Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery and its potential for medical complications Kailash C. Sharrna, MD, Gary Kabinoff, MD, Yvan D u c h e i n e , MD, J e n n i f e r Tierney, RN, a n d R o b e r t D. Brandstetter, MD, FCCP, FCCM, N e w Rochelle a n d Valhalla, N.Y.

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications. (Heart Lung@ 1997;26:52-67.)

I N S T R U C T I O N S TO CE E N R O L L E E S

The closed-book, multiple-choice examination that follows this article is designed to test y o u r understanding of the educational objectives listed below. To enroll in Single Topics, see the instructions at the end of this article. EDUCATIONAL

OBJECTIVES

Based on the content of the article, the enrollee should be able to: 1. Describe techniques o f laparoscopic procedures. 2. Discuss complications and assessments of patients w h o undergo laparoscopic procedures.

From the Departments ot Medicine, Surgery, and Nursing, New Rochelle Hospital Medical Center, and New York Medical College, Valhalla. Reprint requests: Kailash C. Sharma, MD, Division of Pulmonary and Critical Care Medicine, Rush-Presbyterian-St.Luke's Medical Center, 1653West Congress Pkwy., Chicago, IL 60612-3833. Copyright © 1997by Mosby-Year Book, Inc. 0147~9563/97/$5.00+ 0 2/2177942

52

HISTORY SURGERY

OF LAPAROSCOPIC

L a p a r o s c o p y was first i n t r o d u c e d b y K e l l i n g I in 1901 in G e r m a n y w h e n he v i e w e d t h e a b d o m i n a l v i s c e r a of a l i v i n g d o g u s i n g a c y s t o s c o p e . R u d d o c k , 2 an internist, in 1933 was t h e first to use

JANUARY/FEBRUARY1997 HEART & LUNG

peritoneoscopy in the United States. His valuable experience with 500 peritoneoscopic examinations published in a surgical journal was unfortunately ignored by surgeons. 3 Power and Barnes 4 in 1941 were the first to perform laparoscopic sterilization. This minimally invasive procedure became popular amongst gynecologists and patients in the 1960s for its effectiveness and simplicity. Until recently, the equipment used was primitive and inadequate, resulting in unacceptably long operative time. For example, an ectopic pregnancy man~ agement using this approach could take as long as 4 or 5 hours, and thus it fell out of favor. However, advances in video imaging, powerful light-source, automatic pressure-driven insufflator and high-flow suction irrigation technology have made it possible to perform difficult intraabdomihal maneuvers relatively easily. 5 Modern laparoscopic approach, a cumulative result of efforts since the beginning of the century, had a dramatic effect on the way gynecology and surgery has been practiced in the last decade. When Serum, 6 a German gynecologist, performed laparoscopic appendectomy, he was severely criticized by the surgeons. Mouret, in France, performed the first laparoscopic cholecystectomy (LC) in 1987 under great secrecy because of the excessive criticism of this concept by the skeptics. 7 Gallbladder surgery has been revolutionized using this approach and now it is almost exclusively performed by laparoscopy unless contraindicatedl Cholelithiasis affects 15 to 20 million people in the United States, with more than 500,000 cholecystectomies performed each yea& Although various nonoperative modalities such as lithotripsy, gallstone dissolution by medical therapy, and percutaneous drainage have been tried in the past, they have failed because of the high recurrence rates. 9,~° Laparoscopic surgery, especially LC, has rapidly become popular because this technique is associated with generally reduced morbidity and mortality, shorter in-hospital stay, reduced postoperative pain, and earlier return to preoperative activity and employment. ~~However, these advantages do not necessarily apply to all procedures performed using this technique. In addition, open cholecystectomy (OC) remains a very safe and effective procedure with overall less than 1% mortality and still has to be resorted to in technically difficult LC cases. 12 Internists have used laparoscopy mainly for diagnostic purposes, but this application now has largely been replaced by the superior imaging

HEART & LUNG

VOL. 26, NO. I

techniques. ~3 Complications associated with laparoscopy have been known for more than two decades but with increasing popularity of the pro* cedure, more novel complications, both operative and nonoperative are being recognized. Because cholecystectomy is the most commonly performed laparoscopic procedure, in this article we use this procedure as a prototype for the description of the technique and its complications. In general, patients undergoing LC are younger, are less likely to have complicated gallstone disease or to be admitted on an emergency basis, and have fewer comorbid conditions. TM However, elderly persons and patients with significant cardiopulmonary disease, who perhaps otherwise would not have undergone surgery, are being offered this surgical intervention as well. 15 BASIC TECHNIQUE OF LAPAROSCOPIC CHOLECYSTECTOMY LC is traditionally performed by surgeons, but recently a few gastroenterologists, in Japan, have also been performing this procedure with a good success rate. ~6 General anesthesia with endotracheal intubation and sometimes regional anesthe~ sia are used for laparoscopy. General anesthesia provides analgesia for peritoneal irritation, allows control of ventilation, and the endotracheal cuff protects the airways from aspiration of gastric contents during the positional changes. The patient is initially placed in the supine or lithotomy position. A nasogastric tube and bladder catheter are inserted to visualize the viscera as welt as to avoid injury to the stomach and bladder. Carbon dioxide (CO2) is insufflated by means of a Veress needle inserted through a small supraumbilical incision (a closed method) to establish a pneumoperitoneum (PnP), which is necessary to visualize the abdominal contents with the laparoscope. However, some surgeons may prefer an open method to insufflate CO2 to avoid inadvertent extraperitoneal insufflation or visceral injury. An electronic high-flow insufflator confirms the position of the insufflation needle placement and gives a direct reading of the intraabdominal pressure (IAP), which should be <8 mm Hg during low-flow insufflation (1 to 2 L/rain). Higher pressures suggest improper placement of the needle or sheath. During the abdominal procedure, lAP is not allowed to exceed 15 mm Hg, but higher pressures, as high as 25 mm Hg, are used in advanced gynecologic procedures. Through different ports, the laparoscope, trocars, and sheaths are inserted. The patient is put in

53

Trendelenburg position (at a <40-degree angle), reverse Trendelenburg position, or lateral position to visualize the area of interest. One should be prepared to convert LC into OC if dictated by the circumstances. Antibiotics are routinely used if a viscus is violated but is not required in diagnostic procedures. The mean operative time is 118 minutes (35 to 180 minutes) but is operator dependent. ~7 The operative time is getting shorter as surgeons gain experience. Additional description of this technique is beyond the scope of this article. INDICATIONS

An increasing variety of therapeutic procedures have been successfully performed with use of the laparoscopic approach. However, mere ability to perform a procedure should not become an indication. A laparoscopic procedure should demonstrate efficacy, a low morbidity and mortality, and cost benefits over conventional methods. 5 Table I lists the important procedures performed by the laparoscopic approach. 18"38 Emergency diagnostic laparoscopy is being recommended in (1) patients who have had trauma whose clinical picture or physical signs are obscure because of impaired mental status or are no longer valid because of general anesthesia, (2) patients who have unexplained hypotension, (3) patients who have equivocal physical examination findings, and (4) cases in which computed tomographic (CT) scanning and diagnostic peritoneal lavage are not helpful and the clinical situation warrants a diagnostic laparotomy. 18,~9 Laparoscopy in the intensive care unit has been useful in the diagnosis of intraabdominal gram-negative sepsis and abdominal pain. 2°,21 In one case laparotomy was avoided in a patient in whom PnP developed after coronary bypass surgery in whom gas had leaked into the abdomen along the large vessels or congenital pleuroperitoneal connections, raising the likelihood of a perforation. 22 Diagnostic laparoscopy can save unnecessary laparotomies in several other conditions, such as undiagnosed malignancy, abdominal pain, chronic liver disease, or fever of unknown origin. 2>25 The overall diagnostic rate is 99% for acute abdominal pain, 70% for chronic pain syndromes, 95% for focal liver disease, 95% for abdominal masses, 97% for ascites, and >80% for retroperitoneal disease. 26 Diagnostic yield in tuberculous peritonitis is particularly high. 27 Laparoscopy in children and adolescents is used for cholecystectomy, cryptorchidism, pyloric stenosis, ectopic pregnancy,

