Cardiovascular Collapse Tension Pneumoperitoneum

Tension pneumoperitoneum is the precipitous reduction of venous return, cardiac output, and blood pressure due to increased intra-abdominal pressure from gas insufflation (115).

Fatalities have been reported (116). As intra-abdominal pressure becomes excessive, e.g., greater than 40 mmHg, vascular resistance increases and overwhelms the increase in venous pressure driving venous return. The effect of elevated intra-abdom-inal pressure is potentiated by hypovolemia (21,22); therefore, volume status must be optimized before laparoscopy. Parra et al. (117) reported the development of tension pneumoperitoneum caused by a malfunctioning insufflator allowing the intra-abdominal pressure to exceed 32 mmHg. Although the procedure was completed after returning to an appropriate level of pneumoperitoneum and administrating atropine, the patient exhibited hypotension and bradycardia, and suffered a cerebrovascular accident thought to be due to the intraoperative event.

Whenever hemodynamic compromise due to excessive intra-abdominal pressure is suspected, immediate desufflation will quickly improve the situation, and the surgeon may be able to complete the procedure using a lower intra-abdomi-nal pressure (115).

Although brief periods of intra-abdominal pressures of 20 mmHg and above during laparoscopy are well tolerated in healthy patients and are used by many surgeons at the outset of a procedure to make primary port insertion safer and easier, the pressure should be kept at 15 mmHg or less for the majority of the duration of the procedure. Occasionally, even typically acceptable pressures (15 mmHg) can be associated with hemodynamic deterioration (118). A reasonable precaution against hemodynamic compromise is to operate at the minimal intra-abdominal pressure that provides adequate exposure (87).

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