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Handbook of Laparoscopy Instruments, 2023, 39-49 39
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CHAPTER 5
Equipment for Creating And Maintaining the
Pneumoperitoneum
Sanjeev Gianchandani1, Resha Keshwani1, Sachin Gianchandani1 and
Lamture Yeshwant Ramrao
1
Datta Meghe Institute of Higher Education and Research Centre, India
2
Department of General Surgery, JNMC, Sawangi (Meghe), Wardha, India
Abstract: Creating and maintaining a pneumoperitoneum is a vital laparoscopy
procedure. A set of instruments, including an insufflator, are used to achieve
pneumoperitoneum. Despite having a critical role in laparoscopy, it is the least
understood of all laparoscopic devices and appliances. Co2 insufflator, also known as
an endoflator, and laproflator is the most intelligent laparoscopy device as it has to
work under control, considering physiology. In addition, gas cylinders, connector
tubing, dual valves and gas tubing are also utilized for creating pneumoperitoneum.
2,*
Keywords: Insufflator, Mano-Meter, Pneumoperitoneum, Suction irrigator.
INTRODUCTION
Creating and maintaining a pneumoperitoneum is a vital laparoscopy procedure.
A set of instruments, including an insufflator, are used to achieve
pneumoperitoneum. Despite having a critical role in laparoscopy, it is the least
understood of all laparoscopic devices and appliances. An insufflator, also known
as an endoflator, and laproflator is the most intelligent laparoscopy device as it
has to work under control, considering physiology. In addition, gas cylinders,
connector tubing, dual valve and gas tubing are also utilized for creating
pneumoperitoneum.
Insufflator
The insufflator, also known as Endoflator, Laproflator [1, 2], is the device used to
deliver gas inside the layers of the body to create a workspace to inspect or
perform surgery [3]. Initially, manual insufflators were used to create
pneumoperitoneum, gradually evolving into automatic insufflators [4, 5]. Insuffla-
*
Corresponding author Lamture Yeshwant Ramrao: Datta Meghe Institute of Higher Education and Research
Centre, India; E-mail:Sanjeevgianchandani@gmail.com
All rights reserved-© 2023 Bentham Science Publishers
Lamture Yeshwant Ramrao (Ed.)
40 Handbook of Laparoscopy Instruments Gianchandani et al.
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tors are available depending on the maximum gas flow rate and pressure they can
deliver. Insufflators providing six litres per minute to a maximum of 45 litres per
minute are available [6]. An automatic insufflator is the most intelligent device for
laparoscopy. The device does multiple assessments and projects it over the screen
or pressure meters. After gathering the data, it creates the pneumoperitoneum and
maintains it [4]. Furthermore, it has a protective mechanism to stop or modulate
the gas flow and pressure because of patients’ safety. In addition, it has an alarm
system that warns the surgeon about an erroneous step during surgery [7, 8] (Fig.
1).
Fig. (1). Laparoscopic Insufflator.
Lapro-Manometers
The automatic insufflators measure six numerical valves and project them over
the screen [9].
1. Settings
Maximum Gas flow ratea.
Intraperitoneal pressure settingb.
Actual measured values
Actual flow ratea.
Maintaining the Pneumoperitoneum Handbook of Laparoscopy Instruments 41
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Actual Pressureb.
.
The total volume of gas utilizedc.
The volume of gas in the cylinder (Fig. 2)d.
Fig. (2). Laparoscopic Insufflator Screen.
when insufflator swtich on, it calibrates itself to provide excellent pressure values.
Then, it notifies the volume of gas in the cylinder, and the operating team can
assess the need for an additional gas cylinder during the surgery. To begin with,
two parameters are set, the maximum gas flow rate and pressure [10].
Maximum gas flow rate is a value to be set manually before starting the surgery.
The device cannot override the upper level of the set value. Instead, the device
automatically variates the flow rate between zero to the preset value to create and
maintain the pressure without going above the set value. The flow rate is lower to
avoid vasovagal episodes and hemodynamic complications [11]. The flow rate
gradually increases to six ml per hour for intraperitoneal surgeries, and the
pressure is kept between 10 to 14mm of Hg. Most authors recommend a 12 mm
Hg pressure for decent space creation and safe laparoscopic surgery [12]. Most of
the surgeries can be performed at 6litres per minute. Nevertheless, high flow rates
are required to maintain the pressure during surgery requiring high-pressure
suction; for instance, continuous suction is required during bleeding [13, 14].
Different pressures are necessary for various surgeries depending upon the plane
of surgery (Table 1).
42 Handbook of Laparoscopy Instruments Gianchandani et al.
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Table 1. Pressures required in different minimal access surgery [12, 15 - 18].
Intraperitoneal Pressure
Pre-peritoneal Hernia Surgery 15 to 20
Breast Augmentation 25 to 30
Axillar surgery 18 to 22
Endoscopic Perforator Surgery for varicose veins 28 to 30
Thyroid Surgeries 18 to 20
12 to 14
Pulsatile Flow and Plane of Surgery
The insufflator cannot measure the pressure while delivering the gas. It supplies
gas for a few seconds and stops measuring the pressure leading to a pulsatile flow.
This is a protective mechanism to identify the misplacement of the trocar or verres
needles and prevent a sudden pressure rise [18, 19]. The surgical plane can be
identified by looking at the gas flow rate and pressure (Table 2).
Table 2. While creating pneumoperitoneum (Authors recommendation).
