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438
14.1 Analysis and Prevention of Untoward Events in Laparoscopic Surgery
Table 14.1.1 Error analysis. State of the art 1994.
1. What was the clinical presentation?
2. What happened? Type of complication, untoward events,
and frank disasters.
3. Why did it happen? Systematic rigorous objective analysis;
review with experts in management and
safety measures, who may be consultants from non-medical fields.
4. How can the compli-
cation and error be
prevented in the
future?
5. The conclusions reached must be brought to the attention of
participating personnel at all levels.
sciously, either at the operating table or sometimes weeks later.
Obviously, this type of error analysis is not complete, nor is it
necessarily systematic or objective. Above all, this type of analy-
sis is not public as a matter of course. Even the morbidity and
mortality conferences, although they may be systematically organized and rigorously executed in leading hospitals, are closed
sessions limited to surgeons.
There are decisive advantages of error analysis:
− Error analysis provides practical, relevant information to
avoid future errors.
− This does not require large studies. The analysis of a single
case can provide relevant information.
− No major expenses are incurred, and analysis may be obtained quickly, in contrast to large expensive studies. Finally,
error analysis as a concept based on all the available information can be performed on any surgical ward.
Structured detailed instructions for planning and performing an operation is essential.
Laparoscopy During Pregnancy
Few published studies exist, and the evidence presented is not
conclusive. Problems discussed include both the increase in intraabdominal pressure in the various phases of pregnancy and
possible fetal risk due to pressure and CO
placental barrier.
Two pioneers and experts in laparoscopic surgery, Semm and
Mettler, both declare, “pregnancy as such is not a contraindication to laparoscopy.” They observe that “gynecologists have performed endoscopic or pelvioscopic surgery in various phases of
pregnancy for a long time.”
Note: Caution is advised. Gasless laparoscopy may be an option
in the future, but it is currently still in the experimental stage.
absorption across the
2
Laparoscopy for Abdominal Trauma
In animal experiments, laparoscopy has been shown to cause
cardiovascular compromise in unstable, seriously injured animals. It is therefore contraindicated in a comparable clinical situation. Published studies indicate that laparoscopically executed therapeutic measures in the presence of blunt abdominal trauma are severely limited in scope. Only rupture of the diaphragm appears to present an ideal situation for laparoscopic
diagnosis and treatment.
Possible indications for laparoscopy include stab and gunshot
wounds in clinically stable patients. Laparoscopy can be used to
determine if a stab or gunshot wound has penetrated the
abdominal wall and abdominal organs have been injured.
Note: Laparoscopy is not indicated in clinically unstable trauma
patients.
Prevention of Errors in Endoscopic
Surgery
In addition to their benefits, new types of surgical interventions
can entail aspects that may result in previously unknown negative consequences. These aspects can be associated with the
learning curve or can be inherent to the new technique itself.
The greatest danger exists if serious complications are rare, but
absolutely unavoidable. Whenever this occurs, the fundamental
effectiveness of that procedure is severely limited. On the other
hand, the effectiveness of a method is increased when error
analysis and progress along the learning curve can successfully
eliminate disasters.
Errors Involving the
Pneumoperitoneum
CO
2
Endoscopic abdominal surgery currently requires establishing a
CO
pneumoperitoneum. This raises the practical question of
2
whether the carbon dioxide gas or the increased pressure in the
abdominal cavity is responsible for negative events and
whether certain situations exist in which the gas and the in-
creased intraabdominal pressure may be responsible for undesired effects. The important question is, how can these events
be avoided?
Laparoscopy in the Presence
of Peritonitis
The use of laparoscopy in the presence of peritonitis is currently
under consideration and clinical investigation; a conclusion has
not been reached yet.
Solutions to specific problems have been established. For instance peritonitis in the presence of a stomach perforation does
not represent a problem for laparoscopy. However, this peritonitis is a “chemical” inflammation.
Localized peritonitis due to a perforated or necrotic gall bladder
does not affect outcome. Endoscopic cholecystectomy in the
presence of acute cholecystitis is acceptable, and the patient enjoys a postoperative course comparable to laparoscopic
cholecystectomy for chronic disease, if the procedure is technically complete and safely performed.
