Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatectomy

Background: Laparoscopy under carbon dioxide (CO₂) pneumoperitoneum has many advantages. However, the risks of CO₂ pneumoperitoneum during laparoscopic hepatectomy (LH) have not been defined. Methods: The hemodynamics of the hepatic vein were examined during CO₂ pneumoperitoneum both pre- and posthepatectomy in eight pigs. Portal blood flow was measured with Doppler ultrasound during laparoscopic cholecystectomy in 10 human patients. Results: Experimentally, elevated intraabdominal pressure (IAP) with CO₂ insufflation produced significant increases in CO₂ partial pressure and echogenicity of the hepatic vein in the posthepatectomy group. Clinically, elevated IAP caused significant narrowing of the portal vein and significant decreases in portal blood velocity. The mean portal flow was significantly decreased with elevation of IAP >10 mmHg. Conclusions: LH with CO₂ pneumoperitoneum may lead to embolism caused by CO₂ bubbling through the hepatic vein. Elevated IAP may cause a decrease in hepatic blood flow and induce severe liver damage, especially in patients with poor liver function. Gasless laparoscopy using abdominal wall lifting should be employed in LH to avoid the risks of CO₂ embolism and liver damage. Received: 28 March 1997/Accepted: 12 September 1997     

控制性低中心静脉压在腹腔镜肝切除术中的应用

目的:探讨腹腔镜肝切除术中应用控制性低中心静脉压技术的可行性.方法:回顾分析2009年9月至2010年8月为58例患者施行肝切除术的临床资料,分别行腹腔镜肝切除术(23例)和开腹肝切除术(35例),术中应用控制性低中心静脉压技术,观察术中动脉氧分压、二氧化碳分压、氧饱和度、呼气末二氧化碳分压、出血量、总输液量等指标,及...     

控制性低中心静脉压在腹腔镜肝切除术中的应用

目的探讨控制性低中心静脉压(controlled low central venous pressure,CLCVP)技术用于腹腔镜肝切除术的可行性。方法回顾性分析武汉市中心医院肝胆胰外科2013年1月至2016年5月间实施的51例腹腔镜肝切除术病人,其中采用控制性低中心静脉压(腔镜+CLCVP组)23例,正常中心静脉压(normal central venous pressure,NCVP)(腔镜+NCVP组)28例。观察切肝过程中出血量、手术时间、术中输血量等指标,并监测术前术后肝、肾功能的变化。结果腔镜+CLCVP组较腔镜+NCVP组切肝过程中出血量少[(574±107)ml比(979±379)ml],断肝时间少[(105±63)min比(143±85)min],术中输血量少[(425±238)ml比(946±738)ml],两组比较差异均有统计学意义(均P0.05),两组病例间术前术后肝、肾功能比较差异均无统计学意义(均P0.05)。两组病人均未发生有临床意义的气体栓塞等并发症。所有病人均苏醒平顺。结论 CLCVP技术用于腹腔镜肝切除术有效可行,但必须加强术中麻醉管理和监测,以保证病人安全。     

