscope.
Prof. Mridul Panditrao's Peri-operative MANAGEMENT OF Patients for LaparoscopyProf. Mridul Panditrao
Prof. Panditrao takes you in the detailed discussion about the historical aspects, problems, altered physiology, preparation of and Anesthetic/ peri-operative management of the patients for various laparoscopic surgical procedures
Initial development of “minimal access surgery” began
in the animal laboratory and was later studied in selected
academic centers. It was imported to the community
hospitals only when its benefits and safety were established.
The development of laparoscopic cholecystectomy was not
designed to enhance the safety of the procedure, but rather to
reduce the discomfort associated with the surgical incision.
The fierce economical competition in medicine fueled by
the managed care movement led to the rapid adoption of
laparoscopic surgery among surgeons and gynecologist in
community hospitals who were not formally trained in this
technique and acquired their knowledge by subscribing to
short courses.
Low complication rates were reported by centers
specializing in laparoscopic surgery, mostly in academic
centers. These centers were able to reduce the complication
rate to minimum by developing proficiency in this surgery.
Regrettably, many inexperienced surgeons perform this
technique within sufficient training and are responsible for
the majority of complications seen during the performance
of laparoscopic surgery
Initial development of “minimal access surgery” began in the animal laboratory and was later studied in selected academic centers. It was imported to the community hospitals only when its benefits and safety were established.
Prof. Mridul Panditrao's Peri-operative MANAGEMENT OF Patients for LaparoscopyProf. Mridul Panditrao
Prof. Panditrao takes you in the detailed discussion about the historical aspects, problems, altered physiology, preparation of and Anesthetic/ peri-operative management of the patients for various laparoscopic surgical procedures
Initial development of “minimal access surgery” began
in the animal laboratory and was later studied in selected
academic centers. It was imported to the community
hospitals only when its benefits and safety were established.
The development of laparoscopic cholecystectomy was not
designed to enhance the safety of the procedure, but rather to
reduce the discomfort associated with the surgical incision.
The fierce economical competition in medicine fueled by
the managed care movement led to the rapid adoption of
laparoscopic surgery among surgeons and gynecologist in
community hospitals who were not formally trained in this
technique and acquired their knowledge by subscribing to
short courses.
Low complication rates were reported by centers
specializing in laparoscopic surgery, mostly in academic
centers. These centers were able to reduce the complication
rate to minimum by developing proficiency in this surgery.
Regrettably, many inexperienced surgeons perform this
technique within sufficient training and are responsible for
the majority of complications seen during the performance
of laparoscopic surgery
Initial development of “minimal access surgery” began in the animal laboratory and was later studied in selected academic centers. It was imported to the community hospitals only when its benefits and safety were established.
World Laparoscopy Hospital provides learning by doing. It provides real-world laparoscopic surgery experience by allowing the trainee to get hands-on directly with whatever surgeons are learning and developing a sense of empowerment. After taking this laparoscopic training course, surgeons and gynecologists can perform laparoscopic surgery on their patients with confidence.
World Laparoscopy Hospital provides learning by doing. It provides real-world laparoscopic surgery experience by allowing the trainee to get hands-on directly with whatever surgeons are learning and developing a sense of empowerment. After taking this laparoscopic training course, surgeons and gynecologists can perform laparoscopic surgery them self on their patients with confidence.
The anesthetic problems during minimal access surgery
are related to the cardiopulmonary effects of pneumoperitoneum, carbon dioxide (CO2) absorption, extraperitoneal
gas insufflation, venous embolism, and inadvertent injuries
to intraabdominal organs. Optimal anesthetic care of
patients undergoing laparoscopic surgery is very much
important. Good anesthetic techniques facilitate riskfree surgery and allow early detection and reduction of
complications.
In young patients, fit for diagnostic laparoscopy, general
anesthesia is the preferred method and does not impose
any increased risk. Adequate anesthesia and analgesia
are essential and endotracheal intubation and controlled
ventilation should be considered. The pneumoperitoneum
can be created safely under local anesthesia provided that
the patient is adequately sedated throughout the procedure.
For successful laparoscopy under local anesthesia, intravenous (IV) medication for sedation should be given
The anesthetic problems during minimal access surgery are related to the cardiopulmonary effects of pneumoperitoneum, carbon dioxide (CO2) absorption, extraperitoneal
gas insufflation, venous embolism, and inadvertent injuries to intraabdominal organs.