Similarly, in acute appendicitis with localized peritonitis, outcome is comparable to the open operation, if the laparoscopic
procedure is technically feasible and thorough.
Four-quadrant, generalized peritonitis following perforation of
the colon presents a problem of greater magnitude. Rare studies
presently available are somewhat contradictory: The
pneumoperitoneum and increased intraabdominal pressure do
produce further local dissemination and abscess locations, but
do not cause translocation. However if the situation allows the
same measures as in an open operation, e. g., aspiration of pus,
evacuation of fibrous debris, adequate drainage, and controlled
diversion of the fecal stream, then laparoscopic procedures are
equally effective.
Veress Needle
abcd
Fig. 14.1.1 a−d Error analysis. Entering into the abdominal cavity after making a small circumscribed incision in the abdominal wall. See open laparo-
scopic trocar placement. d Mostly solved (prevented) by using endoscopic, threaded, visualizing port.
439
Laparoscopy in the Presence of Reduced
Abdominal Perfusion
Patients with reduced perfusion of the intestine as for example
in abdominal angina have been reported to suffer total ischemia
of the organs supplied by the inferior mesenteric artery during
laparoscopy with a CO
Note: Be aware of the problem. Carefully review the patient’s
past medical history, and accomplish whatever is indicated via
laparotomy.
pneumoperitoneum.
2
Videoendoscopic Surgery: A Matter
of Acquired Skills and Continuous
Experience
Aside from knowledge of these specific risk patterns, the sur-
geon’s individual level of skill and experience is a crucial factor
in avoiding these and other errors. The personal and professional profile as well as institutional motivation include
qualifications such as individual and collective overall clinical
and operative experience, expertise in “open and closed” pro-
cedures, competent and clearly oriented team approach, strong
technological support, a scholarly and inquisitive mind to find
and interpret new developments, common sense and humility
in converting to traditional procedures, economic considera-
tions, knowledge of alternate procedures in other specialty
fields, and above all a total devotion to high-quality and ethical
patient care.
Prevention of Errors in
Specific Laparoscopic Situations
Veress Needle
Establishing a CO2pneumoperitoneum can be one of the most
dangerous phases of laparoscopy.
The Veress needle can penetrate the small bowel and vascular
structures; due to the fine tip of the needle, the surgeon may not
notice the damage immediately. The perforation can even be
completely overlooked and only become clinically significant
on the second or third day after operation with the development of peritonitis or hematoma. Hollow viscera, such as the
two sides with the surgeon locating and treating only the anterior perforation without verifying the integrity of the posterior
wall.
Precautions and prevention:
1. Open trocar placement (Fig. 14.1.1): Incise the skin
(Fig. 14.1.1−a), divide the individual layers of the abdominal
wall by spreading and cutting with scissors (Fig. 14.1.1−b),
make a small incision in the peritoneum and enlarge it with
the index finger (Fig. 14.1.1−c), and enter the abdomen with a
blunt trocar (Fig. 14.1.1−d). Secure the trocar with stay sutures or commercially available retaining mechanisms.
2. Insert the Veress needle in the left upper quadrant as in per-
cutaneous endoscopically assisted gastrostomy (Fig. 14.1.2−
a, b).
3. Be sure to perform the safety tests.
4. Provided the surgeon bears in mind the possible complica-
tions associated with the Veress nee dle and performs the appropriate safety tests, using the needle itself does not represent an error.
440
14.1 Analysis and Prevention of Untoward Events in Laparoscopic Surgery
Fig. 14.1.2a, b
a Double perforation of small bowel. Prevention of this disaster: The
Veress needle is especially dangerous if the insertion is in the wrong
place (close to the navel or insertion of the Veress needle by adhesions). Because of adhesions even a double perforation is possible.
First Trocar
Inserting the first trocar can represent an even greater risk . The
detailed error analysis to follow in this chapter, shows how to
avoid the serious consequences of damage to vascular structures, possibly requiring amputation of the leg or creating a dysfunctional limb as shown in Figure 14.1.3.
