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High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
2011 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 6, 845-852 p.Article in journal (Refereed) Published
Abstract [en]

Background: Various recommendations exist regarding intra-abdominal pressure (IAP) during laparoscopic liver resection. A high IAP may reduce bleeding but at the same time increase the risk of gas embolism. This study investigated the effects of two different IAPs during laparoscopic left liver lobe resection in piglets. Methods: Sixteen piglets underwent laparoscopic left liver lobe resection using carbon dioxide pneumoperitoneum of either 8 or 16 mmHg (8 per group). A combination of CUSA System 200 (TM) and LigaSure (TM) instruments was used for parenchymal division. During resection, a standard injury to the left liver vein was also created to increase the risk of bleeding and/or gas embolism during the operation. Heart rate, cardiac output, and arterial, pulmonary arterial, pulmonary capillary wedge and central venous pressures were measured. Arterial blood gases were monitored continuously. Transoesophageal echocardiography was video recorded to detect and quantify gas embolism within the right cardiac ventricle. The duration of operation and bleeding were noted. Results: High IAP resulted in reduced bleeding (P = 0.016), but gas embolism occurred more frequently (P = 0.001) than with low IAP. Gas embolism disturbed gas exchange, with an increase in arterial pressure of carbon dioxide, and a decrease in arterial partial pressure of oxygen and pH. These effects were sustained for at least 30 min after surgery. Conclusion: High IAP reduces the amount of bleeding but increases the risk of gas embolism. Monitoring for gas embolism is therefore indicated if a high IAP is used during laparoscopic liver resection.

Place, publisher, year, edition, pages
2011. Vol. 98, no 6, 845-852 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-154346DOI: 10.1002/bjs.7457ISI: 000290519300077PubMedID: 21523699OAI: oai:DiVA.org:uu-154346DiVA: diva2:420110
Available from: 2011-05-31 Created: 2011-05-31 Last updated: 2017-12-11Bibliographically approved
In thesis
1. Technical Aspects of Laparoscopic Liver Resection. An Experimental Study
Open this publication in new window or tab >>Technical Aspects of Laparoscopic Liver Resection. An Experimental Study
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Various techniques are used to transect the liver. With increase in laparoscopic liver resections (LLR), it is of even more interest to develop surgical techniques to minimize bleeding and the risk for gas embolism during transection. Instrument like argon enhanced coagulator provides good hemostasis but increases the danger of gas embolism. The CO2 pneumoperitoneum that is routinely used in most types of laparoscopic surgery can be modified by the use of different gas pressure. It can be assumed that different pressure influences bleeding but also the risk for gas embolism.

In presented porcine studies, three instrumental combinations have been studied. In study I sixteen piglets were randomized to LLR with either the cavitron ultrasonic aspirator (CUSA™) in combination with vessels sealing system (Ligasure™) or with CUSA™ and ultrascision scissors (Autosonix™), with the endpoints of intra-operative bleeding and gas embolism.  In study IV sixteen piglets were randomized to LLR either with staple device (Endo-GIA™) or the Ligasure™ - CUSA™ combination with same primary endpoints and additionally secondary endpoints of effect on gas-exchange, systemic- and pulmonary hemodynamic.

Focusing on intra-abdominal pressure (IAP) in study II, sixteen piglets were randomized to LLR with an IAP of either 8 or 16 mmHg.  Primary endpoints were bleeding and gas embolism and secondary endpoints, effect on gas-exchange, systemic- and pulmonary hemodynamic.

In study III effect of argon gas was tested during LLR. Sixteen piglets were randomized to either argon pneumoperitoneum or CO2 pneumoperitoneum. Primary endpoints were effect on gas-exchange, systemic- and pulmonary hemodynamic.

In presented studies, we tested efficacy and safety of different techniques for LLR. CUSA™ can be used in combination with either Ligasure™ or Autosonix™. However, Ligasure™ reduces the amount of bleeding. The recent introduction of staplers seems promising with a further reduction in bleeding, gas embolism, and operating time. The IAP influences both the amount of bleeding as well as gas embolism. It seems reasonable to use a higher IAP to decrease bleeding with caution and with close monitoring for gas embolism. Argon gas embolism gives more extensive effect on gas-exchange and hemodynamic and should probably be avoided in this type of surgery.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. 104 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 756
Keyword
Gas embolism, laparoscopy, liver resection, pneumoperitoneum, carbon dioxide, argon, bleeding, stapling device
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171735 (URN)978-91-554-8321-0 (ISBN)
Public defence
2012-05-11, Enghoffsalen, Akademiska Sjukhuset, entrance 50, ground floor, Uppsala, 13:00 (Norwegian)
Opponent
Supervisors
Available from: 2012-04-20 Created: 2012-03-26 Last updated: 2012-08-01Bibliographically approved

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Fors, DiddiRubertsson, StenArvidsson, Dag

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