The Laparoscopic Working Space: Pneumoperitoneum Techniques and Patient Positioning

Fransson, Boel A.

doi:10.1002/9781118845912.ch9

Cited by 3 publications

(5 citation statements)

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“…uma diminuição no decorrer dos momentos. Este achado pode estar atribuído à posição de cefalodeclive, responsável por aumentar o retorno venoso, o que estaria compensando uma possível redução da pressão arterial [30] e ao pneumoperitônio, por aumentar a resistência vascular sistêmica, elevando a pós-carga [9]. Em um estudo realizado em cães [4], não foi observado alteração da pressão arterial quando aumentou os valores de PEEP, corroborando os achados deste estudo.…”

Section: Discussionunclassified

“…Ato contínuo, realizou-se cateterização da artéria femoral direita, também guiada por ultrassom, conectando-se o cateter arterial (Cateter de artéria femoral do sistema VolumeView) 6 à uma torneira de 3 vias conectada ao canal de pressão arterial invasiva do monitor multiparamétrico (Nihon Kohden MU--631RK) 8 , cujo transdutor foi posicionado à altura do coração. As amostras de sangue para hemogasometria arterial também foram colhidas deste ponto, por meio de conexão de seringa heparinizada (BD Seringa de gasometria com agulha eclipse) 9 à torneira de 3 vias.…”

Section: Delineamento Experimentalunclassified

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Effects of PEEP on Hemodynamic Variables of Pigs Submitted to Volume-controlled Ventilation under Pneumoperitoneum associated to Cephalodeclive

Ido

Nunes

2021

Acta Scientiae. Vet.

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Background: Videolaparoscopic procedures have gained prominence due to their low invasiveness, causing less surgical trauma and better post-surgical recovery. However, the increase in intra-abdominal pressure due to the institution of pneumoperitoneum can alter the patient's homeostasis. Therefore, volume-controlled ventilation, associated with positive end-expiratory pressure (PEEP), improves arterial oxygenation and prevents pulmonary collapse, but it can lead to important hemodynamic changes. The aim of this study was to evaluate, comparatively, the effects of positive end expiratory-pressure (PEEP) on hemodynamic variables of pigs submitted to volume-controlled ventilation, during pneumoperitoneum and maintained in head-down tilt and determine which PEEP value promotes greater stability on hemodynamic variables. Materials, Methods & Results: Twenty-four pigs were used, between 55 and 65-day-old, weighing between 15 and 25 kg, randomly divided into 3 distinct groups differentiated by positive end-expiratory pressure: PEEP 0 (volume-controlled ventilation and PEEP of 0 cmH2O), PEEP 5 (volume-controlled ventilation and PEEP of 5 cmH2O) and PEEP 10 (volume-controlled ventilation and PEEP of 10 cmH2O). Volume-controlled ventilation was adjusted to 8 mL/kg of tidal volume and a respiratory rate of 25 movements per min. Anesthesia was maintained with continuous infusion of propofol (0.2 mg/kg/min) and midazolam (1 mg/kg/h). Pneumoperitoneum was performed with carbon dioxide (CO2), keeping the intra-abdominal pressure at 15 mmHg and the animals were positioned on a 30° head-down tilt. The evaluations of hemodynamic variables started 30 min after induction of anesthesia (M0), followed by measurements at 15-min intervals (from M15 to M90), completing a total of 7 evaluations. The variables of interest were collected over 90 min and submitted to analysis of variance followed by Tukey´s post-hoc test, with P < 0.05. The PEEP 10 group had higher values of CVP and mCPP, while the PEEP 5 group, mPAP and PVR were higher. The PEEP 0 group, on the other hand, had higher means of CI. Regarding the moments, there were differences in HR, SAP, DAP, MAP, CO, IC and TPR.Discussion: According to the literature, important hemodynamic effects due to pneumoperitoneum are reported, which can be caused by the pressure used in abdominal insufflation, CO2 accumulation, duration of the surgical procedure, hydration status and patient positioning. Mechanical ventilation associated with PEEP can also cause an increase in intrathoracic pressure and, therefore, reduce cardiac output. Cardiovascular changes are proportional to the PEEP used. Central venous pressure (PVC) measure the patient's preload, and intrathoracic pressure can interfere with this parameter. The peak pressure values in the PEEP 10 group were higher than the other groups, demonstrating that the increase in intrathoracic pressure results in higher PVC values. Regarding PAPm and PCPm, these variables can be influenced according to the PEEP values and the patient's position. In relation to CI, the increase in PEEP may reflect on intrathoracic pressure, resulting in greater compression of the heart, with a consequent reduction in cardiac output and cardiac index. Therefore, it is concluded that the PEEP effects of 0 cmH2O and 5 cmH2O on hemodynamics are discrete, under the proposed conditions. Keywords: mechanical ventilation, PEEP, head-down tilt, VCV, swine. Descritores: ventilação mecânica, PEEP, posição de Trendelenburg, suínos.

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Section: Discussionunclassified

Section: Delineamento Experimentalunclassified

Effects of PEEP on Hemodynamic Variables of Pigs Submitted to Volume-controlled Ventilation under Pneumoperitoneum associated to Cephalodeclive

Ido

Nunes

2021

Acta Scientiae. Vet.