54

Table I Indications for laparoscopy Therapeutic

Diagnostic

Cholecystectomy Chronic liver Cholecystotomy disease Deroofing of Fever ot unknown hepatic cyst origin Hernia repair Neoplasms Appendectomy Staging of Colectomy lymphoma Gastrointestinal Jejunostomy Nephrectomy hemorrhage Peptic ulcer disease Benign peritoneum Antireflux surgery Acute abdominal Hysterectomy Tubal ligation pain Chronic abdominal Retrieval of ova pain Pelvic lymphadenecAcute abdominal tomy Vascular surgery process Second-look Cardiomyotomy Presacral neurectomy laparoscopy Abdominal trauma Peritoneal dialysis Pancreatic disease Cryptorchidism Varicocele

and genital and ovarian disease. 2s,29 Office laparoscopy for the diagnosis of intraperitoneal carcinomatosis has also been found to be useful. 3° In addition, the procedure may be used to insert jejunostomy tubes and to fix peritoneal dialysis catheters. 31,32 C ONTRAINDICATIONS

Contraindications (Table II) to laparoscopy are important but are not agreed upon by all surgeons; individual variations in criteria may occur. 17 A severely inflamed gallbladder, for instance, may be difficult to handle. The procedure should be avoided in pregnant patients because of the mechanical effects of PnP. Upper abdominal scars and a coagulopathy are relative contraindications. Cardiomyopathy, untreated congestive heart failure, and moderate to severe myocardial ischemia are relative cardiac contraindications, and PC is thought to be safer in such circumstances. 39 •H E M O D Y N A M I C LAPAROSCOPY

EFFECTS

OF

CO2 gas is used to insufflate the intraperitoneal or extraperitoneal space to visualize the field of

JANUARY/FEBRUARY1997 HEART & LUNG

T a b l e II Contraindications to laparoscopy Absolute Pregnancy Severe coagulopathy Unfit for general anesthesia

Relative Severe acute cholecystitis Ductal calculi Sepsis Previous gastrectomy Abdominal adhesions Thickened gallbladder, >4 m m Jaundice Acute pancreatitis Portal h y p e r t e n s i o n

interest. Kelling used air filtered through cotton, but it was Zollikofer who used CO 2 in 1924 for peritoneal insufflation. 4° Hemodynamic changes (Table 11I) induced by CO 2 insufflation are unique and are mainly caused by hypercarbia and raised lAP. Arterial CO 2 tension (Paco2), CO 2 tension in mixed venous blood, and alveolar CO 2 tension rise promptly and the level is determined by the rate and duration of abdominal distention by the insufflated CO 2. On average, Paco 2 increases by 10 mm Hg, and pH decreases by 0, l. 41 Hypercarbia, in spontaneously breathing patients or patients receiving epidural anesthesia, stimulates hyperventilation in healthy patients, but this response may be impaired in patients with cardiopulmonary dysfunction. 15,42 With hypercarbia after prolonged capnoperitoneum (CO 2 PnP), excessive CO 2 accumulates in the body, and it may take several hours before Paco 2 returns to baseline. 43"45 Hypercarbia of 45 to 50 mm Hg, the usual level of Paco 2 achieved in healthy patients, has no significant hemodynamic effects. 46 Hypercarbia of 55 to 70 mm Hg produces increases in heart rate, systemic blood pressure, central venous pressure (CVP), cardiac output (CO), and stroke volume, and a decrease in peripheral vascular resistance. The increase in blood pressure is independent of the gas used to induce PnP.47 However, helium PnP, which is seldom used because of the serious risk of gas embolism, does not cause hypercarbia. 48"5° An IAP of 15 mm Hg raises systemic vascular resistance (SVR), mean arterial pressure (MAP), pulmonary artery pressure, and inferior caval pressure, whereas stroke volume falls. With compensatory tachycardia, the CO is maintained. 51 An IAP of 20 mm Hg causes an increase in right atrial presHEART & LUNG VOL.26, NO. 1

sure and intracranial p r e s s u r e s At higher pressures (IAP ~40 mm Hg), the inferior vena cava is compressed and venous return is reduced, resulting in diminished CO, which is significantly influenced by central blood volume. 51"~3 CO falls by 30% and cardiac index (CI) by 50% in major laparoscopic procedures. 54 In comparison, CI falls by 6% to 13% in laparotomy and 13% to 40% in gynecologic procedures. 55"57 A rise in afterload further increases myocardial oxygen requirement. It is recommended not to increase IAP by >22 mm Hg because of the risk of gas embolism. 5a Tilting the patient's head up reduces cardiac preload and CI. 52 Diaphragmatic movements are reduced because of increased intraabdominal volume and pressure resulting from PnP. Peak and plateau airway pressures rise during mechanical ventilation, while pulmonary compliance and vital capacity f a l l 9 ,6° The Trendelenburg position does not appear to exacerbate the rise in airway pressures. 61 There is a decrease in the functional residual capacity and an increase in alveolar dead space leading to ventilation-perfusion mismatching. 59 However, laparoscopic procedures produce less postoperative pulmonary dysfunction as noted on pulmonary function tests than do open abdominal surgical procedures. 62 Decreased CO may result in oliguria. 46 The intraoperative creatinine clearance rate may be decreased or remain unchanged. At times, howew er, the decreased creatinine clearance rate may be significant. 63 Vasopressin secretion is raised because of reduced intrathoracic volume. 64 Relative hypothermia may occur with a decrease of 0.3 ° C in the core temperature reported for each 50 L of CO 2 insufflated. The presence of irrigating fluid also lowers the temperature. 65 COMPLICATIONS Laparoscopy is a remarkably safe procedure (Table IV). A review of >200,000 laparoscopies suggests that serious complications resulting in surgical intervention can be expected in 1 in 660 cases and 1 death in 2000 cases. 66,67 A European series, in the prelaparoscopic era, reported an average mortality rate of 0.05% (range 0.014% to 0.13%) and an average morbidity of 0.38% (range 0.15% to 0.6%).6a A third of the complications are related to the cardiopulmonary system. The procedures now done by the laparoscopic approach are much longer in duration, intricate, and are being performed not only in elderly persons but also in patients with poor cardiopulmonary status. OC is a gold-standard procedure for gallstone disease and 55

Table III Cardiopulmonary effects of CO 2 PnP (pressure ~15 m m Hg) in typical LC operation in Trendelenburg position

Elevated

Reduced

Respiratory

Respiratory rate Paco 2, mixed venous CO 2 tension, alveolar CO 2 tension Arterial-venous CO 2 difference Peak airway pressure Plateau airway pressure Intrathoracic pressure

pH Forced expiratory volume in 1 sec Forced vital capacity Functional residual capacity Total lung capacity Compliance

Cardiovascular

Heart rate Systemic blood pressure MAP CVP Pulmonary artery pressure SVR

Stroke volume CO unchanged or reduced Venous return unchanged or reduced

is associated with a very low (<1%) mortality and morbidity rate. However, LC-associated complications are comparable (0.28%) and are mainly caused by PnP. Most of the pathophysiologic effects are minor, but some can be life threatening. Accordingly, the laparoscopic team should always be alert in recognizing the complications of the procedure and treat them at an early stage. Laparoscopy has a high benefit-risk ratio, but individual complications largely depend on patient selection, comorbidity, optimal equipment, and operator training and experience.66

Respiratory

complications

Hypercarbia is due to increased CO2 load caused by transperitoneal or subcutaneous absorption of insufflated CO29 ~7~ In addition, there is an increased ventilatory dead space, reduced diaphragmatic movement, and decreased pulmonary CO2 excretion. 42 In some cases, this condition can be prevented by slowing the insufflation rate of CO2 into the peritoneum. 72 Persistent hypercarbia, despite increased minute ventilation, may force the surgeon to convert LC into OC.42 Noninvasive studies such as measurement of end-tidal CO2 (PETc02) may not detect hypercarbia reliably when Paco2 is >41 mm Hg, and thus some patients, in this situation, may require arterial blood gas measurements. 71 CO2 diffusion into the body tissues is more marked during extraperitoneal than intraperitoneal CO2 insufflation. 44

