High Flow Insufflation for the Maintenance of the Pneumoperitoneum during Bariatric Surgery

Abstract

Minimally invasive bariatric procedures next to becoming more and more popular have established a new field of applications for carbon dioxide (CO₂) insufflators. In laparoscopic bariatric procedures, gas isused toinsufflate the peritoneal cavity and increase the intra-abdominal pressure up to 15 mm Hg for optima lexposure and a suitable operating field. The increased intra-abdominal pressure during pneumoperitoneum can reduce femoral venous flow, intra-operative urine output, portal venous flow, respiratory compliance, and cardiac output. However, clinical complications related to these effects are rare. Yet, surgeons should be constantly aware that the duration of an operation is an important factor in reducing the patient’s exposure to CO₂ pneumoperitoneum and its adverse effects. The optimized performance of the bariatric high flow insufflator allows reaching stable abdominal pressure conditions quicker and at a higher level than a common insufflator. Therefore, high flow insufflators offer great advantages in maintaining intra-abdominal pressure and temperature in comparison to conventional insufflators and thus enhance laparoscopic bariatric surgery by potentially reducing the operating time and the undesirable effects of CO₂ pneumoperitoneum.

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“…The reason that lower intra‐abdominal pressure was not achieved may relate to the limitations of the conventional insufflator device, which uses a low flow carbon dioxide delivery system (e.g. 5 l.min −1 through a Varies needle to 10 l.min −1 through a 5 mm trocar) . When the surgeon uses suction to evacuate smoke or fluids from the abdominal cavity, the pneumoperitoneum will collapse if the suction volume exceeds the pneumoperitoneum volume and the capacity of the insufflator to introduce fresh gas.…”

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“…Our previous investigation reported that this effect is statistically significant at 10 mmHg, and was maximal at 15 mmHg (12), yet increased pressures do not yield an increased effect, at least in vitro (12). Since the effect is maximal at 15 mmHg and as 15 mmHg is the pressure most commonly used to inflate the abdomen in laparoscopic surgery (13), 15 mmHg was selected to investigate increased pressures above ambient in the present study.…”

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“…15 Moreover, high thoracic pressure during the operation may decrease pulmonary venous flow, cardiac output, and respiratory compliance, as well as possibly inducing acid-base imbalance due to hypercarbia. 16 On the other hand, gasless methods do not carry the risk of complications such as hypercapnia, respiratory acidosis, tachycardia, subcutaneous emphysema, and air embolism which are present in gas insufflation approaches. 17 Therefore, robotic thyroidectomy is evolving from a gas inflation technique to a gasless technique.…”