控制性低中心静脉压技术在腹腔镜肝切除术中的临床应用

目的 探讨控制性低中心静脉压技术（CLCVP）在腹腔镜肝切除术中的可行性及安全性。方法 选取我院在2016年1月至2017年5月收治的行择期腹腔镜肝切除术患者50例,分为控制性低中心静脉压（CLCVP）组和常规中心静脉压（NCVP）组,各25例,CLCVP组术中应用控制性低中心静脉压技术,维持CVP在3~5cmH2O,保持SAP≥90mmHg,NCVP组采用常规腹腔镜手术,维持CVP在6~12cmH2O;观察两组患者切肝时间、术中出血量、输血例数、平均输血量、血流动力学指标、术后肝肾功能、有无气体栓塞发生。结果 手术指标：CLCVP组切肝时间、术中出血量、平均输血量明显低于NCVP组,差异具有统计学意义（P<0.05）;两组患者术中、术后均无具有临床意义的气体栓塞发生。肝肾功能：两组患者术后第1dALT、AST、TB水平明显升高,之后逐渐下降,至术后第5d时接近术前水平;相同时间点CLCVP组ALT、AST、TB水平低于NCVP组,差异具有统计学意义（P<0.05）;血清白蛋白（ALB）水平术后第1d明显下降,之后轻度升高,相同时间点的组间比较差异无统计学意义（P>0.05）;两组患者BUN、Scr水平术前、术后相同时间点比较差异无统计学意义（P>0.05）,BUN、Scr变化趋势为术后第1d轻度升高,之后逐渐下降。血流动力学指标：术中不同时间点两组患者MAP、HR比较差异无统计学意义（P>0.05）;CLCVP组脑电双频指数（BIS）在切肝开始5min和切肝结束时与NCVP组比较明显下降,差异具有统计学意义（P<0.05）。结论 控制性低中心静脉压技术（CLCVP）在腹腔镜肝切除术中能够减少出血量、缩短切肝时间,促进术后肝功能恢复,具有较高的应用价值。     

经食道超声心动图用于控制性低中心静脉压下腹腔镜右肝切除术的临床观察

目的评价在控制性低中心静脉压技术下行腹腔镜下肝切除术时应用经食道超声心动图监测心脏气栓的重要性。方法拟定择期腹腔镜下右肝部分切除术的患者40例,性别不限,年龄38~73岁,体重40~90 kg,ASA分级Ⅱ或Ⅲ级。采用简单随机数字表法,将其分为2组(n=20)对照组和控制性低中心静脉压组。控制性低中心静脉压组把中心静脉压控制在0~5mmHg的较低范围内,对照组把中心静脉压维持在正常范围。两组患者均应用经食道超声心动图监测心脏是否出现气泡,并记录出现气泡的维持时间,若出现气泡则提醒建议术者行夹闭血管漏口等相关处理。记录两组患者术前术后的平均动脉压、心率、术中出血量、术后是否送ICU治疗、术后神经并发症情况。结果与低中心静脉压组比较,对照组患者心腔内气泡发生以及术中出血量增高(P0.05)。两组患者术后的平均动脉压、心率、术后进入ICU治疗的发生率及神经并发症情况的差异无统计学意义(P0.05)。结论控制性低中心静脉压技术下行腹腔镜下右肝部分切除术可以减少术中的出血量。同时,应用经食道超声心动图监测心脏内的气泡,可以有效保证患者免受或减少气栓的威胁,保证患者安全。     

腹腔镜手术CO_2气腹及体位改变对眼内压的影响

目的 研究CO2气腹及手术体位对眼内压(IOP)的影响.方法 全麻下腹腔镜手术患者36例分为盆腔手术(A组)和胆囊切除术(B组)两组,每组18例.手术体位:A组头低位25°,B组头高位25°.记录麻醉前(T0)、气管插管后5 min(T1)、气腹后5 min(T2)、体位改变后5 min(T3)、体位改变后30 min(T4)和PETCO2降低至正常后(T5)的IOP.结果 两组IOP在全麻诱导后明显下降.A组T4时IOP逐渐增高至(21.0±1.6)mm Hg,T5时降低至(14.6±1.6)mm Hg.B组T4时IOP逐渐增高至(12.1±2.9)mm Hg,T5时降低至(11.1±1.2)mm Hg.两组术中的IOP与PETCO2呈正相关.结论 用丙泊酚全麻诱导可显著降低IOP.头高位手术和保持PETCO2于正常水平是避免IOP升高的重要因素.     

