Chapter 9

Laparoscopy plays a prominent role in urology. Current residents finish their training with considerable exposure to the techniques, and a plethora of courses educate physicians already in practice. Alternatives to standard laparoscopy, including hand assistance and robotic assistance, further enhance capabilities.

Laparoscopy with pneumoperitoneum exposes the patient to physiologic challenges that differ from that of open surgery, but can be met successfully with proper preparation and awareness (Ost et al, 2005).

### Physiology: Cardiovascular

As intra-abdominal pressure increases with pneumoperitoneum, the systemic vascular resistance increases and venous return decreases. A small increase in intra-abdominal pressure augments venous return and cardiac output. As intra-abdominal pressure rises, the increase in resistance exceeds the increase in pressure, and venous return and cardiac output fall (Figure 9–1). This transition point occurs at a lower intra-abdominal pressure in the hypovolemic compared with the normovolemic state. Given normovolemia, an intra-abdominal pressure of 15 mm Hg is associated with tolerable reduction of cardiac output.

###### Figure 9–1.

Reduction of venous return and cardiac output during laparoscopy. (Borrowed with permission from Wolf JS Jr, Stoller ML: The physiology of laparoscopy: Basic principles, complications, and other considerations. J Urol 1994; Aug;152(2 Pt 1):294-302.)

The absorption of insufflated carbon dioxide (CO2) has direct cardio-inhibitory effects, but CO2 also stimulates the sympathetic nervous system. If acidosis develops then there are parasympathetic effects as well. Moderate hypercapnia (excess CO2 in blood) produces an increase in cardiac output and blood pressure and a decrease in systemic vascular resistance, which counteract the effect of intra-abdominal pressure.

Overall, an intra-abdominal pressure of 15 mm Hg and moderate hypercapnia in healthy patients produce a hyperdynamic state (increased central venous pressure, systemic vascular resistance, heart rate, and blood pressure) without significant alteration of cardiac output (Junghans et al, 2005).

### Physiological Complications: Cardiovascular

The cardiovascular complications of laparoscopy include tension pneumoperitoneum, cardiac dysrhythmias, fluid overload, and venous thrombosis.

When the intra-abdominal pressure is excessive, usually >40 mm Hg, the overwhelming increase of vascular resistance can produce “tension pneumoperitoneum.” Venous return, cardiac output, and blood pressure drop precipitously. Volume status must be optimized to prevent tension pneumoperitoneum at lower pressures. In general, the intra-abdominal pressure should be kept below 15–20 mm Hg. The response to “tension pneumoperitoneum” should be immediate desufflation.

Tachycardia and ventricular extrasystoles due to hypercapnia are usually benign, but fatal dysrhythmias can occur with very high arterial partial pressure of CO2 (PaCO2). Vagal stimulation by peritoneal distention can produce bradydysrhythmias (Valentin et al, 2004).

Because insensible fluid losses and urine output are less during laparoscopy than during open surgery, after optimizing volume status before insufflation intraoperative fluid administration should be limited to ...

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