Prevention of Abdominal Wall
Hematomas
(Fig. 14.1.4).
A hematoma in the abdominal wall is a problem that should not
be underestimated. It can result from an injury to the epigastric
vessels in the rectus abdominis muscle by sharp trocars.
This complication can be avoided by:
− Avoiding the use of a sharp trocar.
− Inserting the trocar lateral to the rectus sheath where
possible.
− Being aware of the risk (This helps in itself.)
− Using error analysis.
b Insert the Veress needle close to the left upper quadrant as in percu-
taneous endoscopically assisted gastrostomy, use endoscopic,
threaded visualizing port or open procedure.
Prevention of Bile Duct Injuries
as an example—in detail
(Fig. 14.1.5).
With the advent of laparoscopic surgery, the potential for injury
to the extrahepatic bile ducts has become a reality. We are not
able to quote a true incidence with certainty for a number of
reasons: lack of randomized studies, relative inexperience with
a new technique as compared to the tried and proven traditional operation, and lack of prospective randomized data for
the open operation to compare to.
Analyzing the results and data of the last five years gives the impression that injury to the bile ducts occurs comparatively more
frequently; the incidence is probably about 1%. Roy, a Canadian,
has observed that the type of injury is more severe: First, the injury to the bile duct is closer to the liver hilus. Secondly, in laparoscopic surgery entire segments of the common bile duct
may be removed.
To prevent this rare yet extremely serious complication involves
at least 11 individual steps:
1. Awareness of the problem is the first step for prevention.
2. Wide visual exposure of the right upper quadrant, especially of the gallbladder is required.
3. The triangle of Calot must be clearly demonstrated by appropriate patient positioning and judicious use of all instrument aided maneuvers to bring the various structures into
view (Fig. 14.1.6, 1, applying downward and lateral traction;
2a, elevating the liver near the gallbladder bed).
Prevention of Bile Duct Injuries
441
a
c
Fig. 14.1.3 a−c Error analysis with respect to vascular injury from trocar placement during laparoscopic appendectomy.
Table 14.1.2
Clinical presentation What happened? Why did it happen? How can the error be prevented in the
Six-year-old boy
Normal development
Acute right lower quadrant “syndrome”
Localized pain and
tenderness
Temperature 38 °C
White blood count
10,000
First operative step:
Attempted laparoscopic
appendectomy, visualization not possible
Conversion:
Open appendectomy,
findings of retroperitoneal hematoma, and
injury to the anterior
aspect of the right
common iliac artery.
1. Massive bleeding,
retroperitoneal hematoma.
2. Injury to the right
common iliac artery.
3. Stenosis of the right
common iliac artery.
4. Repeated thrombosis
of injury site.
5. Ischemia of right
lower extremity.
6. Irreversible damage
to the intima.
7. Compartment syndrome of thigh and
leg.
8. Muscle necrosis in
the leg.
9. Extensive loss of sensitivity and motor
function (dysfunctional limb).
10. Amputation recommended.
1. Little or no awareness of the problem
2. Inadequate training.
3. Improper patient positioning: kyphosis instead of lordosis.
4. Improper, inadequate operative
technique.
5. Failure to maintain adequate distance: The abdominal wall was
pushed in a thin individual against
the bony pelvis.
6. A strong, muscular abdominal wall
increases the risk of advancing the
trocar suddenly too far as the
greater resistance is overcome by
excessive force.
I. Vascular injury:
− Lack of awareness of the risk of
damaging the posterior vessel
wall.
− Lack of awareness of the risk of
an intimal flap.
II. Failure to notice a period of
ischemia exceeding 4.5 hours.
III. Inadequate therapy of the compart-
ment syndrome.
IV. Delayed fasciotomy, especially in
patients with healthy vascular structures.
b
future?
1. Awareness of the problem.
2. Effective teaching and training:
Theory: reference to rare but catastrophic
possible errors.
Technique: learn appendectomy in addition
to cholecystectomy.
Realistic training.
3. Do not use a sharp trocar; insert a blunt trocar or an endoscopic threaded port.
4. Do not use blind insertion technique; use
open technique.
