Laparoscopic cholecystectomy and time-course changes in renal function

Background: Recently, the retraction method has been used to reduce intraabdominal pressure (IAP) during laparoscopic surgery. The purpose of this study was to determine the serial changes in renal function during laparoscopic cholecystectomy (LC) using the retraction method. Methods: Urine output, effective renal plasma flow (ERPF), and glomerular filtration rate (GFR) were measured serially in seven patients who underwent LC with 12 mmHg pneumoperitoneum (High-IAP group) and five who underwent LC using the retraction method with 4 mmHg pneumoperitoneum (Low-IAP group). Results: Urine output, ERPF, and GFR were decreased during pneumoperitoneum in the High-IAP group, whereas no significant changes in any of these parameters were observed in the Low-IAP group. Conclusions: Our findings demonstrate that reduction of IAP to 4 mmHg using the retraction method prevents the transient renal dysfunction caused by prolonged 12 mmHg pneumoperitoneum during LC, suggesting that the retraction method reduces the risk of perioperative renal dysfunction during laparoscopic surgery. Received: 26 March 1996/Accepted: 27 July 1996     

Duration of postlaparoscopic pneumoperitoneum

Background: Patients who present with abdominal pain after recent laparoscopic surgery present a diagnostic dilemma when pneumoperitoneum is present. Previous studies do not define the duration of postlaparoscopic pneumoperitoneum. In this study, we attempted to define the duration of laparoscopic pneumoperitoneum and to identify factors which affect resolution time. Methods: We followed 57 patients who underwent laparoscopic cholecystectomy (34), inguinal herniorraphy (20), or appendectomy (three). Serial abdominal films were taken until all residual gas was resolved. Results: Thirty patients resolved their pneumoperitoneum within 24 h; 16 patients resolved between 24 h and 3 days; nine patients resolved between 3 and 7 days; two patients resolved between 7 and 9 days. Mean resolution time for all patients was 2.6 ± 2.1 days. There was no apparent difference in resolution time between the three types of procedures; however, the sample size may be insufficient. Duration of the pneumoperitoneum did not correlate with gender, age, weight, initial volume of CO₂ used, length of time for the procedure, or postoperative complications. Sixteen patients had bile spillage during cholecystectomy which significantly reduced the duration of postoperative pneumoperitoneum (p < 0.008), resulting in a mean resolution time of 1.3 ± 0.9 days. While 14 patients reported postoperative shoulder pain, no correlation was found between the presence or duration of shoulder pain and the extent or duration of pneumoperitoneum. Conclusions: We conclude that the residual pneumoperitoneum following laparoscopic surgery resolves within 3 days in 81% of patients and within 7 days in 96% of patients. The resolution time was significantly less in patients sustaining intraoperative bile spillage during cholecystectomy. There was no correlation found between postoperative shoulder pain and the presence or duration of the pneumoperitoneum. Received: 22 March 1996/Accepted: 12 July 1996     

后腹腔镜手术CO2气腹对脑氧供需平衡的影响

目的探讨后腹腔镜CO2气腹对脑氧供需平衡的影响. 方法选择后腹腔镜下肾及肾上腺肿瘤切除术20例,ASAⅠ～Ⅱ级,分别于气腹前,气腹后10、30、60 min和关气腹后30 min,抽取颈静脉球血和桡动脉血进行血气分析,比较不同时点动脉血PH(aPH )、颈静脉球PH(jvPH)、动脉血二氧化碳分压(PaCO2)、动脉血糖(aGS)、动脉血乳酸(aLac)、颈内静脉血氧分压(PjvO2)、颈内静脉血氧饱和度(SjvO2)、颅内动静脉氧含量差(AjvDO2)、颈内静脉血二氧化碳分压(PjvCO2)、血糖(jvGS)和乳酸(jvLac)的变化. 结果与气腹前比较,气腹后各时间点aPH、jvPH显著降低(P＜0.05);PaCO2、PjvCO2气腹后各时间点与气腹前相比显著升高(P＜0.05);AjvDO2气腹后各时点与气腹前相比显著下降(P＜0.05);jvLac气腹后各时间点与气腹前相比有降低趋势,但无统计学差异(P＞0.05);aGS、 jvGS气腹前后无显著变化(P＞0.05). 结论后腹腔镜手术期间,脑血流量显著增加,未发现脑无氧代谢增加的证据.     

不同气腹压力下腹腔镜胆囊切除术气腹并发症的比较研究

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)气腹并发症的防治. 方法回顾分析1993年10月至2003年1月1 100例LC的临床资料,2001年9月前入院的980例为A组,气腹压力设定14 mm Hg,2001年9月以后的120例为B组,气腹压力设定10 mm Hg. 结果 B组无明显高碳酸血症发生,而A组有2例发生;B组肩部疼痛发生率19.2%(23/120)明显低于A组43.9%(430/980)(χ2=26.951,P=0.000).B组恶心呕吐发生率25.8%(31/120)明显低于A组61.2%(600/980)(χ2=54.750,P=0.000). 结论高碳酸血症、肩部疼痛及恶心、呕吐等气腹并发症可通过术中注意调节通气量,降低气腹压力等措施防治.     

