The impact of pneumoperitoneum on respirtory system: complications and managment strategies in laparoscopic surgery

Laparoscopic surgery, a cornerstone of contemporary surgical practice, revolutionizes traditional surgical techniques by employing minimally invasive procedures. However, this innovative approach poses intricate challenges, particularly in respiratory management, necessitating a comprehensive understanding of its physiological implications. Pneumoperitoneum involves insufflating the abdominal cavity with carbon dioxide (CO2) to create a suitable working space. The introduction of CO2 into the peritoneal cavity elevates intra-abdominal pressure, prompting physiological adaptations that compromise respiratory function. These alterations, including increased peak inspiratory pressure, decreased dynamic respiratory system compliance, and the promotion of intraoperative atelectasis, underscore the intricate interplay between pneumoperitoneum and respiratory physiology.
Amidst these challenges, positive end-expiratory pressure emerges as a crucial intervention for mitigating the adverse effects of pneumoperitoneum on respiratory mechanics. By maintaining airway patency and preventing alveolar collapse during expiration, positive end-expiratory pressure helps counteract the reduction in functional residual capacity associated with elevated intra-abdominal pressure. Additionally, positive endexpiratory pressure serves to optimize lung recruitment, thereby improving ventilation-perfusion matching and enhancing oxygenation.
Mechanical ventilation during laparoscopic procedures further complicates respiratory management, potentially exacerbating lung injury. The application of protective lung ventilation strategies, such as low tidal volume combined with judicious positive end-expiratory pressure titration, represents a cornerstone in mitigating ventilator-induced lung injury and reducing postoperative pulmonary complications. However, the optimal implementation of these strategies remains a subject of ongoing debate, highlighting the need for personalized approaches tailored to individual patient characteristics and surgical contexts.
Understanding the pivotal role of positive end-expiratory pressure in mitigating the adverse respiratory effects of pneumoperitoneum underscores its importance as a cornerstone intervention in laparoscopic surgery. By optimizing positive end-expiratory pressure levels based on patient characteristics and procedural requirements, healthcare practitioners can effectively mitigate the risk of pulmonary complications and enhance surgical outcomes.

1. Ignatenko O. V. Povrezhdajushhee dejstvie razlichnyh rezhimov iskusstvennoj ventiljacii na funkciju ljogkih u bol'nyh s tjazhjoloj travmoj / O. V. Ignatenko, B. R. Gel'fand, D. N. Procenko // Vestnik anesteziologii i reanimatologii. – 2009. – T. 6, № 4. – S. 16-21.

2. Acute Respiratory Distress Syndrome Network, Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome /R. G. Brower, M. A. Matthay, A. Morris et al. //The New England Journal of Medicine. – 2000. – V. 342 (18). – P. 1301-1308.

3. Andersson L. E. Effect of Carbon Dioxide Pneumoperitoneum on Development of Atelectasis during Anesthesia, Examined by Spiral Computed Tomography /L. E. Andersson, M. Bååth, A. Thörne // Anesthesiology. – 2005. – V. 102 (2). – P. 293-299.

4. Arozullah A. M. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery / A. M. Arozullah, S. F. Khuri //Annals of Internal Medicine. – 2001. – V. 135 (10). – P. 847-857.

5. Arozullah A. M. Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men after Major Noncardiac Surgery. The National Veterans Administration Surgical Quality Improvement Program /A. M. Arozullah, J. Daley //Annals of Surgery. – 2000. – V. 232, № 2. – P. 242-253.

6. Baker A. B. Artificial Respiration, the History of an Idea //Medical History. – 1971. – V. 15, № 4. – P. 336-351.

7. Baki E. D. Evaluation of Low Tidal Volume with Positive End-Expiratory Pressure Application Effects on Arterial Blood Gases during Laparoscopic Surgery /E. D. Baki, S. Kokulu, A. Bal //Journal of the Chinese Medical Association. – 2014. – V. 77, № 7. – P. 374-378.

8. Barbosa F. T. Positive End-Expiratory Pressure (PEEP) during Anaesthesia for Prevention of Mortality and Postoperative Pulmonary Complications /F. T. Barbosa, A. A. Castro, C. F. de Sousa-Rodrigues //Cochrane Database of Systematic Reviews. – 2014. – V. 12 (6). – CD007922.

9. Behazin N. Respiratory Restriction and Elevated Pleural and Esophageal Pressures in Morbid Obesity /N. Behazin, S. B. Jones, R. I Cohen //Journal of Applied Physiology. – 2010. – V. 108, № 1. – P. 212-218.

10. Bender S. Intraoperative Lung-Protective Ventilation Trends and Practice Patterns: A Report from the Multicenter Perioperative Outcomes Group /S. P. Bender, W. C. Paganelli, L. P. Gerety // Anesthesia and Analgesia. – 2015. – V. 121, № 5. – P. 1231-1239.

