Why co2 for laparoscopy

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Moffa R, Quinn J, Slotman G Hemodynamic effects of carbon dioxide pneumoperitoneum during mechanical ventilation and positive end-expiratory pressure. Diamant M, Benumof J, Saidman L Hemodynamics of increased intraabdominal pressure: interaction with hypovolemia and halothane anesthesia.

Safran D, Orlando R Physiologic effects of pneumoepritoneum. Markedly increased IAP reduces renal function and urine output owing to an increase in renal vascular resistance and reduction in glomerular filtration rate GFR.

This is compounded by the reduction in cardiac output. Increased IAP may cause regurgitation of gastric contents with associated risk of pulmonary aspiration. This is particularly significant in the obese patient.

Intracranial pressure ICP is increased by the rise in IAP, which may result in a decrease in the cerebral perfusion pressure CPP , especially if there is a reduction in cardiac output. Patient positioning depends on the operation, for example Trendelenburg position head down for gynaecological procedures, reverse Trendelenburg head up for upper abdominal surgery Table 2.

Endobronchial intubation, attributable to cephalad movement of the lungs and carina in relation to the fixed endotracheal tube, should be prevented. Cardiovascularly, there is initially an increase in venous return with subsequent increase in cardiac output, but this causes compensatory vasodilatation with overall minimal effects on the cardiovascular system in a patient with no cardiovascular illness.

There are few respiratory effects in the reverse Trendelenburg position but more marked effects on the cardiovascular system. A decrease in venous return results in decreased cardiac output and therefore blood pressure. These effects are more marked in a patient who is hypovolaemic or compromised cardiovascularly.

Carbon dioxide is the most frequently used gas for insufflation of the abdomen as it is colourless, non-toxic, non-flammable and has the greatest margin of safety in the event of a venous embolus highly soluble. It is absorbed readily from the peritoneum, causing an increase in P a co 2.

This has direct, as well as indirect by raising catecholamine levels , effects on the cardiovascular system. Thus, tachycardia, increased cardiac contractility and reduction in diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischaemia.

Nodal rhythm, sinus bradycardia and asystole attributable to vagal stimulation can be initiated by stretching of the peritoneum. Such effects are more pronounced at the beginning of insufflation because of the rapid stretching of the peritoneum.

Subcutaneous emphysema, pneumomediastinum and pneumothorax may occur because of incorrect positioning of the gas insufflation needle or trocars, anatomical anomalies or by gas dissecting across weak tissue planes attributable to the increased abdominal pressure. Venous gas embolism is a rare but potentially fatal complication.

It may occur if carbon dioxide is insufflated directly into a blood vessel or by gas being drawn into an open vessel by the venturi effect. The physiological effects caused by carbon dioxide are less than that with air because if its greater blood solubility.

Treatment includes rapid deflation of the abdomen and resuscitation of the patient. If severe, the patient may be placed in the left lateral position and the air aspirated via a central line, as recommended for other gas embolisms.

The management of this complication has been reviewed recently in this journal see key references. Introduction of the trocars may cause damage to underlying organs e. Damage to blood vessels can also occur and result in massive haemorrhage. An open procedure is likely to be required to curtail haemorrhage in this situation. The risk of organ damage can be reduced if the trocars are introduced under direct vision.

A full preoperative anaesthetic assessment should be carried out. Particular attention to the cardiovascular and respiratory systems is essential because of potential effects of the pneumoperitoneum and patient position. Morbidly obese patients also need careful assessment as they are at increased risk of respiratory failure postoperatively.

This is particularly important as it has to be considered that all patients are at risk of their surgery being converted to an open procedure with consequent increased postoperative pain and respiratory problems.

Absolute contraindications to laparoscopy are rare; relative contraindications include severe ischaemic or valvular heart disease, increased intracranial pressure e. Premedication is often not required unless the patient is particularly anxious, when a benzodiazepine may be appropriate. H 2 -blockers or proton pump inhibitors may be given to patients with an increased risk of aspiration e.

Atropine may decrease vagus-induced bradycardia but it also causes unpleasant side-effects such as dry mouth and tachycardia. We believe that it is preferable to treat bradycardia when it occurs, rather than routinely prescribing of vagolytics preoperatively.

