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