11. Campos N. S. Intraoperative Positive End-Expiratory Pressure and Postoperative Pulmonary Complications: A Patient-Level Meta-Analysis of Three Randomised Clinical Trials /N. S. Campos, T. Bluth, S. Hemmes //British Journal of Anaesthesia. – 2022. – V. 128, № 6. – P. 1040-1051.

12. Canet J. Prediction of Postoperative Pulmonary Complications in a Population-Based Surgical Cohort /J. Canet, L. Gallart, C. Gomar //Anesthesiology. – 2010. – V. 113, № 6. – P. 1338-1350.

13. Cinnella G. Effects of Recruitment Maneuver and Positive End-Expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery /G. Cinnella, S. Grasso, S. Spadaroio //Perioperative medicine. – 2013. – V. 118 (1). – P. 114-122.

14. Chiumello D. Recruitment Maneuvers in Acute Respiratory Distress Syndrome and during General Anesthesia /D. Chiumello, I. Algieri, S. Grasso //Minerva Anestesiologica. – 2016. – V. 82, № 2. – P. 210-220.

15. Croinin D. O. Bench-to-Bedside Review: Permissive Hypercapnia /D. O. Croinin, N. M. Chonghaile, B. Higgins //Critical Care. – 2005. – V. 9, № 1. – P. 51-59.

16. Duggan M. Pulmonary Atelectasis: A Pathogenic Perioperative Entity /M. Duggan, B. P. Kavanagh //Anesthesiology. – 2005. – V. 102, № 4. – P. 838-854.

17. Dumont L. Changes in Pulmonary Mechanics during Laparoscopic Gastroplasty in Morbidly Obese Patients /L. Dumont, M. Mattys, C. Mardirosoff //Acta Anaesthesiologica Scandinavica. – 1997. – V. 41, № 3. – P. 408-413.

18. Esteban A. Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation: A 28-Day International Study /A. Esteban, A. Anzueto, F. Frutos //JAMA. – 2002. – V. 287, № 3. – P. 345-355.

19. Evans T. W. Lung Injury /T. W. Evans, J. H. Cranshaw //Classic Papers in Critical Care. – London, 2008. – P. 31-57.

20. Fahy B. G. Changes in Lung and Chest Wall Properties with Abdominal Insufflation of Carbon Dioxide Are Immediately Reversible /B. G. Fahy, G. M. Barnas, S. E. Nagle //Anesthesia and Analgesia. – 1996. – V. 82, № 3. – P. 501-505.

21. Fahy B. G. Effects of Trendelenburg and Reverse Trendelenburg Postures on Lung and Chest Wall Mechanics /B. G. Fahy, G. M. Barnas, S. E. Nagle //Journal of Clinical Anesthesia. – 1996. – V. 8, № 3. – P. 236-244.

22. Ferrando C. Rationale and Study Design for an Individualised Perioperative Open-Lung Ventilatory Strategy with a High versus Conventional Inspiratory Oxygen Fraction (iPROVE-O2) and Its Effects on Surgical Site Infection: Study Protocol for a Randomised Controlled Trial /C. Ferrando, M. Soro, C. Unzueta //BMJ Open. – 2017. – V. 7 (7). – e016765.

23. Futier E. A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery /E. Futier, J. M. Constantin, C. Paugam-Burtz //New England Journal of Medicine. – 2013. – V. 369, № 5. – P. 428-437.

24. Futier E. Intraoperative Recruitment Maneuver Reverses Detrimental Pneumoperitoneum-Induced Respiratory Effects in Healthy Weight and Obese Patients Undergoing Laparoscopy /E. Futier, J. M. Constantin, P. Pelosi //Anesthesiology. – 2010. – V. 113, № 6. – P. 1310-1319.

25. Gattinoni L. Bench-to-Bedside Review: Chest Wall Elastance in Acute Lung Injury/Acute Respiratory Distress Syndrome Patients //L. Gattinoni, D. Chiumello, E. Carlesso //Critical Care. – 2004. – V. 8, № 5. – P. 350-355.

26. Güldner A. Intraoperative Protective Mechanical Ventilation for Prevention of Postoperative Pulmonary Complications: A Comprehensive Review of the Role of Tidal Volume, Positive End-Expiratory Pressure, and Lung Recruitment Maneuvers /A. Güldner, T. Kiss, A. Serpa Neto //Anesthesiology. – 2015. – V. 123, № 3. – P. 692-713.

27. Hazebroek E. J. Mechanical Ventilation with Positive End-Expiratory Pressure Preserves Arterial Oxygenation during Prolonged Pneumoperitoneum /E. J. Hazebroek, J. J. Haitsma, B. Lachmann // Surgical Endoscopy. – 2002. – V. 16, № 4. – P. 685-689.

