Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar

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Mendes Hypolito, Octavio Henrique [UNIFESP]
Moreira Coutinho Azevedo, Joao Luiz [UNIFESP]
Lima Alvarenga Caldeira, Fabiana Mara Scarpelli de [UNIFESP]
Azevedo, Otavio Cansancao de [UNIFESP]
Miyahira, Susana Abe [UNIFESP]
Soares Miguel, Gustavo Peixoto [UNIFESP]
Becker, Otavio Monteiro [UNIFESP]
Cabral Guedes Machado, Afonso Cesar [UNIFESP]
Nunes Filho, Gilberto Pinheiro [UNIFESP]
Azevedo, Glicia Cansancao [UNIFESP]
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The aim of this work is to analyze, by means of noninvasive monitoring, the clinical effects of high intraperitoneal pressure for enough time to insert the first trocar.Sixty-seven patients without significant lung problems were randomly divided into groups P12 (n = 30, maximum intraperitoneal pressure 12 mmHg) and P20 (n = 37, maximum intraperitoneal pressure 20 mmHg). A Veress needle was inserted into the left hypochondrium for creation of pneumoperitoneum. the parameters evaluated were heart rate (HR, in bpm), arterial oxygen saturation (SaO(2), expressed as percentage of hemoglobin saturated with oxygen), end-tidal CO(2) (ETCO(2), in mmHg), mean arterial pressure (MAP, in mmHg), and intratracheal pressure (ITP, in cmH(2)O). Clinical parameters were evaluated in both groups at time point 0 (TP0, before CO(2) insufflation), time point 1 (TP1, when intraperitoneal pressure of 12 mmHg was reached in both groups), time point 2 (TP2, 5 min after reaching intraperitoneal pressure of 12 mmHg in group P12 and of 20 mmHg in group P20), and time point 3 (TP3, 10 min after reaching intraperitoneal pressure of 12 mmHg in group P12 and 10 min after TP1 in group P20, when intraperitoneal pressure decreased from 20 to 12 mmHg). Values outside of the normal range or occurrence of atypical phenomena suggestive of organic disease indicated clinical changes.Statistically significant differences were observed between the two groups regarding HR, MAP, ETCO(2), and ITP. No significant clinical changes were observed.Transitory, high intraperitoneal pressure (20 mmHg for 5 min) for insertion of the first trocar resulted in changes in HR, MAP, ETCO(2), and ITP that were within the normal range, and no adverse clinical effects were observed. Therefore, the use of transitory, high intraperitoneal pressure is recommended to prevent iatrogenic injury during blind insertion of the first trocar. Nevertheless, it is not clear that this method would be safe in patients with moderate to severe chronic obstructive pulmonary disease.
Surgical Endoscopy and Other Interventional Techniques. New York: Springer, v. 24, n. 7, p. 1663-1669, 2010.