This document discusses techniques for creating pneumoperitoneum during laparoscopic surgery. It describes the closed veress needle technique and open techniques for accessing the abdominal cavity. It covers confirmation of needle placement, alternate puncture sites, and the Hasson and umbilical cicatrix tube methods for open access. Physiological effects of pneumoperitoneum and positioning are summarized, including effects on respiratory, cardiovascular, and renal systems. Potential complications from pneumoperitoneum like injuries, respiratory issues, gas embolism, and cardiovascular effects are outlined. Gases used for insufflation like carbon dioxide, nitrous oxide, helium, and argon are compared.

1. DR MAJID MUSHTAQUE
MBBS, MS, FICLS, FMAS
MINIMAL ACCESS SURGEON ; MAMC NEW DELHI
PNEUMOPERITONEUM

2. Definition :
 Pneumoperitoneum
 Laparoscopic space

3. CREATION OF PNEUMOPERITONEUM
 Closed veress needle technique
 Open technique
 Direct trocar insertion

4. CLOSED VERESS NEEDLE TECHNIQUE
 VERESS NEEDLE
 TECHNIQUE
- Palpate Abd , Empty bladder , NG tube
- Position of the patient
- Site for insertion
- Lift the Abd-wall & hold veress like
dart
- Angle of insertion
- Spring test

5. Veress Needle

6. Stab incision

7. Veress needle insertion

8. CLOSED VERESS NEEDLE TECHNIQUE
 CONFIRMATION OF NEEDLE POSITION
- Hiss test
- Aspiration test
- Drop test
- Piston test
- Percussion test
- Readings on the insufflator
- Volume test

9. Aspiration test

10. CLOSED VERESS NEEDLE TECHNIQUE
 ALTERNATE PUNCTURE SITES
- Palmers point
- Right subcostal
- Right lower quadrant

11. Palmers point ..

12. OPEN ACCESS TECHNIQUE
 HASSONS TECHNIQUE ( 1971 )
- Hasson canula
- Technique
 USING UMBLICAL CICATRIX TUBE
- MAMC Technique
- Moberg et al

13. Access using umbilical cicatrix tube

14. Access using umbilical cicatrix tube

15. IDEAL GAS FOR INSUFFLATION
 Limited systemic absorption across
peritoneum
 Limited systemic effects if absorbed
 Rapid excretion if absorbed
 High solubility in blood
 Should not support combustion
 Limited effects with intravascular embolism
 Colorless , inert , non-explosive
 Ready available , non-expensive , non-toxic

16. CARBON DIOXIDE [ CO2 ]
 ADVANTAGES
- Does not support combustion
- High solubility
- Eliminated by lungs
- Low risk of gas embolism
- Readily available
- Less expensive

17. CO2
 DISADVANTAGES :
- Hypercarbia and acidosis
- Stored Co2 may take hours to be
eliminated
- Direct effects of acidosis ( Cardio
depressant ,Pul – HTN , Syst – vasodilatation )
- Sympathetic + ( Tachycardia ; Increase in
CVP , MAP , Pul A pressure & Vas-resistance)

18. NITROUS OXIDE
 ADVANTAGES
- Biologically inert / colorless
- Highly soluble
- Insignificant changes in AB balance
- Less pain
 DISADVANTAGES
- Supports combustion
- Hazardous for operating team

19. HELIUM
 ADVANTAGES :
- Neither combustible nor supports
combustion
- Minimal effect on acid-base balance
- Absence of hypercarbia and acidosis
 DISADVANTAGES :
- Risk of venous gas embolism ( less soluble )
- More diffusible ( low density gas )
- Post operative emphysema takes days to get
absorbed .