Auswirkungen von Argon-Gasembolien während eines PneumoperitoneumsRID="*"ID="*"Die Studie wurde zum Teil gefördert von der DFG (Bo 1329/8–1)

Zusammenfassung. In einer experimentellen Studie wurde bei 10 Schweinen mit einem mittleren K?rpergewicht von 18,9 (15–24) kg eine intraven?se CO₂- oder Argon-Embolie mit 10, 20 und 30 ml Gas durchgeführt. Das invasive Monitoring zeigte bei der Gasembolie mit Argon im Gegensatz zur Gasembolie mit CO₂ einen st?rkeren Anstieg des pulmonal arteriellen Drucks (p < 0,001), einen st?rkeren Abfall des endexspiratorischen CO₂ (p < 0,01), des Herzminutenvolumens (p < 0,01) und des mittleren arteriellen Drucks (p < 0,01). In der Argon-Gruppe (n = 5) starben zwei Tiere nach 20 bzw. 30 ml Bolusgabe. Ein weiteres Tier konnte nach Gabe von 30 ml Bolus erfolgreich reanimiert werden. In der CO₂-Gruppe (n = 5) starb weder eines der Tiere noch war eine Reanimation erforderlich. Wenig l?sliche Gase wie Argon sollten in Situationen mit erh?htem Risiko einer Gasembolie nicht angewendet werden. ID=" Dr. T. Junghans Klinik f&uuml;r Allgemein-, Visceral-, Gef&auml;&szlig;- und Thoraxchirurgie Universit&auml;tsklinikum Medizinische Fakult&auml;t der Humboldt-Universit&auml;t Campus Charit&eacute; Mitte Schumannstra&szlig;e 20/21 D-10117 Berlin     

腹腔镜及二氧化碳气腹对腹内感染影响的临床研究

目的研究二氧化碳气腹及腹腔镜手术对细菌性腹膜炎的影响。方法31例急性阑尾炎患儿，分为开腹组16例，腹腔镜组15例，于术前、术后采集病人血液行细菌培养，检测血中自细胞及炎症因子水平，并观察切口及腹腔有无残余脓肿情况。结果开腹组较腹腔镜组，术后切口感染及腹腔脓肿发生率高，术后C反应蛋白、肿瘤坏死因子仅水平及白细胞总数升高更明显，下降缓慢，淋巴细胞受抑制更明显。结论在细菌性腹膜炎时，腹腔镜气腹手术较开腹手术炎症反应轻，免疫功能恢复快。应用腹腔镜及二氧化碳气腹治疗腹部外科感染性腹部外科疾病安全可靠。     

Development of pneumoperitoneum after CPR

INTRODUCTIONChest compressions are performed routinely and have several well-known complications, however one of the rare complications is pneumoperitoneum caused by air entry through a perforation of the viscus. The exact cause of the perforation is not always clear. Furthermore, this rarely reported condition does not have clear management guidelines.PRESENTATION OF CASEWe present an uncommon complication of pneumoperitoneum following successful resuscitation possibly caused by the presence of an orogastric tube at the time of compressions in a 79 year old Hispanic male. Following chest compressions, a distended and tympanic abdomen was noted and air seen under the diaphragm in X-ray imaging.DISCUSSIONA review of previous case reports along with etiology and evaluation of risk factors is presented.CONCLUSIONAlthough the exact cause of pneumoperitoneum cannot be confirmed, emergency personnel should be aware of the risk factors associated with viscus perforation during chest compressions.     

Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy

AIM: To evaluate the inhibitory effects of carbon dioxide (CO₂) insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy (PEG).METHODS: A total of 73 consecutive patients who were undergoing PEG were enrolled in our study. After eliminating 13 patients who fitted our exclusion criteria, 60 patients were randomly assigned to either CO₂ (30 patients) or air insufflation (30 patients) groups. PEG was performed by pull-through technique after three-point fixation of the gastric wall to the abdominal wall using a gastropexy device. Arterial blood gas analysis was performed immediately before and after the procedure. Abdominal X-ray was performed at 10 min and at 24 h after PEG to assess the extent of bowel distension. Abdominal computed tomography was performed at 24 h after the procedure to detect the presence of pneumoperitoneum. The outcomes of PEG for 7 d post-procedure were also investigated.RESULTS: Among 30 patients each for the air and the CO₂ groups, PEG could not be conducted in 2 patients of the CO₂ group, thus they were excluded. Analyses of the remaining 58 patients showed that the patients’ backgrounds were not significantly different between the two groups. The elevation values of arterial partial pressure of CO₂ in the air group and the CO₂ group were 2.67 mmHg and 3.32 mmHg, respectively (P = 0.408). The evaluation of bowel distension on abdominal X ray revealed a significant decrease of small bowel distension in the CO₂ group compared to the air group (P < 0.001) at 10 min and 24 h after PEG, whereas there was no significant difference in large bowel distension between the two groups. Pneumoperitoneum was observed only in the air group but not in the CO₂ group (P = 0.003). There were no obvious differences in the laboratory data and clinical outcomes after PEG between the two groups.CONCLUSION: There was no adverse event associated with CO₂ insufflation. CO₂ insufflation is considered to be safer and more comfortable for PEG patients because of the lower incidence of pneumoperitoneum and less distension of the small bowel.     

气腹性肺损伤的机制与防治策略

背景 腹腔镜手术具有创伤小、恢复快等特点.但手术过程中建立CO2气腹会造成腹腔内高压和酸碱平衡失调,引起不同程度的肺组织损伤,导致术后肺功能不全,严重者甚至可以发展为急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS). 目的 阐述气腹性肺损伤的机制和防治研究新进展. 内容 气腹性肺损伤的发生机制很复杂,可由通气/血流比例失调、氧化和抗氧化系统失衡、缺血/缺氧、缺血/再灌注损伤、促炎和抗炎反应失衡等因素引起.通过小潮气量联合呼气末正压通气的肺通气模式,允许性高碳酸血症,气腹前预处理和药物的应用可以减轻气腹引起的肺损伤. 趋向 通过对CO2气腹引起肺损伤的发生机制及防治策略进行综述,期望为气腹性肺损伤的预防及治疗提供新的思路.