Reexpansion pulmonary edema is a serious complication after sudden expansion of collapsed lung.Re-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax , pleural effusion or removal of any space occupying lesion.
The incidence referred is less than 1%, andmortality can reach up to 20%.
Anaesthetic problems of open chest and pathophysiology of one lung ventilation aratimohan
Mechanics and physiology of lung isolation/ one-lung ventilaion,
Anaesthetic implications of one-lung ventilation and management strategies
West zones of the lung
Ventilation-perfusion mismatch, V-Q
Hypoxic pulmonary vasoconstriction
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Laparoscopy pathophysiology by ma3en abu 7oseh
1. Laparoscopic Surgery Pathophysiology
The unique feature of endoscopic surgery in the peritoneal cavity is the need to lift the
abdominal wall from the abdominal organs. Two methods have been devised for
achieving this.7 The first, used by most surgeons, is the induction of a
pneumoperitoneum. Throughout the early twentieth century intraperitoneal visualization
was achieved by inflating the abdominal cavity with air, using a sphygmomanometer
bulb. 8 The problem with using air insufflation is that nitrogen is poorly soluble in blood
and is slowly absorbed across the peritoneal surfaces. Air pneumoperitoneum was
believed to be more painful than nitrous oxide pneumoperitoneum but less painful than
carbon dioxide pneumoperitoneum. Subsequently, carbon dioxide and nitrous oxide were
used for inflating the abdomen. N2O had the advantage of being physiologically inert and
rapidly absorbed. It also provided better analgesia for laparoscopy performed under local
anesthesia when compared with CO2 or air. 9 Despite initial concerns that N2O would not
suppress combustion, controlled clinical trials have established its safety within the
peritoneal cavity. 10 In addition, nitrous oxide has recently been shown to reduce the
intraoperative end-tidal CO2 and minute ventilation required to maintain homeostasis
when compared to CO2 pneumoperitoneum. 10 The effect of N2O on tumor biology and
the development of port site metastasis are unknown. As such, caution should be
exercised when performing laparoscopic cancer surgery with this agent. Finally, the
safety of N2O pneumoperitoneum in pregnancy has yet to be elucidated.
The physiologic effects of CO2 pneumoperitoneum can be divided into two areas: (1)
gas-specific effects and (2) pressure-specific effects (Fig. 13-2). CO2 is rapidly absorbed
across the peritoneal membrane into the circulation. In the circulation, CO 2 creates a
respiratory acidosis by the generation of carbonic acid. 11 Body buffers, the largest
reserve of which lies in bone, absorb CO2 (up to 120 L) and minimize the development
of hypercarbia or respiratory acidosis during brief endoscopic procedures. 11 Once the
body buffers are saturated, respiratory acidosis develops rapidly, and the respiratory
system assumes the burden of keeping up with the absorption of CO2 and its release
from these buffers.
In patients with normal respiratory function this is not difficult; the anesthesiologist
increases the ventilatory rate or vital capacity on the ventilator. If the respiratory rate
required exceeds 20 breaths per minute, there may be less efficient gas exchange and
increasing hypercarbia. 12 Conversely, if vital capacity is increased substantially, there is
a greater opportunity for barotrauma and greater respiratory motion–induced disruption
of the upper abdominal operative field. In some situations it is advisable to evacuate the
pneumoperitoneum or reduce the intra-abdominal pressure to allow time for the
anesthesiologist to adjust for hypercarbia. 13 While mild respiratory acidosis probably is
an insignificant problem, more severe respiratory acidosis leading to cardiac arrhythmias
has been reported. 14 Hypercarbia also causes tachycardia and increased systemic
vascular resistance, which elevates blood pressure and increases myocardial oxygen
demand. 11,14
Page 1 | s x x
2. The pressure effects of the pneumoperitoneum on cardiovascular physiology also have
been studied. In the hypovolemic individual, excessive pressure on the inferior vena
cava and a reverse Trendelenburg position with loss of lower extremity muscle tone may
cause decreased venous return and cardiac output. 11,15 This is not seen in the
normovolemic patient. The most common arrhythmia created by laparoscopy is
bradycardia. A rapid stretch of the peritoneal membrane often causes a vagovagal
response with bradycardia and occasionally hypotension. 16 The appropriate
management of this event is desufflation of the abdomen, administration of vagolytic
agents (e.g., atropine), and adequate volume replacement. 17
With the increased intra-abdominal pressure compressing the inferior vena cava, there is
diminished venous return from the lower extremities. This has been well documented in
the patient placed in the reverse Trendelenburg position for upper abdominal operations.