Actual Flow Actual Pressure Possibility
On the set value 6 to 7mm of Hg and not changing Inferior Vena Cava
On the set value
On the set value to begin with,
rapidly reducing
Reduced flow or no flow High pressure Arterial placement
Lower, to begin with, gradually increasing to
the set value
The rapid rise in a pressure value Extraperitoneal
Intraperitoneal
Gas for Pneumoperitoneum
Initially, the air was used to create pneumoperitoneum; however, it can lead to air
embolism and support combustion. The ideal insufflating agent for laparoscopic
procedures should be physiologically inert, colourless, non-explosive and highly
soluble in blood. In addition to this, it should be inexpensive, readily available,
and non-toxic. Carbon dioxide is the recommended gas at present. Carbon dioxide
is readily available and supplied in the liquid form under pressure. So the cylinder
should be kept vertical to avoid problems in the insufflators device [18 - 20].
Carbon Dioxide
Carbon dioxide is commonly used in laparoscopic procedures because it has a low
risk of gas embolism and is non-explosive. However, it can lead to hypercarbia,
Maintaining the Pneumoperitoneum Handbook of Laparoscopy Instruments 43
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acidosis, decreased cardiac contractility, systemic vasodilation, and pulmonary
hypertension [21, 22] (Fig. 3).
Fig. (3). Central Co2 supply (Yellow) and Co2 cylinder.
Other gases used in laparoscopy are nitrous oxide (NO), helium (He), and argon.
Gas-specific insufflators are also available in the market (Fig. 4). Nevertheless,
the safety of other gases over carbon dioxide is yet to be established [23].
O
T
S
KARL STORZ
40
0
70
-
80
bar
R
ENDOSKOPE
-
160
Z
120
20
10
0
Fig. (4). N2O Specific insufflators [24].
N2O endoflator
10
20
30
40
50
mmHg
10mmHg
I/min
0
Operating modesGas reserve Insufflation outlet
I/min
30mmHg
8
6
4
10
3
2
1
0
0
Intra-abdominal pressure
30
40
50
mmHg
26411120
44 Handbook of Laparoscopy Instruments Gianchandani et al.
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Other Instruments
A gas tube connects the insufflator with the Verres needle or the trocar, and a
heating device is placed over the gas tubing to warm the gas to avoid hypothermia
[25]. A microfilter is connected between the insufflator and the tube. It removes
impurities and bacteria from the gas delivered into the pneumoperitoneum [26].
Furthermore, a carbon dioxide gas double valve is available in the market. It is
required in the surgery, requiring a high amount of gas. It helps quickly switch an
empty cylinder to a gas-filled one [27] (Figs. 5 and 6).
Fig. (5). CO2 insufflator tubing with a warmer.
Suction Irrigation Machine
It is used for cleaning and flushing the abdominal cavity and cleaning during
operations. It is used routinely at the time of laparoscopy to make the field of
vision clear. Saline is commonly used for irrigation; primarily, normal saline is
used.
In order to maintain a clear operative field, irrigation and suction are crucial
during laparoscopic surgeries. It comes in 5 mm and 10 mm reusable sizes. The
suction tip is helpful for intermittent suction and is also used as a blunt dissecting
Maintaining the Pneumoperitoneum Handbook of Laparoscopy Instruments 45
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instrument. Suction or irrigation tubes are thoroughly cleaned with running tap
water before autoclaving them [28, 29] (Fig. 7).
Fig. (6). Carbon dioxide changeover valve.
Fig. (7). Suction and irrigation cannula.
46 Handbook of Laparoscopy Instruments Gianchandani et al.
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CONCLUSION
Pneumoperitoneum creation is an essential step of laparoscopic surgery.
Therefore, understanding the instrument and its proper utilization is paramount. A
circuit of tools is placed to create pneumoperitoneum, starting from the carbon
dioxide cylinder, a connector tube, a double valve, an insufflator, a microfilter,
gas tubing and a Verres needle and a trocar [30 - 35]. It is advisable to start
checking the instruments from one end to the other, beginning with the volume
and pressure in the Co2 cylinder. Further, as the pneumoperitoneum is created, the
focus should be on the actual flow rate and pressure, which will guide the surgeon
in understanding the plane of the pneumoperitoneum.
The pneumoperitoneum should be created gradually with a low gas flow rate and
pressure to avoid complications. A sudden rise in pressure or obstruction in the
flow of gas indicates misplacement of the trocar or veress needle. Furthermore, a
microfilter must be connected before gas tubbings to filter microorganisms. Gas
in the cylinder or circuit is cold and dry; it is desirable to attach a warmer to
reduce the chances of hypothermia. In addition, the amount of gas flow, gas leak
and duration of surgery should be monitored as it can lead to hypothermia and Co
narcosis.
Every instrument in the entire circuit used to create pneumoperitoneum is vital
and should be checked before surgery. Monitoring pressure values during surgery
provide information like the plane of surgery, avoids erroneous steps and prevents
complications. Thus, appropriate knowledge of instruments and physiology
involved in creating pneumoperitoneum is paramount to provide a safe surgical
environment and avoid complications.
2
Practice Points
Create pneumoperitoneum gradually with a low gas flow rate and pressure
complications.
The manometric values should be monitored while creating the peritoneum. A
sudden rise in pressure could be due to a preperitoneal placement, and a constant
pressure despite a non-obstructive flow of gas could be an Inferior Vena Cava
placement.
The microorganism can grow in the insufflator and carbon dioxide cylinder, so a
microfilter is recommended.
Although the evidence of its advantages is not sufficient, humidifiers and gas
warmers should be preferred.
Maintaining the Pneumoperitoneum Handbook of Laparoscopy Instruments 47
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ACKNOWLEDGEMENTS
Department of Surgery, D.M.I.M.S is acknowledged for their contribution.
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