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“…Laparoscopic procedures require distention of the abdomen with gas (CO 2 , air, He or N 2 O) and then inserting a laparoscope through a portal in the abdominal wall [1,16]. This is a critical step because of the potential for iatrogenic trauma to abdominal organs or vasculature during port placement [17,18].…”

Section: Introductionmentioning

confidence: 99%

A Comparison of Times Taken for the Placement of the First Portal and Complication Rates between the Veress Needle Technique and the Modified Hasson Technique in Canine Ovariectomy Laparoscopic Surgery

Bianchi

Collivignarelli

Vignoli

et al. 2021

Animals

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Minimally invasive surgery is increasingly being used in veterinary medicine. Laparoscopic procedures have several advantages compared with open surgery. These include the magnification of the field of surgery, reduced post-surgical pain and associated stress, reduced post-operative infection rates, and decreased hospitalization time. The establishment of a pneumoperitoneum is a critical step; however, this procedure can prolong the operation time, and most of the complications associated with laparoscopic surgery have been attributed to the insertion of devices into the abdominal cavity. Two main techniques have been employed to create pneumoperitoneum: the closed-entry method using the Veress needle and the open Hasson technique. The first portal is necessary to start insufflation and, subsequently, to realize the operative channel to insert the laparoscopic instruments into the abdomen. Many authors have compared the time necessary to create the first portal using different techniques in human medicine, but studies on this topic in veterinary medicine are lacking. In the veterinary medicine literature, complications associated with the creation of a pneumoperitoneum and the placement of ports include spleen, bowel, or bladder injuries; pneumothorax; and subcutaneous emphysema. The aim of the present study was to compare the times required for the placement of the first portal and the creation of pneumoperitoneum, and the rates of intraoperative complications using the Veress needle technique (VNT) and the open modified Hasson technique (MHT). The sample population comprised 30 female dogs who underwent laparoscopic ovariectomies. The dogs were randomly organized into two groups and two different entry techniques were used: Veress needle (VNT = group A) and the modified Hasson technique (MHT = group B). Complications related to abdominal entry were classified as major, in cases of organ perforation, and minor, in cases of subcutaneous emphysema and gas leakage. The VNT and MHT required 374.0 s and 242.9 s, respectively, for the placement of the first portal and for establishing pneumoperitoneum (p < 0.05). Their major complications rates were 20% and 0%, respectively (p < 0.05). Their minor complications rates were 20% and 35%, respectively (p < 0.05). No surgical procedures required laparotomy. The MHT was associated with a lower major complication rate and required less time to create the first portal, compared with the Veress needle technique.

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“…In small animals, most laparoscopic techniques including retroperitoneal organ surgeries have been performed using a transperitoneal technique . Therefore, the evaluation of retroperitoneal laparoscopy in veterinary patients is warranted, considering the promising benefits in people.…”

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confidence: 99%

“…3,5 In small animals, most laparoscopic techniques including retroperitoneal organ surgeries have been performed using a transperitoneal technique. 6 Therefore, the evaluation of retroperitoneal laparoscopy in veterinary patients is warranted, considering the promising benefits in people. To the authors' knowledge, the only study describing retroperitoneoscopy in dogs was performed by medical doctors in 1979 as a technical feasibility study for clinical application in people.…”

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Retroperitoneal Laparoscopy in Dogs: Access Technique, Working Space, and Surgical Anatomy

Jeong

Lim

et al. 2016

Veterinary Surgery

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ObjectiveTo develop and describe a laparoscopic retroperitoneal access technique, investigate working space establishment, and describe the surgical anatomy in the retroperitoneal space as an initial step for clinical application of retroperitoneal laparoscopy in dogs.Study DesignCadaveric and experimental study.AnimalsCadaveric (n=8) and healthy (n=6) adult dogs.MethodsThe retroperitoneal access technique was developed in 3 cadavers based on the human technique and transperitoneal observation. Its application and working space establishment with carbon dioxide (CO2) insufflation alone was evaluated in 5 cadavers by observing with a transperitoneal telescope and in 6 live dogs by repeated computed tomography (CT) scans at pressure of 0, 5, 10, and 15 mmHg. Recordings of retroperitoneoscopy as well as working space volume and linear dimensions measured on CT images were analyzed.ResultsRetroperitoneal access and working space establishment with CO2 insufflation alone were successfully performed in all 6 live dogs. The only complication observed was in 1 dog that developed subclinical pneumomediastinum. As pressure increased, working space was established from the ipsilateral to the contralateral side, and peritoneal tearing eventually developed. Working space volume increased significantly from 5 mmHg and linear dimensions increased significantly from 0 to 10 mmHg. With pneumo‐retroperitoneum above 5 mmHg, retroperitoneal organs, including kidneys and adrenal glands, were easily visualized.ConclusionThe retroperitoneal access technique and working space establishment with CO2 insufflation starting with 5 mmHg and increasing to 10 mmHg provided adequate working space and visualization of retroperitoneal organs, which may allow direct access for retroperitoneal laparoscopy in dogs.

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The Laparoscopic Working Space: Pneumoperitoneum Techniques and Patient Positioning

Cited by 3 publications

References 25 publications

Effects of PEEP on Hemodynamic Variables of Pigs Submitted to Volume-controlled Ventilation under Pneumoperitoneum associated to Cephalodeclive

Effects of PEEP on Hemodynamic Variables of Pigs Submitted to Volume-controlled Ventilation under Pneumoperitoneum associated to Cephalodeclive

A Comparison of Times Taken for the Placement of the First Portal and Complication Rates between the Veress Needle Technique and the Modified Hasson Technique in Canine Ovariectomy Laparoscopic Surgery

Retroperitoneal Laparoscopy in Dogs: Access Technique, Working Space, and Surgical Anatomy

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