56

Hypercarbia worsens with associated pneumothorax, pulmonary edema, and altered pulmonary mechanics because of raised intrathoracic pressure and lowered lung compliance. 73 Pneumothorax develops in 0.03% of cases as a result of leakage through vulnerable points in the diaphragm. 74"79These leakage points could be the result of congenital pleuroperitoneal connections, so endometriosis, or actual diaphragmatic injury intraoperatively, s~ An IAP of 25 mm Hg translates to a force of about 30 gm/cm 2 and may thus exert a total pressure of 50 kg on the diaphragm. 82,a3 Insufflated gas may cause retroperitoneal dissection and travel along the great vessels into the mediastinum and further progress to pneumothorax or subcutaneous emphysema or both. Pneumothorax usually requires no treatment but may require tube thoracostomy if it is under tension 84,a~ or interferes with ventilation or oxygenation. This condition should be considered likely if there is a sudden increase in airway pressures while the patient's lungs are mechanically ventilated, increased PETco2, or arterial desaturation. CO2 insufflation should be stopped and PnP may have to be desufflated promptly. Pneumothorax occurs not only with CO~ :; but also with any other gas such as air, nitrogen, helium, or nitrous oxide used to create PnP. Pseudopneumothorax may be caused by the retroperitoneal gas leaking upwards along the great vessels into the extrapleural space. The gas dissects through the lateral wall compressing pari-

JANUARY/FEBRUARY1997 HEART & LUNG

Table IV Complications of laparoscopy Respiratory Hypercarbia Acidosis Pneum.othorax Tension pneumothorax Atelectasis Subcutaneous emphysema Hydropneumothorax Tension hydropneumothorax Pneumomediastinum Pleural effusions

Cardiovascular

Other

Ventricular ectopic beats Bradyarrhythmias Hypotension Cardiovascular collapse Cardiac arrest Cardiomyopathy Deep-vein thrombosis Pulmonary edema Myocardial infarction Myocardial ischemia Gas embolism PnP

Shoulder pain Retinal hemorrhage Gastric hemorrhage Ascites Oliguria Transient ischemic attack Bowel ischemia Bowel edema Hypothermia Necrotizing fasciitis Tumor inoculation Reflux esophagitis

etal pleura against the lung and behaves just like a typical pneumothorax. 7~ Subcutaneous emphysema is due to inadvertent insufflation of CO 2 into the subcutaneous space if the Veress needle does not penetrate deeply enough to enter peritoneal cavity. This is usually small but in severe cases it can affect the trunk, neck, face, and even scrotum. A faulty pressure gauge may deliver too much gas raising t h e IAP to dangerous levels. 86 This is absorbed rapid~ ly from the loose areolar tissue raising Paco2, sometimes even as long as 4 hours after desufflation, causing hypercarbia. 7° In addition to subcutaneous emphysema, hypercarbia should also raise the suspicion of ventilator or circuit leaks, malpositioned endotracheal tube, CO 2 embolus, pneumothorax, malignant hyperthermia or airway obstruction. 69 Clinically, subcutaneous emphysema is recognized by crepitus that is palpable or on auscultation as crackles over the affected area. Fifty-six percent of patients are found to have it routinely on CT scan studies, but clinically significant cases occur only in 2 to 12 per 1000 cases, and usually in these cases it resolves spontaneously within 24 hours. 87'88 In such cases, the use of CO 2 is safer than the use of nitrous oxide because it is resorbed quickly as a result of its greater solubility. Other pulmonary complications can be found on postoperative CT scan studies. Atelectasis and pleural effusions were observed in 44% and 33% of patients, respectively. These findings were pre~ sumably the result of compressive effects on the thoracic cavity due to PnP and for the most part have no clinical significance. If microatelectasis is included, the incidence of focal and segmental HEART & LUNG

VOL. 26, NO. I

atelectasis was only 25% after LC compared with 65% after OC. s7 Postoperative complications like pneumonia (0.07%) and deterioration in pulmonary function are significantly less than in comparable patients undergoing laparotomy. 89 Air and nitrogen emboli may cause bronchoconstriction where~ as He and CO2 have not been reported to do so. 9° In rare circumstances in the presence of ascites, insufflation of gas in the peritoneum under pressure can cause tension hydropneumothorax by pushing the ascitic fluid into the pleural space, s~,91 Small blebs in the tendinous hemidiaphragm and small diaphragmatic defects through which fluid crosses over to the pleural space explain this complication; they may act as a one-way valve. Most often this mechanism is right sided because the left hemidiaphragm is covered by pericardium, with the heart also on the left side. During CO 2 PnP, the lAP increases to 15 mm Hg. This change is further influenced by the patient's age, weight, abdominal girth, and Trendelenburg position, s5,~6 In the presence of negative intrapleural pressure, fluid is sucked into the thorax, causing diminished venous return with an increased resistance to pulmonary blood flow, diminished stroke volume, CO, blood pressure, and mixed venous oxygen saturation. Hypotension, tachycardia, and hypoxemia result, with an unanticipated cardiorespiratory deterioration. Pneumomediastinum occurs in 0.08% of the cases and may develop as a result of rupture of a bleb or air leak through a distended alveolus without perforation of visceral pleura. 79,92,93These complications can be life threaten~ ing and require immediate attention because of tamponade. 57

Cardiovascular complications Arrhythmias are often transient and for the most part have no clinically adverse effects. They are three times more likely to occur with CO2 PnP than with nitrous oxide PnP because of acidosis and catecholamines release during CO2 insufflation. 94,95 Ventricular ectopic beats are the commonest arrhythmias. Bradyarrhythmias including asystole (sinus arrest) seem to be due to reflex vagal stimulation or peritoneal irritation and these are reduced by atropine. 96,97 Arrhythmias can also b e reduced if CO2 is insufflated at a rate of <1 L/rain and Paco2 is maintained within normal range by mechanically increasing the minute ventilation98 lntracardiac stretch receptors are unlikely to pre~ cipitate an arrhYthmia because they are activated at a much higher pressure than is used in routine laparoscopies. In one study, 47% had arrhythmias during laparoscopy under usual IAP and 30% of these were bradyarrhythmias. 99 ]3-Blocking agents may reduce the frequency of cardiac arrhythmias during anesthesia but their routine use is not recommended, l°° Arrhythmias may also signify gas embolism, hypoxemia, or the development of pneumothorax and thus should be investigated appropriately. Pulmonary edema may occur after absorption of crystalloid irrigating fluid during laparoscopy and also as a result of myocardial dysfunction in patients with hypertension or ischemia. 101,102This situation occurs in as many as 0.34% of patients undergoing endoscopic uterine surgery. 1°3 The incidence of deep vein thrombosis is less than that with OC, and it is perhaps due to early ambulation and minimal tissue trauma.l°4,1°~ Gas embolism is a life-threatening complication of laparoscopy occurring in 15 per 100,000 cases per year. 1o4,~06,107 It tends to occur if a vein is cannulated inadvertently or from absorption through open venous channels, usually in the first 5 to 8 minutes after the start of insufflation.l°a There is initial tachycar~ dia leading to ventricular dysrhythmia followed by bradycardia and then cardiac arrest. Jugular veins are distended and the patient is cyanosed. Gas locks in right atrium and there is a "mill-wheel" murmur. The patient can collapse as a result of pulmonary h y p e r t e n s i o n or transient cerebral strokes. Typically, hypoxia is present, and the PETco 2 is raised transiently after initially low PETco 2 readings during the initial tachycardia stage and then before asystole. 1°9 It is unreliable if Paco 2 is >41 m m Hg; moreover, embolization to the right ventricle and pulmonary circulation m a y b e d e l a y e d b y as much as 1 hour b y p a s s a g e of gas through the portal system. 1~° As little as 0.1 ml of gas can b e 58