The choice of anaesthetic depends on the type of operation and patient characteristics. The aims of laparoscopic surgery in the day-case environment, which is predominantly gynaecological, are to achieve rapid recovery with minimal residual effects, good pain control and no nausea or vomiting.

Laparoscopic surgery for major abdominal procedures have different priorities as the patients will have undergone more extensive tissue trauma, but will remain in hospital where greater analgesia and monitoring are available. All operations must accommodate surgical requirements as well as considering the effects of physiological changes on the patient. The options for laparoscopic surgery include general, regional or local anaesthesia.

General anaesthesia with endotracheal intubation and controlled ventilation is considered the safest technique as it protects the airway, enables control of P a co 2 and aids surgical exposure; it is highly recommended for long procedures or for patients with a history of gastro-oesophageal reflux. Gastric distension should be avoided during hand ventilation, as this increases the risk of damage by the trocar and impairs the surgical view. A gastric tube may be necessary to decompress the stomach if distension occurs.

This prevents microatelectasis and therefore hypoxaemia but causes an increase in intrathoracic pressure and adverse effects on cardiac function.

The use of positive end-expiratory pressure PEEP raises intraoperative FRC, reduces hypoxaemia and may also help to reduce postoperative atelectasis. However, PEEP can reduce cardiac output, especially in the presence of a pneumoperitoneum; therefore it should be used with caution.

Spontaneous ventilation with a laryngeal mask airway LMA may be used for patients with no history of reflux or obesity who are undergoing short procedures with a low IAP and small degree of head tilt. However, LMA neither protects the airway from aspiration of gastric contents nor allows control of ventilation to maintain the P a co 2.

The induction of anaesthesia should be conducted as indicated by the patient's condition. Maintenance with nitrous oxide is controversial, as it is thought to be associated with bowel distension and therefore altered laparoscopic view. An increase in post operative nausea and vomiting with nitrous oxide anaesthesia probably only occurs after gynaecological laparoscopic procedures but not after other forms of laparoscopic surgery. Heated gas apparently did not change length of hospitalisation, lens fogging or length of operation.

Recovery room stay was shorter with heated gas but the data was heterogeneous highly variable. When we only included studies at low risk of bias, the data became homogeneous less variable and the recovery room time was not significantly different between the heated and cold gas groups. While heated, humidified gas leads to slightly smaller decreases in core body temperatures, this does not account for improvement in any patient outcomes.

Therefore, there is no clear evidence for the use of heated gas insufflation, with or without humidification, in laparoscopic abdominal surgery. While heated, humidified gas leads to mildly smaller decreases in core body temperatures, clinically this does not account for improved patient outcomes, therefore, there is no clear evidence for the use of heated gas insufflation, with or without humidification, compared to cold gas insufflation in laparoscopic abdominal surgery.

Intraoperative hypothermia during both open and laparoscopic abdominal surgery may be associated with adverse events. For laparoscopic abdominal surgery, the use of heated insufflation systems for establishing pneumoperitoneum has been described to prevent hypothermia.

Humidification of the insufflated gas is also possible. Past studies on heated insufflation have shown inconclusive results with regards to maintenance of core temperature and reduction of postoperative pain and recovery times. To determine the effect of heated gas insufflation compared to cold gas insufflation on maintaining intraoperative normothermia as well as patient outcomes following laparoscopic abdominal surgery.

We also searched grey literature and cross references. Searches were limited to human studies without language restriction. Only randomised controlled trials comparing heated with or without humidification with cold gas insufflation in adult and paediatric populations undergoing laparoscopic abdominal procedures were included. We assessed study quality in regards to relevance, design, sequence generation, allocation concealment, blinding, possibility of incomplete data and selective reporting.

Two review authors independently selected studies for the review, with any disagreement resolved in consensus with a third co-author.

Two review authors independently performed screening of eligible studies, data extraction and methodological quality assessment of the trials. We classified a study as low-risk of bias if all of the first six main criteria indicated in the 'Risk of Bias Assessment' table were assessed as low risk.

We used data sheets to collect data from eligible studies. We used Review Manager RevMan 5. We took publication bias into consideration and compiled funnel plots.