Venous engorgement and decreased venous return promote venous thrombosis. 18,19
Many series of advanced laparoscopic procedures in which deep venous thrombosis
(DVT) prophylaxis was not used demonstrate the frequency of pulmonary embolus. This
usually is an avoidable complication with the use of sequential compression stockings,
subcutaneous heparin, or low-molecular-weight heparin. 20 In short-duration
laparoscopic procedures, such as appendectomy, hernia repair, or cholecystectomy, the
risk of DVT may not be sufficient to warrant extensive DVT prophylaxis.
The increased pressure of the pneumoperitoneum is transmitted directly across the
paralyzed diaphragm to the thoracic cavity, creating increased central venous pressure
and increased filling pressures of the right and left sides of the heart. If the intra-
abdominal pressures are kept under 20 mm Hg, the cardiac output usually is well
maintained. 19,20,21 The direct effect of the pneumoperitoneum on increasing
intrathoracic pressure increases peak inspiratory pressure, pressure across the chest
wall, and also the likelihood of barotrauma. Despite these concerns, disruption of blebs
and consequent pneumothoraces are rare after uncomplicated laparoscopic surgery. 21
Increased intra-abdominal pressure decreases renal blood flow, glomerular filtration
rate, and urine output. These effects may be mediated by direct pressure on the kidney
and the renal vein. 22,23 The secondary effect of decreased renal blood flow is to increase
plasma renin release, thereby increasing sodium retention. Increased circulating
antidiuretic hormone (ADH) levels also are found during the pneumoperitoneum,
increasing free water reabsorption in the distal tubules. 24 Although the effects of the
pneumoperitoneum on renal blood flow are immediately reversible, the hormonally
mediated changes, such as elevated ADH levels, decrease urine output for up to 1 hour
after the procedure has ended. Intraoperative oliguria is common during laparoscopy,
but the urine output is not a reflection of intravascular volume status; intravenous fluid
administration during an uncomplicated laparoscopic procedure should not be linked to
urine output. Because fluid losses through the open abdomen are eliminated with
laparoscopy, the need for supplemental fluid during a laparoscopic surgical procedure is
rare.
The hemodynamic and metabolic consequences of pneumoperitoneum are well tolerated
by healthy individuals for a prolonged period and by most individuals for at least a short
period. Difficulties can occur when a patient with compromised cardiovascular function is
Page 2 | s x x
3. subjected to a long laparoscopic procedure. It is during these procedures that alternative
approaches should be considered or insufflation pressure reduced. Alternative gases that
have been suggested for laparoscopy include the inert gases helium, neon, and argon.
These gases are appealing because they cause no metabolic effects, but are poorly
soluble in blood (unlike CO2 and N2O) and are prone to create gas emboli if the gas has
direct access to the venous system. 19 Gas emboli are rare but serious complications of
laparoscopic surgery. 20,25 They should be suspected if hypotension develops during
insufflation. Diagnosis may be made by listening (with an esophageal stethoscope) for
the characteristic "mill wheel" murmur. The treatment of gas embolism is to place the
patient in a left lateral decubitus position with the head down to trap the gas in the apex
of the right ventricle. 20 A rapidly placed central venous catheter then can be used to
aspirate the gas out of the right ventricle.
In some situations minimally-invasive abdominal surgery should be performed without
insufflation. This has led to the development of an abdominal lift device that can be
placed through a 10- to 12-mm trocar at the umbilicus. 26 These devices have the
advantage of creating little physiologic derangement, but they are bulky and intrusive.
The exposure and working room offered by lift devices also are inferior to those
accomplished by pneumoperitoneum. Lifting the anterior abdominal wall causes a
"pinching in" of the lateral flank walls, displacing the bowel medially and anteriorly into
the operative field. A pneumoperitoneum, with its well-distributed intra-abdominal
pressure, provides better exposure. Abdominal lift devices also cause more
postoperative pain, but they do allow the performance of MIS with standard
(nonlaparoscopic) surgical instruments.