detected by echocardiography. ~1~This condition is treated by stopping the gas insufflation and placing the patient head-down in the left lateral posi~ tion. The patient's lungs are mechanically hyperventilated, and an attempt is made to aspirate air through a central intravenous line.l~2 Severe cases may lead to pulmonary infarction. 1~3 Helium causes more severe effects resulting from gas embolism because it is 50 times less soluble in blood than is CO2 and permeates 17 times more slowly through the ventricular wall, making its complication more serious. 114 Similarly, air embolism is five times more toxic than CO2 because of its poor solubility in the blood. A delayed manifestation of gas embolism may be pulmonary e d e m a or s u d d e n death. 1°2,~°7 The complication resolves rapidly p r o v i d e d cardiovascular s u p p o r t can b e maintained. Gas embolization may b e an o v e r d i a g n o s e d condition as this is o n e of t h e first-thought-of c o n s i d e r a t i o n s to explain h y p o t e n s i o n , an i n c r e a s e in PETco 2, arrhythmia, or a new murmur, l ~ A p n e u m o p e r i cardium a l m o s t always occurs with a s s o c i a t e d anterior chest wall and neck s u b c u t a n e o u s e m p h y s e m a but sometimes it can occur alone. 82,94A16.117 A mediastinal crunch, caused by air in the mediastinum, may be heard and the chest roentgenogram may confirm air in the mediastinum and pericardium. Gas may push through the diaphragmatic hiatus into the pericardium and mediastinal pleura along congenital defects. Hemodynamic compromise has not been reported, but its potential does exist. 93,94 Hypotension and cardiovascular collapse may occur as a result of profound vasovagal response to rapid peri~ toneal distention. Hypotension develops in 12.8% during the procedure with blood pressures <80 mm Hg for _>5 consecutive minutes. ~8 Cardiac arrest has been reported in 1 in 2500 gynecologic laparoscopies and with possible mechanisms offered such as peritoneal irritation, vagal stimulation, hypercapnia, hypoxia, raised IAP, pneumopericardium, and reduced CO.119 Other

complications

Occasional complications related to the laparoscopic procedure affecting other systems have been reported in the literature. Shoulder pain is common and is produced by CO2 irritation of the diaphragm along with suprahepatic pocket residual gas and this may last for several days. 12°,~2~ Epidural anesthesia does not relieve this referred pain, but intraperitoneal local anesthetic may help. Instillation of 1 to 2 L of fluid at the completion of the procedure significantly decreases the JANUARY/FEBRUARY1997 HEART & LUNG

frequency of subdiaphragmatic and shoulder pain on sitting or standing up. This pain is probably produced by traction on the triangular or coronary ligaments of the liver because of loss of the suction effect by the diaphragm. ~22 Bowel ischemia and edema may develop as a result of reduced blood supply to the gut caused by the raised IAP.123 Necrotizing fasciitis is rare and usually occurs in diabetics. 124 Transient compression neuropathies involving femoral nerve, lateral cutaneous nerve of the thigh, peroneal nerve, and brachial plexus have been described as resulting from the multiple intraoperative positions required. ~2~,~26These patients tend to be obese, with lower-limb lesions corresponding to the position of the strap pads. Retinal hemorrhage caused by associated hypoxia, hypercarbia, and retinal venous dilatation aggravated by the Trendelenburg position has been reported.~ 27 Intracranial pressure is raised because of reduced venous return from the superior vena cava while the patient is in Trendelenburg position but it is of no clinical significance.47,12a However, patients with closed-head injury may require lowering of IAP to approximately 8 mm Hg to avoid any complications due raised intracranial pressure. 129 Ocular pressures in patients with glaucoma may be dangerously high also in the Trendelenburg position.130 Bacteremia has been associated with liver biopsy through the laparoscope in 2.9% to 13% of the cases, but sepsis is rare. 131 Gastric hemorrhage has been described after laparoscopy. 132 Dropped loose clips into the peritoneal cavity from the operated sites may cause postoperative pelvic pain. 133 Every 50 L of CO2 insufflated brings the body temperature down by 0.3 ° C. Irrigating fluid also lowers the temperature further. Hypothermia tends to occur in one third of patients when the procedure lasts >2 hours. Hypothermia can be prevented by insufflating CO2 at 30° C. 1la,134 Irrigation fluid used during laparoscopy can also be warmed up to avoid hypothermia. 135 Tumor inoculation may occasionally occur during laparoscopic surgery for carcinoma gallbladder and other visceral malignancies as well.136 Reflux esophagitis may occur in as many as 4.8% of patients undergoing laparoscopy. ~37 A nasogastric suction tube helps preventing any significant reflux effects, which may occur in as many as 52% of the cases. 13s Ascites may be detected in 19% by CT scan of the abdomen and is probably due to blood, lymph, or bile. It is not due to the irrigation fluid used as it is of small molecular weight and gets absorbed within 24 hours. This is usually of no clinical significance, a7 Transient ischemic attack affecting the HEART & LUNG VOL.26, NO. I

facial nerve, paradoxical CO2 embolism causing neurologic dysfunction, and cases of cerebrovascular accidents have also been reported.139 LAPAROSCOPY CIRCUMSTANCES

IN SPECIAL

Because of the usually benign nature of CO2 PnP in healthy, young patients, there is a common assumption that a patient unfit for laparotomy may safely have laparoscopic surgery. 45'140 However, in hemodynamically unstable patients, the pathophysiologic effects of CO2 PnP may be deleterious. Every patient should be assessed individually and the risks involved must be carefully balanced against its advantages. In a recent survey of laparoscopic versus open appendectomy, it was found that surgeons had a bias for the open procedure in American Society of Anesthesiologists class 11I patients and elderly persons. TM In patients with a modified acute physiologic score of >10, intraoperative and postoperative complications are not significantly different. In LC group, hospital stay is shorter and overall mortality is less than in the OC group. ~42

High-risk patients disease

with cardiac

Cardiac patients for laparoscopy are at a higher risk because of physiologic stress of PnP and hypercarbia. 39,~5,~19 MAP, SVR, and venous resistance rise and venous return falls as a result of the raised IAP and the effects of general anesthesia. Heart rate and afterload increase to maintain CO, resulting in increased oxygen requirement and left ventricular wall tension. There is diminished systemic and coronary perfusion pressure leading to left ventricular dysfunction and ischemia. lntravascular volume loading will negate the effects of raised IAP by increasing the right-side heart filling pressure and thus restoring CO. Cardiac patients on optimum treatment may have borderline preload and afterload making them prone to decompensation caused by sudden changes in the intravascular volume and IAP.143 A high-risk patient with cardiac disease has an elevated MAP, SVR, and heart rate and a low CO and CVP, which together are suggestive of intravascular volume depletion. An intraoperative rise in CVP, pulmonary artery diastolic pressure, and reduced mixed venous oxygen saturation may be an early sign of cardiovascular decompensation. 144 Postoperative myocardial infarction, congestive heart failure, malignant hypertension and pulmonary edema may develop. Cardiac decompensation occurs 1.5 to 3 hours after desufflation and is pre59

dicted by hemodynamic changes in the first postoperative hour) 9 With intensive perioperative monitoring by means of balloon-tipped pulmonary artery catheters and radial artery catheters, most of these cases can be managed well.