5. Even where exposure is good, insert the
blunt trocar using open or semi-open technique.
6. Adequate vascular surgery, knowledge and
understanding of vascular injuries and their
consequences (avoid an intimal flap, see
Fig. 14.1.3a, thoroughly inspect the poste-
rior wall, treat and apply prophylaxis to
avoid compartment syndrome, early fasciotomy in patients with healthy vascular
structures, and use heparin).
7. Precisely planned, structured training programs under the responsible control of the
scientific community and professional organizations, not industry.
442
14.1 Analysis and Prevention of Untoward Events in Laparoscopic Surgery
Fig. 14.1.4a, b Error analysis. Prevention of hematomas in the abdominal wall. a Incorrect trocar position. b Correct trocar position, avoiding the epi-
gastric vessels.
dabc
Fig. 14.1.5 a−d Error analysis. Prevention of injuries to the bile ducts.
4. Dissection always begins on the gallbladder neck at Hartmann’s pouch by the surgeon pushing the areolar tissue
toward the hepatoduodenal ligament (Fig.14.1.6, 2b, line
delineating the dissection on the gallbladder; 3 and 4, dissection of the gallbladder neck toward the hepatoduodenal
ligament).
5. It is helpful to begin the dissection along the inferior
aspect of the gallbladder neck and cystic duct; never on
the anterior side of the triangle of Calot, since one could
easily end up on the left side of the common bile duct
(Fig. 14.1.6, 3).
6. Careful anatomic exposure of the individual structures follows. This requires patient, progressive tissue separation. A
segment of the cystic duct of appropriate length, the
branches of the cystic artery, or the cystic artery itself
should be exposed. The greatest care is required at the junction of the cystic duct with the common hepatic duct; do
not force the dissection here. Never use a hooked-electrode
and electrocautery to coagulate at the junction of the common hepatic and the cystic ducts (Fig. 14.1.6, 5).
7. The cystic duct and artery should be ligated individually.
From the start, we have used an absorbable clip for the cystic duct and either a metal or absorbable clip for the
branches of the cystic artery.
8. If bleeding occurs, never attempt to place a clip blindly. To
solve the problem, apply suction carefully, clamp the source
of bleeding with a hemostat, and precisely locate the source
of bleeding.
9. Only monopolar electrocautery may be used in the dissection. It is best to avoid the use of electrocautery altogether.
10. The routine practice of intraoperative cholangiograms does
not prevent injury to the bile ducts. Intraoperative cholangiograms require initial exposure of the cystic duct. These studies must be performed to technical perfection, i. e., the
proper contrast medium must be used, the patient must be
positioned appropriately, two films are taken at 90 degrees
to each other, and the images must be carefully interpreted.
The incidence of false positives under these conditions is
more than 20%. Therefore, radiographic studies are only
helpful in individual cases in which the surgeon is convinced that they will provide anatomic information or reveal an injury.
11. In case of doubt, conversion to an open procedure is indicated.
Prevention of Trocar Site Hernias
(Fig. 14.1.7).
Hernias at trocar site incisions requiring repeated corrective
surgery can lead to lethal complications: “The details kill the
patient.” This complication can be avoided by:
Prevention of Trocar Site Hernias
2a
2b
1
3
5
4
443
− Awareness of these risks.
− Use of Semm’s Z technique (with problems of its own;
Fig. 14.1.7b, 1, 2, and 3).
− Careful closure of the trocar incisions with interrupted sutures using various suture techniques.
− Use endoscopic threaded visualizing port.
10 mm
2
b
Fig. 14.1.6 Error analysis. Steps to avoid serious biliary complications.
1−5 See text.
1
3
a
Fig. 14.1.7 a−d Error analysis. Prevention of hernias.
1−3 See text.
c
d
444
14.2 Pneumoperitoneum-Associated Alterations and Risk Factors in Laparoscopic Surgery
Prevention of the Most Important Complications in Endoscopic Appendectomy
Serious complications that have been reported in endoscopic
appendectomy include:
1. Injuries to vascular structures when inserting the trocars
into the lower abdomen (see Fig. 14.1.3).
