• Laparoscopy describes minimally invasive surgical procedures within the chest, abdomen, pelvis, /or neck. Carbon dioxide (CO₂) insufflation exps cavities (e.g., pneumoperitoneum [PPN]) to facilitate surgical visualization intervention. Visualization of joints (arthroscopy) the bladder (cystoscopy) can be performed with fluid insufflation.
• Patient position varies depending on surgery. Common positions include lateral decubitus (nephrectomy), supine (appendectomy), Trendelenburg (prostatectomy), /or reverse Trendelenburg (gastric bypass).
• Generally requires 2–5 incisions for the insertion of multiple ports/trocars; however, some procedures may be performed through a single incision (e.g., appendectomy).
• Surgical time varies depending on the patient's prior surgical history the specific procedure being performed; simple procedures such as cholecystectomy appendectomy are generally 1 hour.
• Greater than 2 million laparoscopic procedures are performed annually.

• Insufflation is generally accomplished using a gas, although liquid is used for a small subset of procedures (arthroscopy, cystoscopy).
  • CO₂ is the most commonly used gas for insufflation because it is colorless (enhances visualization), inexpensive, non-combustible, highly soluble in blood (decreases risk of a venous air embolism).
  • Nitrous oxide oxygen are combustible are associated with an increased risk of OR fires.
  • Air helium have decreased blood solubility are more likely to cause gas emboli.
• Physiologic effect of a pneumoperitoneum:
  • Cardiac: Decreased preload, increased afterload (secondary to norepinephrine), decreased cardiac output. Initiation of PPN may be associated with a vagal response /or asystole; atropine or glycopyrrolate should be immediately available.
  • Respiratory: Decreased functional residual capacity (FRC), decreased lung compliance, decreased PaO₂, increased peak inspiratory pressures caused by insufflation-induced cephalad migration of the diaphragm abdominal contents
• Trendelenburg or reverse Trendelenburg position is used to improve visualization by using gravity to displace the bowel other organs from the surgical site.
• Physiologic effects of Trendelenburg position:
  • Cardiac: Increased venous return cardiac output. Mitigates some of the adverse cardiac effects of a PPN.
  • Respiratory: Decreased FRC, lung compliance, PaO₂, increased peak inspiratory pressures caused by gravity-induced cephalad displacement of diaphragm abdominal contents
• Physiologic effects of reverse Trendelenburg position:
  • Cardiac: Decreased venous return (caused by venous pooling in lower extremities) decreased cardiac output
  • Respiratory: Increased FRC pulmonary compliance, decreased peak inspiratory pressures by facilitating caudal displacement of diaphragm abdominal contents. Mitigates some of the adverse respiratory effects of a PPN.

• Mortality related to laparoscopy is rare, estimated at 1 in 10,000.
• Morbidity associated with laparoscopic procedures usually involves complications related to formation of PPN, physiologic effects of hypercarbia, /or trocar placement (inadvertent insufflation of a cavity or space other than peritoneum occurs in 2% of laparoscopic surgeries).
• Vagal reflex or asystole with institution of the pneumoperitoneum
• CO₂ venous embolus: Insertion of a Veress needle or trocar directly into a blood vessel may lead to a CO₂ embolus (associated with a 28% mortality). Manifestations range from subclinical to hypoxemia, profound hypotension, dysrhythmias, even cardiac arrest.
• Referred shoulder pain from diaphragmatic irritation (C3–5 innervation)
• Hypercarbia: CO₂ insufflation can lead to hypercarbia if minute ventilation does not increase proportionately. The ensuing respiratory acidosis can lead to:
  • Cardiac contractility
  • Arrhythmias
  • Pulmonary vasoconstriction
  • Hyperkalemia
  • Increased intracranial pressures
• Perforation: Placement of Veress needle or trocars can lead to inadvertent organ or blood vessel perforation.
  • Vascular injury is the most lethal complication (up to 15% mortality); insertion of a Veress needle or trocar into a major blood vessel can cause life-threatening bleeding is an indication for conversion to an open procedure.
• Pneumothorax/pneumomediastinum:
  • Risk factors include insufflation pressures >15 mm Hg, surgery duration >200 minutes, congenital or acquired defects in the diaphragm or pleura.
  • Signs include hypercarbia, increased airway pressure, hemodynamic instability (tension pneumothorax).
  • Treatment involves release of the PPN; placement of a chest tube may be necessary in the event of hemodynamic instability.
• Subcutaneous emphysema
  • Risk factors include malposition of Veress needle in subcutaneous tissue, insufflation pressures >15 mm Hg, /or surgery duration >200 minutes.
  • Manifestations include crepitus, increased EtCO₂, respiratory acidosis.

• Advantages of laparoscopy:
  • Improved cosmesis
  • Shorter recovery time
  • Decreased pain
  • Decreased blood loss
  • Decreased pulmonary complications
  • Lower incidence of wound infections
  • Faster recovery of bowel function
  • Minimizes stress, inflammatory, metabolic response
• Relative contraindications to laparoscopy:
  • Intracranial hypertension
  • Hypovolemia
  • Severe cardiac disease (coronary, valvular, cardiomyopathy)
  • Severe pulmonary disease (chronic obstructive pulmonary disease, restrictive diseases)
  • Coagulopathy
• Length of hospital stay varies; simple procedures may be performed as outpatient surgeries.

See Table below

• Cystoscopy
• Appendectomy
• Cholecystectomy
• Video-Assisted Thoracoscopic Surgery (VATS)

Colin Bauer , MD

Judith A. Turner , MD, PhD