Patients w i t h chronic obstructive pulmonary disease The stress on the cardiopulmonary system is higher in patients with chronic obstructive pul~ monary disease because of the increased CO2 load, altered pulmonary mechanics, and raised airway pressures. PnP may cause severe hypercarbia, which may not be corrected by increased minute ventilation and the patient may require a laparotomy for the completion of the surgical procedure. 41,42There is, however, less postoperative pain, and thus a decreased risk of pneumonia with deterioration of pulmonary function tests in patients undergoing laparoscopic surgery. Furthermore, patients with chronic obstructive pulmonary disease who undergo laparoscopy ambulate earlier and have a better cough reflex than patients undergoing laparotomy, a9

Patients receiving ventilation with p o s i t i v e e n d - e x p i r a t o r y pressure Laparoscopy in the intensive care unit in a ventilated patient with positive end-expiratory pressure can be deleterious owing to reduced CI and the increased CVP, pulmonary capillary wedge pressure, pulmonary vascular resistance and blood lactate levels. Moreover, some of these patients may be hypotensive and hypovolemic, thus aggravating the deleterious hemodynamic effects.~4~

Patients with hypovolemia Diagnostic laparoscopic evaluation is becoming increasingly popular in patients with abdominal trauma. These patients may be hypovolemic and hypotensive because of blood loss. The hemodynamic effects of PnP in such circumstances are more pronounced and potentially fatal. Fluid replacement may improve blood pressure temporarily without correcting the underlying effects of hemorrhage. Moreover, these effects may not be easily detected by routine monitoring in the emergency department. Hypercarbia may not raise the MAP significantly under hypovolemic conditions. These patients' condition may deteriorate more rapidly because of the effects of acidemia) 7

Obese patients Obesity was considered to be a relative contraindication until recently. Currently these

60

patients have no greater risk of development of any significant morbidity related to the procedure compared with other patients. Operative time, however, in obese patients is longer. 146

Children a n d a d o l e s c e n t s Laparoscopy in children and adolescents is well tolerated. However, the instruments are expensive, and moreover, the credentialing of pediatric surgeons is a problem because of the limited availability of trained pediatric laparoscopists. The procedure, however, is gradually becoming more popular with pediatric surgeons. 29 NONTECHNICAL

CAUSES OF

DEATH Before the recent widespread use of laparoscopic surgery, the mortality ranged between 4 and 8 per 100,000 gynecologic laparoscopies. Recently, among 77,604 LC cases, there were 33 deaths out of which 15 were due to nontechnical causes. They were myocardial infarction (3) pulmonary embolism (3), pneumonia (2), ischemic bowel (2), respiratory failure (1) necrotizing fasciitis (1), sepsis (1), and unknown {2). I04 NURSING

PERSPECTIVES

A team coordinator ensures that all the instruments are in working order and supervises other personnel. Reusable and disposable instruments should be ordered judiciously to lower the cost of the procedure. The patient educator explains the procedure, postoperative shoulder and abdominal pain, and the analgesia to be used. Pressure palsies should be avoided by using pads as cushions. lntraoperative blood pressure measurements, electrocardiography, pulse oximetry, and PETco2 analysis should be performed. Blood gases may have to be monitored in prolonged procedures or in patients with impaired ventilatow drive. Balloontipped pulmonary artery and radial artery catheters are required to monitor cardiac patients whose functional status is of New York Heart Association class IlI or IV because they are at higher risk of cardiac instability. Ringer's lactate for irrigation should be warm at 37° C. Subcutaneous emphysema and hypercarbia should be looked for intraoperatively and postoperatively. Smoke generated during the use of laser or electrocautery should be evacuated properly. There should be commitment to staff education and one should keep pace with the fast changing technology in this field. 147

JANUARY/FEBRUARY1997 HEART& LUNG

OUTLOOK Most of the nontechnical c o m p l i c a t i o n s in laparoscopy center around CO 2 PnP.5,~48151 New techniques such as "gasless" or low-pressure (IAP ~8 mm Hg) laparoscopy with mechanical lifting devices to retract the viscera are being evaluated. Three-dimensional cameras and the use of robots are also being evaluated. Some critics have grave concerns about the techniques being a d o p t e d by surgeons without formal training and any meaningful studies to assess the real benefits, Economic forces have pushed the doctors and the institutions to invest heavily for the latest innovations and offer "same~day" surgery to realize a return on their investment. Training and credentialing is a major problem. 5 LC may be for every patient but not for every surgeon. ~51 Doctors with no surgical training should not a t t e m p t the procedure although gastroenterologists in Japan have safely performed the procedure. ~6 Operative laparoscopy will continue to play a dominant role in the future. The a b i l i t y to accomplish the procedure should not be an indication for surgery; rather, the decision to perform the procedure should be based on low cost, efficacy, and low mortality and morbidity. Rational, professional, and responsible application of these techniques will require much greater scrutiny and study than have so far been applied. It has been hailed as a signal event in the evolution of surgical specialty destined to change how we operate. ~52 CONCLUSIONS Operative laparoscopy is a rapidly growing procedure that is popular both with the physicians and patients alike. Thousands of procedures are being safely performed with this technique. The overall incidence of m e d i c a l complications remains low thus making it a procedure of choice in many surgical conditions. Physicians should be aware of these possible complications, which may require urgent recognition and treatment. Accordingly, the team performing the laparoscopy should be able to handle all of the anticipated complications. In addition, t h e y should be well versed with conventional surgical techniques and t h e i r respective complications, because those techniques may be necessary in case of laparoscopic procedure failure. Laparoscopic surgery is here to stay with or without the use of a gas for insufflation. Most surgeons will have to train themselves in this skill if they want to survive in this new era of m i n i m a l l y invasive "gentle" surgery.

HEART & LUNG VOL. 26, NO. 1

We thank Shakun Sharma for preparing this manu~ script.

REFERENCES 1. Kelling G. Uber Oesophagoskopie, Gastroskopie and Zolioskopie. Munchene Mediziniche Wochenschrift 1902;49:21-4. 2. Ruddock ]C. Peritoneoscopy. West J Surg Obstet GynecoI i934;42:392-4. 3. RuddockL Peritoneoscopy.Surg GynecolObstet I937;65:62339. 4. Power FH, Barnes AC. Sterilization by means of peritoneoscopic fulguration: a preliminaryreport. Am JObstet Gynecol 194t;41:1093. 5. Rock IA, Warshaw R. The history and future of operative laparoscopy.Am JObstet Gynecol 1994;170:7-! 1. 6. SerumK. Endoscopic appendectomy. Endoscopy 1983;15:5964. 7. CuschieriA, Dubois F, Mouriel J, Mouret P, BeekerH, BuessG, et al. The EuroPean experiencewith laparoscopic cholecystectomy. Am I Surg 1991;161:385-7. 8. Hermann RE, Vogt DP. Biliary system. In: Davis IH, editor. Clinical surgery.St. Louis: CV Mosby, 1987:1637~80. 9. VillanovaN, BazzoliT, Taroni E Frabboni R, MazzellaG, Festi D, et al. Gallstone recurrence after uccessful oral bile acid treatment. A 12 year follow~up study and evaluationof longterm post dissolutiontreatment.Gastroenterology1989;97:72631. 10. Vergunst H, Terpstra QT, Brake1 K, Lameris IS, Van Blankenstein M, Schroder FH. Extracorporeal shockwave lithotripsy of gallstones: possibilities and limitations. Ann Surg 1989;210:565-74. 11. GravesHA Jr, Ballinger]E Anderson WJ. Appraisal of laparoscopic cholecystectomy.Ann Surg 1991;213:655-62. 12. McSherryCK. Cholecystectomy:the gold standard.Am JSurg 1989;158:174-8. 13. Dagnini G. Diagnostic laparoscopy: its current indications [French]. Chirurgie 1992;I18:454-6. 14. Escarce JJ, Chen W, Schwartz ]S. Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy, lAMA 1995;273:2581~5. 15. Safran DB, Orlando R 1II. Physiologiceffects of pneumoperitoneum. Am I Surg 1994;167:281-6. 16. TaniguchiY, Ido K, Kimura K, YoshidaY, Ohtani M, Kawamoto C, et al. Introduction of a "safetyzone"for the safetyof laparoscopic cholecystectomy.Am ] Gastroenterol 1993;88:1258-61. 17. ZuckerKA, BaileyRW,GadaczTR, ImbemboAL. Laparoscopic guided cholecystectomy.Am ] Surg 1991; 161:36~42. 18. CuschieriA. The spectrum of laparoscopic surgery. World J Surg 1992;16:1089-92. i9 Coluccillo SA. Blunt abdominal trauma. Emerg Med Clin North Am 1993;11:107-23. 20. BenderIS, Talmini MA. Diagnosticlaparoscopyin critically ill intensive~care-unitpatients. Surg Endosc 1992;6:302~4. 21. BrandtCP,PriebPA, EckhauserML. Diagnosticlaparoscopyin the intensive care patients: avoiding the nontherapeutic laparotomy. Surg Endosc 1993;7:168-72. 22. Shulman AG, Berci G, Lee ME. Pneumoperitoneum complicating coronarybypasssurgery:managementwithout laparotomy. Surg Endosc 1987;1:63-4. 23. Paterson-Brown S. The acute abdomen: the role of laparoscopy. BaillieresClin Gastroenterol 1991;5:691-703. 24. SackierJM. Laparoscopy in the emergency setting. World J Surg 1992;16:1083-8. 25. Nagy AG, lames D. Diagnostic laparoscopy. Am I Surg 1989;157:490-3. 26. Salky B. Diagnostic laparoscopy. Surg Laparosc Endosc 1993;3:132-4.