2. Thermal necrosis of intestinal segments resulting from the
use of monopolar electrocautery.
3. Complications involving the stump of the appendix.
Avoidance of the first complication is shown in error analysis
(see Fig. 13.2.8).
Injury from electrocautery can be avoided by dispensing with
monopolar electrocautery entirely.
Complications involving the stump of the appendix are best
avoided by taking the following steps:
4. Placing two Roeder knots about 2−4 mm apart on a stump
without pathological findings. Never close the stump with a
clip.
5. Burying the stump of the appendix in the conventional manner with a pursestring or Z suture. Note that this is done endoscopically.
6. In case of doubt, convert to an open procedure to treat the
whole of the cecum.
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Safran DB, Orlando R. Physiologic effects of pneumoperitoneum. Amer. J.
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pneumoperi-
2
14.2 Pneumoperitoneum-Associated Alterations and Risk Factors
in Laparoscopic Surgery
C. Bloechle, T. Strate, C. Busch, J. R. Izbicki
Effect of Pneumoperitoneum
on the Cardiovascular and
Pulmonary System
A pneumoperitoneum is required in laparoscopic surgery in
order to provide adequate surgical exposure and allow operative manipulation within the abdominal cavity. The most common mode of establishing a pneumoperitoneum to expand the
abdominal cavity is insufflation of carbon dioxide (CO
sufflation, however, may affect acid-base balance, cardiovascu-
lar and pulmonary physiology, and may lead to further deterioration of existing intraperitoneal inflammation or sepsis.
). CO2-in-
2
The cardiovascular effects of a CO
divided into pressure related phenomena and direct systemic
CO
effects.
2
Pressure Related Phenomena
The increased abdominal pressure has an effect similar to positive end-expiratory pressure (PEEP) on hemodynamic variables
(Buchard et al. 1989). Thus, in animal studies a decrease in cardiac output (CO) of 18% to 66% of baseline values with a concomittant increase of the central venous pressure (CVP) and the
peripheral systemic vascular resistance (SVR) was observed
after implementation of a pneumoperitoneum (Berg et al. 1995,
pneumoperitoneum can be
2
Direct Systemic CO2Effect
445
Ivankovich et al. 1975, Kashtan et al. 1981). In most studies with
healthy individuals, the effects of pneumoperitoneum on car-
diac output, systemic vascular resistance, central venous pres-
sure, and mean arterial pressure (MAP), a similar trend is found,
albeit not as severe in absolute figures (Cunningham and Brull
1993, Gehring et al. 1994, Wurst and Finsterer 1990). Different
results were reported by Kelman et al. (1972) who found a slight
increase in cardiac output after establishing a pneumoperi-
toneum, while Marshall and coworkers (1972) did not find significant dif ferences in cardiac output in a series of anesthetised
spontaneously ventilated patients. Also Motew et al. (1973) did
not report on significant changes in cardiac output, while mean
arterial pressure, systemic vascular resistance, and central
venous pressure were elevated. Only after elevation of the in-
traabdominal pressure from 20 to 30 mm Hg did central venous
pressure descrease somewhat, but still remained elevated compared to baseline levels. These contradictory results can prob-
ably be explained by different clinical or experimental proto-
cols.
In high-risk cardiac patients, the effect of CO
pneumoperi-
2
toneum is more pronounced as compared to healthy individuals
(Fox et al. 1993, Stuttmann et al. 1994). Safran et al. (1993)
showed a decrease in heart rate (HR) and cardiac output
without the compensatory mechanism of an elevated systemic
venous resistance. They suggested that mixed venous oxygen
saturation is the most sensitive parameter in monitoring car-
diovascular function.
Pressure-related effects of a pneumoperitoneum include a
decreased blood flow through the inferior vena cava. This in
turn leads to a reduce f illing volume and pressure in the right
and left atrium with consequent decreases in preload. According to the Frank-Starling law this effect can be compensated up
to a point after which the cardiac output falls. Increases in cen-
tral venous pressure due to higher intrathoracic pressure during
mechanical ventilation and additional pneumoperitoneum
falsely suggest a sufficient volume status. Therefore, a decrease
in cardiac output is the sequel of a decreased preload, which is
compensated by an increase in afterload from a rise in systemic
venous resistance. The net effect is a stable or slightly decreased
cardiac output and mean arterial pressure under normal condi-
tions, i.e., adequate cardiac reserve and sufficient volume status.