20. ARGON
 ADVANTAGES :
- Non- combustible
- Chemically nonreactive
- Maintains stable AB-balance
 DISADVANTAGE :
- Cardiac depressant

21. PHYSIOLOGICAL EFFECTS OF
LAPAROSCOPY
 PNEUMOPERITONEUM
 POSITION OF THE PATIENT
 ANAESTHESIA

22. EFFECTS OF PNEUMOPERITONEUM ON
RESPIRATORY SYSTEM :
 Increased PaCO2 [ and ѴCo2 ]
 Splinting of the diaphragm
 Decreased lung volumes and capacities (
FRC ; TLV ; Compliance )
 Increased airway resistance
 V / Q mismatch --- Co2[ (a – A) D Co2 ]
 Endobronchial movement of ETT
 Hypoxia and hypercarbia

23. EFFECTS OF PNEUMOPERITONEUM ON
CARDIOVASCULAR SYSTEM :
 Hypercarbia and Sympathetic stimulation.
 Tachycardia , Arrhythmias , HTN .
 Decreased cardiac output .
 Increased CVP [Decreased venous return].
 Increased SVR .
 Humoral factors .
 Decreased splanchnic blood flow .
 No change in coronary blood flow .

24. EFFECTS OF PNEUMOPERITONEUM ON
KIDNEYS :
 Decreased renal blood flow .
 Decreased GFR and urine output.

25. OTHER EFFECTS OF
PNEUMOPERITONEUM
 Regurgitation and aspiration .
 Hypothermia .
 Increased IOP .
 Increased ICP .

26. PHYSIOLOGICAL EFFECTS DUE TO
POSITION OF THE PATIENT :
 RESPIRATORY SYSTEM :[Trendelenberg
position]
- Decreased capacities & compliance
- ET shift
 CVS :
Trendelenberg position --
- Increased Venous return , CVP , C.O.
- Increased IOP and ICP .
[ No change in BP due to reflux vasodilatation
and bradycardia . ]

27. POSITION OF THE PATIENT :
Reverse Trendelenberg ..
- Pooling of blood in peripheral vessels
[ Decreased venous return , CO , BP ]
- Venous stasis [ DVT and Pul-Emb ]

28. EFFECTS DUE TO ANAESTHESIA
 Local / Regional : No change in PaCo2
- Minute ventilation increased
- Absence of ventilatory depressant effect of G.A
 G.A with spontaneous breathing :
- Increased minute ventilation not sufficient to
keep PaCO2 within normal range ( due to
ventilatory depressant effect of G.A )

29. EFFECTS DUE TO ANAESTHESIA
 Mechanical ventilation under G.A :
- PaCO2 increases , plateaus after 15-20
minutes .
- Minute volume to be adjusted on
ventilator.

30. COMPLICATIONS :
 TRAUMATIC COMPLICATIONS :
- Bleeding from abdominal wall
- Visceral injury
- Major vascular injury

31. Injuries caused by the Veress needle ( % of cases )
 696,519 cases of abdominopelvic laparoscopic
procedures [55 articles ].
 Total of 1,575 injuries [ 0.23% ]
 Major vascular injuries (0.006%)
 Major injury to hollow viscera ( 0.0025% )
[ Small gut was most common ]
 Minor injuries to hollow viscera ( 0.0016 )
[ Stomach was most common ]

32. Incidence of injuries
One large meta-analysis showed an incidence
of vascular injury to be 0.44% in the closed
cases compared to 0% in the open cases.
They found a bowel injury rate of 0.7% to
0.5% respectively as well.

33. COMPLICATIONS
 RESPIRATORY :
- Subcutaneous emphysema
- Pneumothorax
- Pneumomediastinum
- Pneumopericardium

34. Pneumothorax
 Causes :
- Potential channels may open
- Defects in diaphragm
- Weak points in aortic/esophageal hiatus
- Pleural tear during surgery at GE junction
- Rupture of pulmonary bullae

35. Pneumothorax
 C/F :
- Sudden/progressive hypoxemia
- Increased peak airway pressure
- Subcutaneous emphysema
- Auscultation
- Decreased movement of one
hemi diaphragm.