61

27. Bhargava DK, Shriniwas MD, Chopra P. Peritoneal tuberculosis: laparoscopic patterns and diagnostic accuracy. Am J Gastroenterol 1992;87:109-12. 28. Moir CR. Diagnostic laparoscopy and laparoscopic equipment. Semin Pediatr Surg 1993;2:148-58. 29. Rogers DA, Lobe TE, Schropp KP. Evolving uses of laparoscopy in children. Surg Clin North Am 1992;72:1299313. 30. Childers ]M, Hatch KD, Surwit EA. Office laparoscopy and biopsy for evaluation of patients With intraperitoneal carcinomatosis using a new optical catheter. Gynecol Oncoi 1992;47:337-42. 31. KimmelstJel FM, Miller RE, Molinelli BM, Lorch LA. Laparoscopic management of peritoneal dialysis catheters. Surg Gynecol Obstet 1993;176:565-70. 32. Colver RM. Laparoscopy: basic technique, instrumentation, and complications. Surg Laparosc Endosc 1992;2:35-40. 33. Easter DW, Cuschieri A~ Nathanson LK, Lavelle-Jones M. The utility of diagnostic laparoscopy for abdominal disorders: audit of 120 patients. Arch Surg 1992;127:379-83. 34. De Groen PC, Rakela ], Moore SC, McGill DB, Burton DD, Ott BJ, eta]. Diagnostic laparoscopy in gastroenterology: a 14 year experience. Dig Dis Sci 1987;32:677-8i. 35. Kortsik C, Winckelmann G, Beck K, Lutke A. What does laparoscopy contribute to explaining fever of unknown origin? [German]. Dtsch Med Wochenschr 1987;112:1657-60. 36. Sherwood R, Berci G, Austin E, Morgenstern L. Minilaparoscopy for blunt abdominal trauma. Arch Surg 1980; ] 15:672-3. 37. Ho HS, Saunders CI, Corso FA, Wolfe BM. The effects of CO2 pneumoperitoneum on hemodynamics in hemorrhaged animals. Surgery 1993;I 14:38I-8. 38. Mezghebe HM, Leffall LD Jr, Siram SM, Syphax B. Asymptomatic pneumoperitoneum: diagnostic and therapeutic dilemma. Am Surg 1994;60:691-4. 39. Portera CA, Compton RP, Waiters DN, Browder IW. Benefits of pulmonary artery catheter and transesophageal echocardiographic monitoring in Iaparoscopic cholecystectomy patients with cardiac disease. Am J Surg 1995;169:202-7. 40. Zollikofer R. Zur Laparoskopie. Schweiz Med Wochenschr 1924;54:84-7. 41. Liu S-Y, Leighton TA, Davis I, Klein S, Lipmann M, Bongard F. Prospective analysis of cardiopulmonary response to laparoscopic cholecystectomy. J Laparoendoscopic Surg 1991;5: 241-6. 42. Wittgen CM, Andras CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski DL. Analysis of hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991 ; 126:997-1000. 43. Kent RB 111.Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy. Arch Surg 1991;126: 1154-6. 44. Mullett CE, Viale JP, Sagnard PE, Miellet CC, Ruynat LG, Counioux HC, et al. Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg 1993;76:622-6. 45. Liu S-Y, Bongard FS. Cardiopulmonary pathophysiology of laparoscopy and pneumoperitoneum. In: White RA, Klein SR, editors. Endoscopic surgery. St. Louis: Mosby-Year Book, 199I:159-69. 46. lwase H, Takenaka H, Yagura A, Ishizaka T, Ohuta T, Takagaki M, et al. Hemodynamic change during laparoscopic cholecystectomy in patients with heart disease. Endoscopy 1992;24: 771-3. 47. lvankovitch AD, Miletich DJ, Albrecht RF, Heyman HJ, Bonnet RE Cardiovascular effects of intraperitoneal insuff]ation with carbon dioxide and nitrous oxide in the dog. Anesthesiology 1975;42:281-7. 48. Leighton T, Pianim N, Liu S-Y, Kono M, Klein S, Bongard E Effectors of hypercarbia during experimental pneumoperitoneum. Am Surg 1992; 58:717-21. 49. Huang SJ, Lee CY, Veh FC, Chang CL. Hypercarbia is not the determinant factor of systemic arterial hypertension during

62

carboperitoneum in laparoscopy. Ma Tsui Hsueh Tsa Chi 1991 ;29:592-5. 50. Bongard FS, Pianim N, LJu Sy, Lippman MM, Davis I, Klein S. Using helium for insufflation during laparoscopy, lAMA I991;266:3131. 51. Ho HS, Gunther RA, Wolfe BM. lntraperitoneal carbon dioxide insufflation and cardiopulmonary functions: Iaparoscopic cholecystectomy in pigs. Arch Surg 1992;127:928-33. 52. Williams MD, Murr P. LaparoscopJc insufflation of the abdomen depresses cardiopulmonary function. Surg Endosc 1993;7:12-6. 53. Kashtan ], Green JF, Parsons EQ, Holcroft IW. Hemodynamic effects of increased abdominal pressure. J Surg Res 198l;3:249-55. 54. Johannsen G, Andersen M, Juhl B. The effect of general anesthesia on the hemodynamic events during Iaparoscopy with carbon dioxide insufflation. Acta Anaesth Scand 1989;33: 132-6. 55. Westerband A, Van De Water 1M, Amza]lag M, Lebowitz PW, Nwasokwa ON, et al. Cardiovascular changes during ]aparoscopic cholecystectomy. Surg Gynecoi Obstet 1992; 175:53%8. 56. McKenzie R, Wadhwa RK, Bedger RC. Noninvasive measure~ ment of cardiac output during laparoscopy. J Reprod Med 1980;24:247-50. 57. Torrielli R, Cesarini M, Winnock S, Cabiro C, Mene ]M. Hemodynamic changes during celioscopy: a study carried out using thoracic electric bioimpedance.[FrenchJ Can J Anaesth 1990;37:46~51. 58. Hodgson C, McClelland RMA, Newton JR. Some effects of the peritoneal insufflation of Carbon dioxide at laparoscopy. Anaesthesia 1970;25:382-90. 59. Puri GD, Singh H. Ventilatory effects of laparoscopy under general anaesthesia. Br J Anaesth 1992;68:211-3. 60. Brown DR, Fishburne II, Robertson VO, Hulk IF. Ventilatory and blood gas changes during laparoscopy with local anesthesia. Am J Obstet Gynecol 1976;I 24:741-5. 61. Kelman GR, Swapp GH, Smith I. Cardiac output and arterial blood gas tension during laparoscopy. Br J Anaesth 1972;44:1155-62. 62. Williams MD, Sulentich SM, Murr PC. Laparoscopic cholecystectomy produces less postoperative restrictions of pulmonary functions than open cholecystectomy. Surg Endosc 1993;7:489~92. 63. Kubota K, Kajiura N, Teruya M, Ishihara T, Tsusima H Ohta S, et al. Alterations in respiratory function and hemodynamics during laparoscopic cholecystectomy under pneumoperitoneum. Surg Endoscopy 1993;7:500-4. 64. Melville RI, Frizis HI, Forsling ML, LeQuesne LP. The stimulus for vasopressin release during laparoscopy. Surg Gynecol Obstet 1985;161:253-6. 65. Ott DE. Laparoscopic hypothermia. ] Laparoendoscopic Surg 1991;I:127-31. 66. Nord HJ. Complications of laparoscopy. Endoscopy 1992;24:693-700. 67. Fishburne J. Anesthesia for laparoscopy: considerations, complications and techniques. J Reprod Med 1978;21:37-40. 68. Bongard E Dubecz S, Klein S. Complications of therapeutic laparoscopy. Curr Probl Surg 1994;31:857~924. 69. Pearce DJ. Respiratory acidosis and subcutaneous emphysema during laparoscopic cholecystectomy. Can J Anaesth 1994;41:314-6. 70. Rittenmeyer H. Carbon dioxide toxicity related to a laparoscopic procedure. J Post Anesth Care 1994;9:157-6i. 71. Wahba RWM, Mamazza J. Ventilatory requirements during laparoscopic cholecystectomy. Can ] Anaesth 1993;40:206-10. 72. Toub DB, Sedlacek TV, Campion MJ. Acidemia associated with the use of high flow insufflators during laparoscopy. Am ] Obstet Gynecol 1994;170:959-60. 73. Wolf IS Jr, Stoller ML. The physiology of laparoscopy: basic principles, complications and other considerations. I Uro] 1994;152:294-302. 74. Glauser FL, Bartlett RH. Pneumoperitoneum in association with pneumothorax. Chest 1974;66:536-40.