Early it was predicted that the surgical stress response would be significantly lessened
with laparoscopic surgery, but this is not always the case. Serum cortisol levels after
laparoscopic operations are often higher than after the equivalent operation performed
through an open incision. 27 In terms of endocrine balance, the greatest difference
between open and laparoscopic surgery is the more rapid equilibration of most stress-
mediated hormone levels after laparoscopic surgery. Immune suppression also is less
after laparoscopy than after open surgery. There is a trend toward more rapid
normalization of cytokine levels after a laparoscopic procedure than after the equivalent
procedure performed by celiotomy. 28
Transhiatal mobilization of the thoracic esophagus is commonly performed as a
component of many laparoscopic upper abdominal procedures. Entering the posterior
mediastinum transhiatally exposes the thoracic organs to positive insufflation pressure
and may result in decreased venous return and a resultant decrease in cardiac output. If
there is compromise of the mediastinal pleura with resultant CO2 pneumothorax, the
defect should be enlarged so as to prevent a tension pneumothorax.
Page 3 | s x x
4. 7. Smith RS, Fry WR, et al: Gasless laparoscopy and conventional instruments: The next phase of minimally-
invasive surgery. Arch Surg 128:1102, 1993. [PMID: 8215870]
8. Litynski GS: Highlights in the history of laparoscopy. Frankfurt am main, Germany: Barbara Bernet, Verlag,
1996, p 78.
9. Hunter JG, Staheli J, et al: Nitrous oxide pneumoperitoneum revisited: Is there a risk of combustion? Surg
Endosc 9:501, 1995. [PMID: 7676370]
10. Tsereteli Z, Terry ML, et al: Prospective randomized clinical trial comparing nitrous oxide and carbon
dioxide pneumoperitoneum for laparoscopic surgery. J Am Coll Surg 195:173, 2002. [PMID: 12168963]
11. Callery MP, Soper NJ: Physiology of the pneumoperitoneum, in Hunter (ed): Baillière's Clinical
Gastroenterology: Laparoscopic Surgery. London/Philadelphia: Baillière Tindall, 1993, p 757.
12. Ho HS, Gunther RA, et al: Intraperitoneal carbon dioxide insufflation and cardiopulmonary functions. Arch
Surg 127:928, 1992. [PMID: 1386506]
13. Wittgen CM, Andrus CH, et al: Analysis of the hemodynamic and ventilatory effects of laparoscopic
cholecystectomy. Arch Surg 126:997, 1991. [PMID: 1830738]
14. Cullen DJ, Eger EI: Cardiovascular effects of carbon dioxide in man. Anesthesiol 41:345, 1974. [PMID:
4412334]
15. Cunningham AJ, Turner J, et al: Transoesophageal echocardiographic assessment of haemodynamic
function during laparoscopic cholecystectomy. Br J Anaesth 70:621, 1993. [PMID: 8329253]
16. Harris MNE, Plantevin OM, Crowther A, et al: Cardiac arrhythmias during anaesthesia for laparoscopy. Br
J Anaesth 56:1213, 1984. [PMID: 6237663]
17. Borten M, Friedman EA: Choice of anaesthesia, in Laparoscopic Complications: Prevention and
Management. Toronto: BC Decker, 1986, p 173.
18. Jorgenson JO, Hanel K, Lalak NJ, et al: Thromboembolic complications of laparoscopic cholecystectomy
(Letter). Br Med J 306:518, 1993.
19. Ho HS, Wolfe BM: The physiology and immunology of endosurgery, in Toouli JG, Gossot D, Hunter JG
(eds): Endosurgery. New York/London: Churchill-Livingstone, 1996, p 163.
20. Sackier JM, Nibhanupudy B: The pneumoperitoneum-physiology and complications, in Toouli JG, Gossot
D, Hunter JG (eds): Endosurgery. New York/London: Churchill-Livingstone, 1996, p 155.
21. Kashtan J, Green JF, Parsons EQ, et al: Hemodynamic effects of increased abdominal pressure. J Surg Res
30:249, 1981. [PMID: 7230773]
22. McDougall EM, Monk TG, Wolf JS Jr., et al: The effect of prolonged pneumoperitoneum on renal function
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