36. Pneumothorax
 Management :
- Avoid ICCT
- Increase FiO2 (ventilator setting)
- Stop NO2
- Reduce IAP
- PEEP (if no pulmonary trauma)
- Needle drainage ( If spontaneous
resolution does not occur after 1 hour
of exsufflation ).

37. COMPLICATIONS:
 GAS EMBOLISM :
C/F :
- Gas lock in vena cava/right atrium
- Tachycardia, Hypotension, Hypoxia
- Increased CVP, Arrhythmias , ECG changes
- Circulatory collapse
- B/L Mydriasis
- Delayed recovery , coma, fits , paresis ….

38. Gas embolism
 Diagnosis :
- Mill wheel murmur
- Aspiration of gas through CV catheter
- Precordial / Esophageal Doppler
- Capnometry [ Biphasic P ET CO2 ]

39. Gas embolism
 Management :
- Stop insufflation & release pneumoperito.
- Steep head down and L-lateral position
- Increase FiO2 and stop NO2
- Hyperventilation
- Aspirate gas through CV catheter
- CPR

40. COMPLICATIONS ( Cont..)
 CARDIOVASCULAR :
- Arrhythmias
- Changes in heart rate
- Changes in BP
- Circulatory collapse

41. cvs
 Prevention/Management :
- Treat CVS problems preoperatively
- Avoid excessive IAP
- Correct hypoxia and hypercarbia
- Slow insufflation / exsufflation
- Correct hypovolemia
- Slow gradual change in position
- Avoid halothane
- Drugs -- Atropine , Inotropes , Beta blockers,
Nitroglycerin .

42. COMPLICATIONS :
 ASPIRATION
 HYPOTHERMIA

43. REFERENCES :
 Hasson HM: A modified instrument and method for laparoscopy.Am J Obstet
Gynecol 1971;110:886–887.
 Art of Laparoscopic Surgery ; Text book and atlas . C.Palanivelu : First
edition ; Volume 1 .
 Pawanindra L, Sharma R, Chander J, Ramteke VK: A technique for open
trocar placement in laparoscopic surgery using the umbilical cicatrix tube.
Surg Endosc 2002;16:1366–1370
 An open Access technique to create pneumoperitoneum in laparoscopic
surgery . A.-c. moberg, u. petersson, A. montgomery ; Scandinavian Journal
of Surgery 96: 297–300, 2007.
 P . Lal , A .Vindal , R. Sharma , J .Chander , V.K.Ramteke . Safety of open
technique for first trocar placement in laparoscopic surgery: a series of 6000
cases. . Surg Endosc . 2011

44. REFERENCES :
 Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1–5.
 Dingfelder JR. Direct laparoscopic trocar insertion without prior
pneumoperitoneum. J Reprod Med 1978;21:45–7.
 Munro MG. Laparoscopic access: complications, technologies and
techniques. Curr Opin Obstet Gynecol 2002;14:365–74.
 George A. Vilos, MD, Artin Ternamian, Jeffrey Dempster, Philippe Y. Laberge
Laparoscopic Entry: A Review of Techniques, Technologies, and Complications
SOGC Clinical practice guideline . JOGC , No. 193, May 2007 , Page 433 -447.
 Batra MS , Discoll JJ et al . Evanescent NO2 pneumothorax after
laparoscopy . Anaesth-Analg 1983 ;62 : 1121-23.

45. REF….
 Shulman D , Aronson AB . Capnography in early diagnosis of Co2 embolism
in laparoscopy . Can J Anaest 1984 ; 31 : 455-59.
 Joris JL , Noirot DP , Legrand MJ et al . Haemodynamic changes during
laparoscopic cholecystectomy . Anaesth Analg 1993 ; 76 : 1067-71 .
 Neumann GG , Sidebotham G et al . Laparoscopy explosion hazards with
nitrous oxide . Anaesthesiology 1993 ; 78 : 875-79 .
 Yacoub OF , Cardona I et al . Co2 embolism during laparoscopy .
Anaesthesiology 1982 ; 57 : 533-35 .

46. THANK YOU