JANUARY/FEBRUARY ]997 HEART & L U N G

75. Batra MS, Driscoll II, Coburn WA, Marks WM. Evanescent nitrous oxide pneumothorax after laparoscopy. Anesth Analg 1983;62:l 121-3. 76. Doctor NH, Hussain Z. Bilateral pneumothorax associated with laparoscopy: a case of a rare hazard and review of the literature. Anaesthesia 1973;28:75-81. 77. Shapiro M. Spontaneous pneumothorax complicating pneumoperitoneum therapy: a review and report of a case. Ann Intern Med 1955;43:876-92. 78. Ronsse G, Stalport J, Burnon D. Pneumothorax bilateral, complication exceptionalle d'une laparoscopic gyneco]ogique. Acta Chit Belg 1980;5:345-8. 79. Bruh] W. Complications of laparoscopy and liver biopsy under vision: the results of a survey. German Med Monthly 1967;12:31-2. 80. Whiston RJ, Eggers KA, Morris RW, Stamatakis JD, et al. Tension pneumothorax during laparoscopic cholecystectomy. Br J Surg 1991;78:1325. 81. Murray DP, Rankin RA, Lackey C. Bilateral pneumothoraces complicating peritoneoscopy [letter]. Gastrointest Endosc ]984;30:45-6. 82. Nicholson D, Berman N. Pneumopericardium following laparoscopy. Chest 1979;76:605-7. 83. Seed R, Shakespeare T, Muldoon M. Carbon dioxide homeostasis during anaesthesia for ]aparoscopy. Anaesthesia 1970;25:223~33. 84. A]oise F, Rossi EM, Cadregari F, Pastorcich A, Filosa L, Costanzo H,et al. Errors in digestive surgery: a case of tension pneumothorax during ]aparoscopic cholecystectomy [Italian]. Minerva Chir 1994;49:841~2. 85. McConnell MS, Finn JC, Feeley TW. Tension hydropneumothorax during ]aparoscopy in a patient with ascites. Anesthesiology 1994;80:1390-3. 86. Bard TA, Chen LS. Subcutaneous emphysema associated with laparoscopy. Anesth AnaIg ] 990;7 ] : 10 ]-2. 87. McAllister JD, D'Altorio RA, Snyder A. CT findings after uncomplicated percutaneous laparoscopic cholecystectomy. J Comput Assist Tomogr 199 ] ; 15:770-2. 88. Phillips JM. Complications in ]aparoscopy. lnt J Gynecol Obstet 1977;95: ] 57~62. 89. Schauer PR, Luna l, Ghiatas AA, Glen ME, Warren IM, Sir]neck KR. Pulmonary function after ]aparoscopic cholecystectomy. Surgery 1993; l ]4:389-99. 90. Kahn MA, Alka]ay 1, Suetsugu S, Stein M. Acute changes in lung mechanics following pulmonary emboli of various gases in dogs. J Appl Physiol 1972;33:774-7. 91. Ramage AA, Singh M, Griffin JW lr, Tedesco FJ. Hydropneumothorax following peritoneoscopy. J Clin Gastroenterol 1986;8:483-5. 92. Kalhan SB, Reaney JA, Collins RL. Pneumomediastinum and subcutaneous emphysema during laparoscopy. Cleve Clin J Med 1990;57:639-42. 93. Pauscal JB, Baranda MM, Tarrero MT, et al. Subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumopericardium after laparoscopy [letter]. Endoscopy 1990;22:59. 94. Carmichael DE. Laparoscopy: cardiac considerations~ Ferti] Steri] 1971;22:69-70. 95. Scott DB, Julian DG. Observations on cardiac arrhythmias during laparoscopy. Br Med I 1972;l:411~3. 96. Doyle DJ. Laparoscopy and vaga] arrest lletter]. Anaesthesia 1989;44:448. 97. Shifren JL, Adelstein -L, Finkler NJ. Asystolic cardiac arrest: a rare complication of laparoscopy. Obstet Gynecol 1992;79:840~1. 98. Crist DW, Gadacz TR. Complications of laparoscopic surgery. Surg C]in North Am 1993;73:265-89. 99. Myles PS. Bradyarrhythmias and ]aparoscopy: a prospective study of heart rate changes with ]aparoscopy. Aust NZ l Obstet Gynecol 199 ] ;3 ]: ] 7 ] -3. 100. Burns IM, Hart DM, Hughes RL, Kelman AW, Hillis WS. Effects of nadolol on arrhythmias during laparoscopy performed under general anaesthesia. Br J Anaesth 1988;61:34%6.