There is evidence that increasing intraabdominal pressure
decreases splanchnic blood flow, which adversely affects mu-
cosal microcirculation. Knolmayr and coworkers (1998) found a
significant correlation between increasing intraabdominal
pressure and decreasing gastric mucosal pH measured by
tonometry during CO
pneumoperitoneum in a porcine model.
2
These results were interpreted as a significant end-organ impairment, while at the same time significant differences in macrocirculatory parameters such as heart rate, cardiac output, pulmonary capillary wedge pressure (PCWP), and central venous
pressure were not observed.
Direct Systemic CO2Effect
Using a porcine model, Ho and associates (1992) measured an
increase in CO
suggesting that transperitoneal absorption of CO
cause of hypercapnia when a CO
lished.
Hypercapnia has several effects on the cardiovascular system
(Fig. 14.2.1). Mild hypercapnia may lead to an increase in sys-
temic venous resistance thus increasing cardiac output and
production without increase in O2consumption
2
pneumoperitoneum is estab-
2
is the main
2
CO2 Pneumoperitoneum
Gas
Absorption of CO
Hypercapnia
Dissolved CO
Acidosis
Arrhythmias
Mild
Acidemia
Sympathetic
Stimulation
Increased
MAP, HR, SVR
Fig. 14.2.1 Synopsis of CO2pneumoperitoneum related effects on cardiovascular function.
2
2
Acidemia
Negative inotropic
Depressed left
ventricular function
Position
Severe
effect
Pressure
Mechanical effect of
increased IP
Compression of
venous structures
Decreased venous
return
(Preload)
Cardiac output
mean arterial pressure, while extensive hypercapnia causes depression of cardiac function (Marshall et al. 1972, Rasmussen et
al. 1978, van den Bos et al. 1979). Furthermore, it has been
shown to induce cardiac arrhythmias (Scott and Julian 1972).
After establishing a CO
pneumoperitoneum, the systemic CO
2
concentration rises due to the partial pressure difference between the intraperitoneal CO
of approximately 670 mm Hg, leading to diffusion of CO
and the capillary blood pressure
2
2
into
the blood. The resulting hypercapnia augments the respiratory
frequency and tidal volume in order to excrete the additional
CO
. These compensatory mechanisms warrant an intact buffer-
2
ing system. In sick patients, however, additional CO
might
2
overwhelm this system and augment preexisting acidosis (e. g.,
in septic patients). Thus, a CO
pneumoperitoneum in severe
2
abdominal sepsis may be detrimental and should therefore be
avoided (Bloechle et al. 1998, Bloechle et al. 1995). This aspect
may have significant implications considering reports on laparoscopic repair of hollow viscus perforations (Abri et al. 1993,
Fletcher and Jones 1992, Kavic 1993, Mouret et al. 1990, Nathanson et al. 1990, Sigman et al. 1992, Tate et al. 1993).
There are somewhat contradictory reports on changes in pO
during laparoscopy. Effects of the pneumoperitoneum vary
from decrease, to no change to an increase in pO
. These discre-
2
pancies may be explained by the Trendelenburg position of the
patient and different modes of ventilation between groups of
patients. While patients who are breathing spontaneously show
a lower pO
, patients on the respirator have an elevated pO
2
2
2
2
446
14.2 Pneumoperitoneum-Associated Alterations and Risk Factors in Laparoscopic Surgery
Table 14.2.1 CO2pneumoperitoneum related changes in pulmonary
function.*
Pulmonary function Change
Peak inspiratory pressure (PIP) up
Pulmonary compliance (dV/dT) down
Vital capacity (VC) down
Functional residual capacity (FRC) down
Intrathoracic pressure (ITP) up
* Adapted from DB Safran and R Orlando. Am. J. Surg. 1994; 167:281−288
probably due to a higher FiO2(Axon et al. 1984, Sarr et al. 1981,
Watanapa and Williamson 1992). The changes in pulmonary
function occuring during a CO
marized in Table 14.2.1.
