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Laparoscopic surgeries

Types of gases

CO2
Helium
N2O
Nitrogen
Argon
Oxygen

CO2
The most commonly used because it
is :
Cheap , available , non-inflammable,
colorless, noncombustible (
safe
cautery usage ) and highly absorbed
in blood (
little or no potential
for air embolism) , and normal
individual will cope with hypercapnia
and will not develop acidosis)

Helium
very promising alternative to CO2
Helium is clear and colorless,
allowing unimpeded vision to the
operator. It is non toxic, not
flammable or explosive and can be
safely used with electrocautery and
laser, no hemodynamic or acid-base
changes.
Unfortunately , it has the potential
for air embolism ), dissolve slowly

N2O
Has analgesic and sedative effect,
available, no hypercapnia but it is
combusitable
may result in
expulsion if cautery is used .
Also it has the potential for air
embolism, absorbs slower than CO2.
The others : Oxygen , argon and
nitrogen
are not preferred

conclusions
CO2 maintains its role as the primary
insufflation gas in laparoscopy
But N2O has a role in some cases of
depressed pulmonary function or in
local/regional anesthesia cases.
Other gases have no significant
advantage over CO2 or N2O.

Pathophysiology of
pneumoperitoneum
Mechanical effects.
Biochemical effects .

Mechanical effects
increased intra abdominal pressure leading
to :
* Compression of inferior vena cava
Decreased venous return and decreased
cardiac output
increased peripheral
vascular resistance and tachycardia.
* Compression on the diaphragm
decreased tidal volume , functional residual
capacity and compliance
respiratory
acidosis

* shifting blood from the outer renal


cortex to the juxtamedullary zone
(majority of glomeruli reside in the
cortex)
the glomerular
filtration rate will decrease resulting
in activation of renin- angiotensinaldosterone system and decreased
urine output.

Biochemical effects
Due to absorption of gas from the
peritoneum
acidosis and hypercapnia
(CO2)
Prevent acidosis careful monitoring of
arterial blood gases is necessary in
high-risk patients.
Hypercapnia and associated acidosis
may be controlled by increasing
minute ventilation.

Disadvantages
Needs training and experience ,
The tool endpoints move in the
opposite direction to the surgeon's
hands due to the pivot point, making
laparoscopic surgery a non-intuitive
motor skill that is difficult to learn.
This is called the Fulcrum effect

Surgeons must use tools to interact with


tissue rather than manipulate it directly with
their hands. This results in an inability to
accurately judge how much force is being applied
to tissue as well as a risk of damaging tissue by
applying more force than necessary. This
limitation also reduces tactile sensation, making
it more difficult for the surgeon to feel tissue
(sometimes an important diagnostic tool, such as
when palpating for tumors) and making delicate
operations such as tying sutures more difficult.

The surgeon has limited range of


motion at the surgical site .
Some surgeries (carpal tunnel for
instance) generally turn out better
for the patient when the area can
be opened up, allowing the surgeon
to see "the whole picture"
surrounding physiology, to better
address the issue at hand.

risks
The most significant risks are
fromtrocarinjuries during insertion into
the abdominal cavity, as the trocar is typically
inserted blindly. Injuries includeabdominal wall
hematoma, umbilical hernias, umbilical wound
infection, and penetration ofblood vesselsor
small orlarge bowel.
The risk of such injuries is increased in
patients who have a lowbody mass index or
have a history of priorabdominal surgery.

Some patients have sustained


electrical burns unseen by
surgeons who are working
withelectrodesthat leak current into
surrounding tissue. The resulting
injuries can result in perforated
organs and can also lead to
peritonitis. This risk is eliminated
by utilizing active electrode
monitoring.

There may be an increased risk


ofhypothermiaand peritoneal
trauma due to increased exposure to
cold, dry gases duringinsufflation .
The use ofSurgical Humidification
therapy, which is the use of heated
and humidified CO2for insufflation,
has been shown to reduce this risk.

Not all of the CO2introduced into the


abdominal cavity is removed through the
incisions during surgery. Gas tends to rise, and
when a pocket of CO2rises in the abdomen, it
pushes against thediaphragm , and can exert
pressure on thephrenic nerve. This produces a
sensation of pain that may extend to the patient's
shoulders. In some cases this can also cause
considerable pain when breathing. In all cases,
however, the pain is transient, as the body tissues
will absorb the CO2and eliminate it through
respiration


Intra-abdominal adhesionsformation is a risk
associated with both laparoscopic and open
surgery and remains a significant, unresolved
problem . Generally, they occur in 50-100% of all
abdominal surgeries,with the risk of developing
adhesions being the same for both
procedures.Complications of adhesions
includechronic pelvic pain,bowel obstruction,
andfemale infertility. In particular,small bowel
obstructionposes the most significant problem.
The use ofsurgical humidificationtherapy
during laparoscopic surgery may minimize
the incidence of adhesion formation.

complications
Injury to surrounding organs and
vessels.
CO2 embolism.
Hypercapnia
Respiratory acidosis
Pneumothorax/pneumomediastinum
Subcutaneous emphysema

contraindications
Absolute:
Uncorrectable
coagulopathy.
Intestinal
obstruction with
massive distention.
Hemorrhagic shock.
Cardiac dysfunction.
Concomitant
disease requiring
laparotomy.

Relative:
Not able to
tolerate GA.
Sever COPD.
Diaphragmati
c hernia.
Pregnancy
(best in 2nd)