HEART & LUNG

VOL. 26, NO. 1,

101. Healzer JM, Nezhat C, Brodsky JB, Brock~Une JG, Seidman DS. Pulmonary edema after absorbing crystalloid irrigating fluid during laparoscopy. Anesth Analg 1994;78:1207. 102. Desai S, Roaf E, Liu P. Acute pulmonary edema during laparoscopy. Anesth AnaIg 1982;61:699-700. 103. Hulka JF, Peterson HB, Phillips IM, Surrey MW. Operative hys~ teroscopy: American Association of Gynecologists and Laparoscopists 1991 membership survey. J Reprod Med 1993;38:572~3. 104. Deziel DI, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: results of a national survey of 4292 hospitals and analysis of 77,604 cases~ Am J Surg 1993;165:9-14. 105. lorgensen lO, Hanel K, Hunt DR, North L, Morris DL. Thromboembolic complications of laparoscopic cholecystec~ tomy [letter]. Br Med J 1993;306:518~9. 106. Greville AC, Clements AF, Erwin DC, McMillan DL, Wellwood IM. Pulmonary air embolism during laparoscopic cholecystectomy. Anaesthesia 1991;46: ] 13-4. 107.Yacoub OF, Cardona 1, Coveler LA, Dodson MG. Carbon dioxide embolism during laparoscopy. Anaesthesia 1982;57: 533~5. ]08. Crozier TA, Luger A, Dravecz M, Sydow M, Radke J, Rath W, et al. Gas embolism with cardiac arrest during hysteroscopy: a case report of three patients IGerman]. Anaesthesiol lntensivmed Notfallmed Schmerzther ] 991 ;26:412-5. 109. Shulman D, Aronson HB. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can Anaesth Soc J 1984;31:455-9. ]]O. Root B, Levy MN, Pollack S, Lubert M, Pathak K. Gas embolism death after laparoscopy delayed by "trapping" ~in portal circulation. Anesth Analg ]978;57:232-7. I l l . Chang JL, Chestnut JS, Carroll RG, Newfield P, Maivald P, Albin MS. Air embolism. Anesthesiology 1977;46:307. ] ]2. McMohan AJ, Baxter JN, O'Dwyer PJ. Preventing complications of laparoscopy. Br J Surg 1993;80:1593~4. ] ]3. Seigismund K, Kreller E, Held HJ. Pulmonary gas embolism in laparoscopy: a rare complication [German]. Zentralbl Gynakol 1985;107:435-9. ] 14. Southern DM, Stein M. Mapleson WW. Which insufflation gas for laparoscopy? [letter[. Br Med l 1993;307:1424. 115. Cooperman AM Complications of laparoscopic surgery. In: Arregui ME, Fitzgibbons RJ, Kathouda N, McKernan JB, Reich H, editors. Principles of [aparoscopic surgery: basic ahd advanced techniques. New York: Springer-Verlag, ]995:71-7. ] 16. Knos GB, Sung Y-F,Toledo A. Pneumopericardium associated with laparoscopy, l Clin Anesth 1991;3:56-9. ]17~Barba MA, Saez L, Garcia-Molinero MJ, Aguilera M Pneumopericardium without subcutaneous emphysema, pneumomediastinum, or pneumothorax after laparoscopy [letter]. Gastrointest Endosc 1993;39:740. 118. Rose DK, Cohen MM, Soutter DI. Laparoscopic cholecystectomy: the anaesthetist's point of view. Can I Anaesth 1992;39:809-15. 119. Hu]ka JF, Soderstrom RM, Corson SL, Brooks PG. Complications committee of the American Association of Gynecologic laparoscopists: first annual report. J Reprod Med 1973;10:30I~6. 120. Narchi P, Benhamou D, Fernandez H. lntraperitoneal local anaesthetic for shoulder pain after day case laparoscopy. Lancet 1991;338:]569-70. 121. Sharp JR, Pierson WP, Brady CE. Comparison of CO2 and N20 induced discomfort during peritoneoscopy under local anesthesia. Gastroenterology 1982;82:453-6. 122. Perry CP, Tombrello R. Effect of fluid instillation on postla~ paroscopic pain. J Reprod Med 1993;38:768-70. 123. Pianim NA, Dubecz S, Bongard FS, Klein S. Bowel hypoxia during pneumoperitoneum: effect of gas and pressure. Surg Forum 1992;51:517-9. 124. Sotrel G, Hirsch E, Edelin KC. Necrotizing fasciitis following diagnostic laparoscopy. Obstet Gynecol 1983;62(3 Suppl):67S~9S.

63

125. Hershlag A, Loy RA, Law G, De Cherney AH. Femoral neuropathy after laparoscopy: a case report. J Reprod Med 1990;35575-6. 126. Johnston RV, Lawson NW, Nealson WH. Lower extremity neuropathy after iaparoscopic cholecystectomy. Anesthesiology 1992;77:835. 127. Stow PJ. Retinal hemorrhage following laparoscopy [letter[. Anaesthesia 1986;4I:965-6. 128. Prentice JA, Martin IT. The Trendelenburg position: anesthesiologic considerations. In: Martin JT, editor. Positioning in anesthesia and surgery. Philadelphia: WB Saunders, 1987:127-45. 129. Schiller WR. The Trendelenburg position: surgical aspects. In: Martin IT, editor. Positioning in anesthesia and surgery. Philadelphia: WB Saunders, 1987:117-26. 130. Gartner S, Beck W. Ocular tension in Trendelenburg position. Am J OphthalmoI 1965;59:1040. 13l. Cotton PB, Tytgat GNT, Williams CB. Annual of gastrointestinal endoscopy. London: Current Science Limited, 1990. 132. Di Gregorio A, Visentin L, Volpi E, Seinera R Maccario S, Schettini S, et al. Gastric hemorrhage in a patient subjected to laparoscopy [Italian[. Minerva Ginecol 1987;39:515-7. 133. Hansen KA, Wood R. An unusual complication of Iaparoscopic cholecystectomy. Endoscopy 1994;26:322-3. 134. Ott DE. Correction of laparoscopic insufflation hypothermia. J Laparoendosc Surg 1991; 1: 183-6. 135. Hurd WW, Toglia MR, Smith YR. Laparoscopic irrigation using a prewarmed pressurized system. J Laparoendosc Surg 1993;3:573-5. 136.O'Rourke N, Price PM, Kelly S, Sikora K. Tumor inoculation during laparoscopy [letter, comment[. Lancet I993;342:368. 137. Hulka JE Complications of laparoscopy. Curr Prob Obstet Gynecol 1980;4:3~63. 138. Waldvogel HH, Schneck HJ, Felber A, Von Hundelshauren B. Anesthesia relevant features of Iaparoseopy: the value of capnometry [German]. Anaesthesiol Reanim 1994;19:4-10. 139. Schirmer BD, Edge SB, Dix J, Hyser ME Hanks JB, Jones RS. Laparoscopic cholecystectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg 1991;213:665-77.

140. Safran D, Sgambati S, Orlando R II1. Laparoscopy in high risk cardiac patients. Surg Gynecol Obstet 1993;176:548-54. 141. lkard RW, Federspiel CE Laparoscopic versus open appendectomy [letter[. N Engi J Med 1995;333:881. 142. Wittgen CM, Andrus JP, Kaminski DL. Cholecystectomy: which procedure is best for the high-risk patient? Surg Endoscopy 1993;7:395-9. 143. Charlson ME, McKenzie CR, Gold JR Ales KL, Topkins M, Shires GT. Intraoperative blood pressure. Ann Surg 1990;212:567-80. 144. Orlando III R. Mixed venous oximetry in critically ill surgical patients: "high tech" cost effectiveness. Arch Surg 1986; 121:470-1. I451Moffa SM, Quinn ]V, Slotman GJ. Hemodynamic effects of carbon dioxide pneumoperitoneum during mechanical ventilation and positive end~expiratory pressure. J Trauma 1993;35:613-8. 146. Schirmer BD, Dix J, Edge SB, Hyser MJ, Hanks JB, et al. Laparoscopic cholecystectomy in the obese patient. Ann Surg 1992;216:146-52. 147. De Lisle NP, Jackson KD, Raschall V, Wagner K, et al. The team: nursing perspectives. In: Arregui ME, Fitzgibbons RJ, Kathouda N, McKernan JB, Reich H, editors. Principles of laparoscopic surgery: basic and advanced techniques. New York: Springer-Verlag, I995:91-100. 148.Anonymous. GasIess laparoscopy eliminates complications caused by pneumoperitoneum. Minimally lnvasive Surgical Nursing 1994;8:2-6. 149. Schneider JJ, Smith SS, Organ CH. Apneumic laparoscopy in surgical oncology. Semin Surg Oneol 1994;10:391-6. 150. Banting S, Shimi G, Vander Velpen G, Cuschieri A. Abdominal wall lift: low pressure pneumoperitoneum laparoseopic surgery. Surg Endosc 1993;7:57-9. 15 I. Peters JH, Gibbons GD, Innes JT, Nichols KE, Front ME, Roby SR, et al. Complications of laparocholecystectomy. Surgery 1991;I 10:769-78. 152. DeCherney AH. "The leader of the band is tired--" FertiI Steril 1985;44:299-302.

AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Heart & Lung®: The Journal of Acute and Critical Care for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $9.50 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one-third off on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, or call (800)453-4351 or (314)453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106, (313)761-4700.

64

JANUARY/FEBRUARY]997 HEART & LUNG