In comparison to an open operation, postoperative pulmonary
function seems to be better after laparoscopy. Frazee and coworkers (1991) reported a better pulmonary function postoperatively in patients undergoing laparoscopic cholecystectomy as compared to patients undergoing open surgery.
When compared with baseline values postoperative forced vital
capacity (FVC) was 52%, forced expiratory volume in one second
(FEV 1) 53% and forced expiratory flow (FEF) 53% in the open
group. In the laparoscopic group values were 73%, 72%, and 81%,
respectively.
pneumoperitoneum are sum-
2
Pneumoperitoneum and Abdominal
Sepsis
Following the rapid acceptance of elective laparoscopic
cholecystectomy, additional applications for minimal invasive
surgery have been sought. Among these, laparoscopic closure of
peptic ulcer perforation has been added to our operative armamentarium (Fletcher and Jones 1992, Mouret et al. 1990,
Nathanson et al. 1990, Sigman et al. 1992, Tate et al. 1993).
However, in conditions related to peritonitis recent experimental evidence has drawn attention to a theoretical risk concerning the CO
et al. 1995 a, Bloechle et al. 1995b, Evasovich et al. 1996, Gurtner
et al. 1995).
Laparoscopic surgical techniques require the distension and
elevation of the abdominal wall from the viscera to allow visualization and manipulation. In the clinical situation this is generally realized by intraperitoneal gas insufflation and maintenance of a continuous positive intraabdominal pressure of approximately 8 to 12 mm Hg. As observed in an experimental
study, distension of the abdominal wall imposed by a
pneumoperitoneum results in temporary stretching of the
parietal mesothelial cells with concomittant flat bending of microvilli. Normal conformation of the mesothelium returns
within two hours after release of the pneumoperitoneum
(Bloechle et al. 1999). This finding corresponds well with the
clinical experience that a pneumoperitoneum during an elective laparoscopic cholecystectomy, for example, is not harmful.
An increased intraabdominal pressure due to the use of carbon
dioxide insufflation apparently leads to the same ultrastructural
changes observed after saline injection (Tsilibary and Wissig
1983). Thus, it may be concluded that it is the increased intraabdominal pressure rather than a specific agent or gas that
causes the described changes.
pneumoperitoneum (Bloechle et al. 1998, Bloechle
2
The parietal peritoneum physiologically functions as a barrier
with controlled pathways to remove fluids, particles, and cells
from the peritoneal cavity. The abdominal secretions are
drained by large terminal lymphatics which are located beneath
the mesothelium of the peritoneal surface of the diaphragm.
The absorbed fluid is then transported to the venous system by
the thoracic duct. Increased intraabdominal pressure has been
shown to increase the resorption rate of intraperitoneal secretions (Leak and Rahil 1978, Tsilibary and Wissig 1983, Tsilibary
and Wissig 1987).
Furthermore, inflammatory stimuli are known to cause marked
changes of the ultrastructural integrity of the mesothelial cell
layer. Shrinking of mesothelial cells leads to disintegration and
opening of the latticed intercellular network (Lierse 1985, Tsilibary and Wissig 1983). The combination of increased intraabdominal pressure due to the CO
gastric perforation with secondary inflammation results in premature deterioration of mesothelial integrity. The process of destruction includes numerical reduction as well as shrinking and
coarsening of otherwise abundantly present microvilli. Furthermore, mesothelial cellular continuity is interrupted allowing
the formation of stomata to the submesothelial cell layer. These
changes to the ultrastructural anatomy of the mesothelial cell
layer impair the barrier function of the parietal peritoneum
giving way to uncontrolled resorption of abdominal secretions,
which may induce bacteremia, endotoxemia, and ultimately
septic shock (Bloechle et al. 1998, Bloechle et al. 1999, Schein et
al. 1996). Based on these observations, the experimental evidence demonstrating an aggravation of peritonitis and sepsis in
conditions related to severe, long-lasting peritonitis is substantiated (Bloechle et al. 1998, Bloechle et al. 1995a, Evasovich et al.