Influence of nitrous oxide anesthesia on venous gas embolism with carbon dioxide and helium during pneumoperitoneum

Background: Gas embolism is a potential hazard during laparoscopic procedures. The aim of this study was to evaluate the effects of nitrous oxide (N₂O) inhalation in the case of gas embolism with carbon dioxide (CO₂) and helium during pneumoperitoneum. Methods: For this study, 20 anesthetized pigs were ventilated with N₂O (67% inspired) in O₂ (n= 10) or with halothane (0.7–1.5 inspired) in O₂ (n= 10). In each group, CO₂ (n= 5) or helium (n= 5) pneumoperitoneum was established and gas embolism induced at different rates (CO₂ at 0.5, 1, or 2 ml/kg/min; helium at 0.025, 0.05, or 0.1 ml/kg/min) through the left femoral vein a maximum of 10 min while all hemodynamic parameters were continuously monitored. Results: In the CO₂ group without N₂O, all the animals tolerated rates of 0.5 and 1 ml/kg/min over the 10 min, whereas only 3 of 4 animals in the CO₂ group with N₂O tolerated a rate of 0.5 ml/kg/min, and 2 of 4 animals a rate of 1 ml/kg/min. In the helium group without N₂O, all the animals tolerated gas embolism at all rates, whereas in the helium group with N₂O, 4 of 5 animals needed to be resuscitated at a rate of 0.1 ml/kg/min and one death occurred. Conclusions: Inhalation of N₂O worsens the negative cardiovascular effects of venous CO₂ or helium gas emboli and increases the risk of emboli-induced death when CO₂ or helium are used to establish pneumoperitoneum. The volume of venous venous helium gas emboli causing such effects is substantially smaller than that for venous CO₂ gas emboli. Received: 20 September 1999/Accepted: 1 October 2000/Online publication: 4 August 2000     

Transoesophageal echocardiography shows high risk of gas embolism during laparoscopic hepatic resection under carbon dioxide pneumoperitoneum

BACKGROUND: The ultrasonically activated scalpel (UAS) enables safe and effective laparoscopic tissue dissection, making hepatic resection feasible. This study compared blood loss and risk of gas embolism using the UAS during open hepatic resection and laparoscopic hepatic resection. METHODS: Female pigs were divided into two groups for laparoscopic (n = 7) and open (n = 5) left hepatic lobectomy. The UAS was used for both tissue cutting and coagulation. Laparoscopic liver resection was performed under carbon dioxide pneumoperitoneum (intraperitoneal pressure 12 mmHg). During surgery animals were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Two-dimensional transoesophageal echocardiography (2D-TEE) was used to detect gas emboli with special attention to the right atrium and ventricle. Gas emboli were graded according to size, and correlated with haemodynamic and blood gas data. RESULTS: During open and laparoscopic hepatic resection the UAS resulted in minimal blood loss and effective tissue dissection. No air embolism was seen during open surgery. With laparoscopic hepatic resection 2D-TEE revealed gas embolism in all animals. Gas embolism was accompanied by cardiac arrhythmia in four of seven animals. No direct correlation was observed between embolism episodes and blood gas variables. There were no deaths after episodes of embolization. A significant decrease in arterial partial pressure of oxygen was seen at the end of the laparoscopic procedure in all animals. CONCLUSION: The UAS causes minimal blood loss during both open and laparoscopic hepatic resection. Laparoscopic liver dissection under carbon dioxide pneumoperitoneum carries a high risk of gas embolism.     

腹腔镜胆囊切除术中气腹后中心静脉压的变化

目的观察腹腔镜下胆囊切除术中气腹后中心静脉压的变化情况,探讨其临床意义。方法无其他因素影响中心静脉压的30例病例行腹腔镜下胆囊切除术,观察二氧化碳气腹前、中、后中心静脉压的变化情况。结果二氧化碳气腹后中心静脉压明显升高,但仍在正常范围内,停止气腹后,中心静脉压快速恢复至术前水平。结论行腹腔镜下胆囊切除术时,二氧化碳气腹后的中心静脉压增加对循环系统功能影响不明显,仍在机体代偿范围,无常规检测的必要。     