1996). In contrast, another experimental setting in which the
interval between bacterial inoculation and onset of
pneumoperitoneum lasted only 60 minutes (Bloechle et al.
1995b, Gurtner et al. 1995), did not reveal any adverse effects.
However, aggravation of peritonitis and the subsequent
development of bacteremia and sepsis was demonstrated in
other animal studies focussing on the effect of a pneumoperitoneum during severe peritonitis (Bloechle et al. 1998, Bloechle
et al. 1995a, Evasovich et al. 1996).
Lately, Jacobi and associates (1998) have presented their results
on the effect of laparoscopy compared to laparotomy in a rat
model of peritonitis induced by a standardized fecal inoculum.
Recovery was observed to be better and increase of TNF-alpha
plasma levels was determined to be lower in the laparoscopy
group. However, the time lag between bacterial inoculum and
measurement of significant TNF-alpha plasma level differences
was only one hour, with no differences of TNF-alpha plasma
concentrations at days 2 and 7. Furthermore, none of the animals of any group died during the follow-up period of seven
days implying that the severity of peritonitis was limited.
However, most recently, Greif and Forse (1998) have reported
that, in contrast to laparotomy, laparoscopy resulted in significant hemodynamic compromises related to septic shock when
pigs were conditioned with endotoxin.
Technical feasibility has been advanced as an argument to
justify the clinical performance of laparoscopic procedures
without previous experimental studies to rule out potential
risks. In conditions related to abdominal infection, the clinical
experience has so far been limited to a number of case reports
and small studies on laparoscopic repair of peptic ulcer perforation or iatrogenic colon perforations combined with lavage of
the associated peritonitis (Eypasch et al. 1994, Fletcher and
Jones 1992, Matsuda 1995, Mouret et al. 1990, Nathanson et al.
pneumoperitoneum and of a
2
Bibliography
447
1990, Regan et al. 1994, Sigman et al. 1992, Tate et al. 1993). In
one of these reports comparing open versus laparoscopic repair
of peptic ulcer perforation in a non-randomized study, 2 out of
14 patients exposed to a pneumoperitoneum died subsequently
from peritonitis and septic complications. The time interval be-
tween peptic ulcer perforation and laparoscopic repair had not
been recorded in that study; thus the correlation between time
lag until surgical intervention and mortality due to sepsis could
not be estimated established (Eypasch et al. 1994).
Postoperative Recovery
Most recently, one prospective randomized study addressing
the outcome of laparoscopic versus open repair of peptic ulcer
perforation revealed that there was no significant difference be-
tween the laparoscopic and open groups in terms of patient
assessed visual analogue scale for pain during the first 24 hours
postoperatively. The duration of nasogastric aspiration, in-
travenous drips, hospital stay, and time to resume normal diet,
as well as the time interval until return to normal activity and
work were not significantly different between the groups. The
only difference reported to be significant was the lower need for
analgesics during the postoperative period in the laparoscopic
group. This, however, is highly questionable if one takes into ac-
count that pain intensity according to the visual analogue scale
did not differ between the groups, and that the study was in fact
not blinded for the nursing staff supplying pain medication (Lau
et al. 1996).
In a prospective multicenter trial on laparoscopic repair of pep-
tic ulcer perforation, which included a series of 100 consecutive
patients, morbidity and mortality were 9% and 5%, respectively
(Druart et al. 1997). Despite this comparable low rate of compli-
cations and casualties the authors conclude from the results of
their study that especially older patients with significant comorbidity and patients with generalized peritonitis should bet-
ter be served by conventional open operation.
Based on the currently available experimental and clinical evi-
dence a considerable risk for a pneumoperitoneum to aggravate
peritonitis and to generate septic complications may be anticipated in conditions related to severe abdominal sepsis. Time,
the potential benefit of laparoscopic repair of peptic ulcer perforation, for example, is not comparable to the advantages of
minimally invasive operations that can be performed electively,
e. g., cholecystectomy. Critical appraisal of laparoscopic surgery
is warranted in conditions associated with severe, long-standing peritonitis.
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