两种腹腔镜胆囊切除术术式对机体血气参数及PET CO2的影响

目的观察对比气腹腹腔镜与悬吊腹腔镜胆囊切除术对心肺功能正常患者血气分析及呼吸末CO2分压（PET CO2）的影响。方法选择60例心电图、胸部正位片正常的患者,均在全身麻醉下行腹腔镜胆囊切除术,按术式分为气腹组和悬吊组,每组30例。分别于麻醉后5 min（T1）、术中气腹或悬吊后20 min（T2）、术后停气腹或悬吊后30 min（T3）抽取患者足背动脉血行血气分析,记录各个时段动脉血pH值、PaCO2、CO2总量以及T1、T2时段的PET CO2。结果两组术前及术后各项指标差异无统计学意义（P〉0.05）,术中两组间各项指标差异有统计学意义（P〈0.05）。气腹组术前、术中各项指标及术中、术后各项指标比较差异有统计学意义（P〈0.05）,术前、术后比较仅pH值差异有统计学意义（P〈0.05）。悬吊组术前、术中、术后各项指标两两比较差异无统计学意义（P〉0.05）。结论气腹腹腔镜手术对机体血气的影响大于悬吊腹腔镜手术,合并心肺功能障碍、老年患者、预计手术时间长的患者,提倡选择悬吊腹腔镜手术。     

低中心静脉压的腹腔镜肝切除术在原发性肝癌患者中应用效果研究

目的探讨低中心静脉压的腹腔镜肝切除术对原发性肝癌患者的应用效果及术后肝功能的影响。 方法回顾性分析2014年1月至2018年12月原发性肝癌患者78例资料,根据不同手术方法分为腹腔镜组43例行腹腔镜肝切除术,开腹组35例行传统开腹肝切除术。采用统计学软件SPSS24.0进行数据分析。手术相关指标、术前术后1 d、7 d肝功能指标以( ±s)描述,组间比较采用独立t检验;术后并发症发生率采用χ²验,P<0.05表示差异有统计学意义。 结果腹腔镜组与开腹组比较,术中切肝时间较短、出血量较少、术后排气时间较短、住院时间较短,差异均有统计学意义(P<0.05);术后并发症胆漏、肺部感染、伤口感染的发生率均少于开腹组(P<0.05);术后肝功能指标对比,腹腔镜组患者ALT、AST、TBIL水平均优于开腹组(P<0.05)。 结论低中心静脉压的腹腔镜肝切除术治疗原发性肝癌的临床效果更优,术后并发症发生率更低,肝功能恢复更快。     

Pulmonary embolism during laparoscopic cholecystectomy detected by sudden decrease in end-tidal carbon dioxide pressure

We report a case of intraoperative pulmonary embolism, detected by a sudden decrease in end-tidal carbon dioxide pressure (PETCO2). The patient was a 56-year-old female without any history of pulmonary disease. The patient was intubated and ventilated manually during the operation under anesthesia with sevoflurane, nitrous oxide, and vecuronium. The percutaneous oxygen saturation (SpO2) and PETCO2 were monitored continuously. Twenty minutes after starting the laparoscopic procedure, PETCO2 decreased suddenly from values between 34 and 38 mmHg to 24 mmHg, and SpO2 decreased from 99% to 95%. Nitrous oxide was discontinued. Removal of the drape revealed profound subcutaneous emphysema. Postoperative pulmonary scanning revealed areas with reduced pulmonary perfusion (Fig. 2). An intravenous bolus of heparin (3000 IU) was given immediately, followed by 10,000 IU heparin over the next 24 hours. The patient was discharged on the fifteenth postoperative day without any sequelae. Although monitoring pulmonary arterial pressure is generally considered a more reliable method for the early detection of pulmonary embolism, an invasive monitoring procedure, such as the insertion of a Swan-Ganz catheter, is usually not indicated in laparoscopic surgery. For the early detection of pulmonary embolism, we therefore recommend the continuous monitoring of PETCO2 during laparoscopic surgery.     

不同压力CO2气腹对腹腔镜胆囊切除术后肩部疼痛发病影响的临床观察

目的研究腹腔镜胆囊切除术 (laparoscopiccholecystectomy ,LC)后肩部疼痛发生的原因、机理及防治方法。方法将 12 0例行LC的患者随机分为A、B、C组 ,每组 4 0例。气腹压力设定A组 10mmHg ,B组 12mmHg ,C组 14mmHg。观察 3组术前、术后的PaO2 、PaCO2 、动脉血 pH值以及术后 1、3、6、12、2 4、4 8、72、96h肩痛的发生率和疼痛程度 (视觉模拟评分 VAS)。结果术中CO2 用量C组较A组多 ,差异有显著意义 (F =11 38,P <0 0 5 )。C组术前、术后的PaO2 差值与A、B组术前、术后PaO2 差值相比较大 ,且差异有显著意义 (F =6 92 ,P <0 0 1)。随 3组气腹压力的增高 ,术后 3、12、2 4、4 8h肩痛发生率有增高趋势 (χ2 值分别为 2 36 6 ,2 32 4 ,2 72 9,2 340 ,P <0 0 5 ) ;其VAS评分也明显上升 (F =19 5 3,P <0 0 1)。结论LC术后肩痛的主要原因可能与人工气腹张力对膈肌的牵拉有关。在 10mmHg低压气腹下行LC ,可显著降低LC术后肩痛的发生率及疼痛程度。     

Cardiopulmonary responses to experimental venous carbon dioxide embolism

Background: Although the low-flow CO₂ insufflation rate used to initiate pneumoperitoneum may reduce the severity of potential venous embolism, its safety is not established. Methods: Anesthetized pigs were ventilated with room air at a fixed minute ventilation. After 1 h of baseline, they were intravenously infused with CO₂ at the rate of 0.3, 0.75, or 1.2 ml/kg/min for 2 h (n = 5 for each group), followed by 1 h of recovery. Results: All animals experienced pulmonary hypertension, depressed stroke volume, hypoxemia, hypercarbia, and acidemia during intravenous CO₂ infusion. They had systemic hypertension at the low rate and hypotension at the highest rate of infusion. End-tidal CO₂ levels briefly decreased, then increased in all cases. In the highest rate group, three of the five animals (60%) died at 50, 65, and 100 min of infusion. These three animals had severe hypotension and hypoxemia, with visible coronary gas embolism. There was no patent foramen ovale at necropsy in any animals. Conclusions: The low-flow insufflation rate exceeds the fatal rate of continuous intravenous CO₂ infusion. End-tidal CO₂ levels were increased in venous CO₂ embolism, not decreased as seen in venous air embolism. Severe hypoxemia and hypotension are predictors of potentially fatal cases.     

不同CO2气腹压力对腹腔镜胆囊切除术后肩痛的影响

目的研究不同CO2气腹压力对腹腔镜胆囊切除术(LC术)后肩部疼痛的影响。方法将100例行LC术的患者随机分为两组,每组50例,分别设定气腹压力为1.2kPa(10mmHg)和2kPa(15mmHg)下行LC术。对比两组术后肩部疼痛发生率及程度。结果在1.2kPa下手术组,患者的术后肩部疼痛程度明显低于2kPa手术组,差异有统计学意义(χ2=22.698,P<0.05)。结论LC术后肩部疼痛的主要原因可能与人工气腹张力对膈肌牵拉刺激有关。在10mmHg低压气腹下行LC术,可显著降低LC术后肩部疼痛的发生率及程度。     

控制性低中心静脉压在肝脏切除术中的应用

肝脏切除术中出血往往会增加患者围术期的输血需求、并发症发生率和死亡率。控制性低中心静脉压(CLCVP)可显著减少肝脏切除术的出血量,不影响患者术后重要脏器的功能,被广泛应用于临床。然而,有研究表明,CLCVP用于肝脏切除术尚存在不足,未能有效地降低术中出血量、减少术后并发症、改善患者远期生存率,且其控制程度无统一标准。本文旨在客观评估CLCVP在肝脏切除术中的优势和不足,以便临床医师更为合理地应用该项技术。