28. Ho H. S. Effector of Hemodynamics during Laparoscopy: CO2 Absorption or Intra-Abdominal Pressure? /H. S. Ho, C. J. Saunders, R. A. Gunther //The Journal of Surgical Research. – 1995. – V. 59, № 4. – P. 497-503.

29. Hong J. Y. The Changes of Ventilatory Parameters in Laparoscopic Colecystectomy /J. Y. Hong, K. H. Chung, Y. J. Lee //Yonsei Medical Journal. – 1999. – V. 40, № 4. – P. 307-312.

30. International Consensus Conferences in Intensive Care Medicine. Ventilator-Associated Lung Injury in ARDS. American Thoracic Society, European Society of Intensive Care Medicine, Societé de Réanimation Langue Française //Intensive Care Medicine. – 1999. – V. 25, № 12. – P. 1444-1452.

31. Jaber S. A Multicentre Observational Study of Intra-Operative Ventilatory Management during General Anaesthesia: Tidal Volumes and Relation to Body Weight /S. Jaber, Y. Coisel, G. Chanques // Anaesthesia. – 2012. – V. 67, № 9. – P. 999-1008.

32. Kaba A. Anaesthesia for Laparoscopic Surgery /A. Kaba, J. Joris //Current Anaesthesia & Critical Care. – 2001. – V. 12. – P. 159-165.

33. Kacmarek R. M. Lung-Protective Ventilation in the Operating Room Individualized Positive End-Expiratory Pressure Is Needed! /R. M. Kacmarek, J. Villar //Anesthesiology. – 2018. – V. 129, № 6. – P. 1057-1059.

34. Klingstedt C. The Influence of Body Position and Differential Ventilation on Lung Dimensions and Atelectasis Formation in Anaesthetized Man /C. Klingstedt, G. Hedenstierna, H. Lundquist //Acta Anaesthesiologica Scandinavica. – 1990. – V. 34, № 4. – P. 315-322.

35. Klopfenstein C. E. Laparoscopic Colon Surgery: Unreliability of End-Tidal CO2 Monitoring /C. E. Klopfenstein, E. Schiffer, C. M. Pastor //Acta Anaesthesiologica Scandinavica. – 2008. – V. 52, № 5. – P. 700-707.

36. Ladha K. Intraoperative Protective Mechanical Ventilation and Risk of Postoperative Respiratory Complications: Hospital Based Registry Study /K. Ladha, M. Melo, D. J. McLean //BMJ. – 2015. – V. 351. – h3646.

37. Lee C. M. Laparoscopic Techniques and Strategies for Gastrointestinal GISTs /C. M. Lee, S. Park //Journal of Visualized Surgery. – 2017. – V. 3. – P. 62.

38. Levine S. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans /S. Levine, M. T. Budak, S. Sonnad //N. Engl. J. Med. – 2008. – V. 358 (13) . – P. 1327-1335.

39. Lipes J. Low Tidal Volume Ventilation in Patients without Acute Respiratory Distress Syndrome: A Paradigm Shift in Mechanical Ventilation /J. Lipes, A. Bojmehrani, F. Lellouche //Critical Care Research and Practice. – 2012. – V. 2012. – P. 416862.

40. Loring S. H. Respiratory Mechanical Effects of Surgical Pneumoperitoneum in Humans /S. H. Loring, N. Behazin, A. Novero //Journal of Applied Physiology. – 2014. – V. 117, № 9. – P. 1074-1079.

41. Lundquist Hans. CT-Assessment of Dependent Lung Densities in Man During General Anaesthesia /H. Lundquist, G. Hedenstierna, Å. Strandberg //Acta Radiologica. – 1995. – V. 36, № 6. – P. 626-632.

42. Macklin C. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications //Archives of Internal Medicine. – 1939. – V. 64, № 5. – P. 913.

43. Malbrain M. L. Prevalence of Intra-Abdominal Hypertension in Critically Ill Patients: A Multicentre Epidemiological Study /M. L. Malbrain, D. Chiumello, P. Pelosi //Intensive Care Medicine. – 2004. – V. 30, № 5. – P. 822-829.

44. Manzano F. Positive-End Expiratory Pressure Reduces Incidence of Ventilator-Associated Pneumonia in Nonhypoxemic Patients /F. Manzano, E. Fernández-Mondéjar, M. Colmenero //Critical Care Medicine. – 2008. – V. 36, № 8. – P. 2225-2231.

45. Mascia L. Effect of a Lung Protective Strategy for Organ Donors on Eligibility and Availability of Lungs for Transplantation: A Randomized Controlled Trial /L. Mascia, D. Pasero, A. S. Slutsky //JAMA. – 2010. – V. 304, № 23. – P. 2620-2627.

46. Mietto C. Transpulmonary Pressure Monitoring during Mechanical Ventilation: A Benchto-Bedside Review /C. Mietto, M. L. Malbrain, D. Chiumello //Anaesthesiology Intensive Therapy. – 2015. – V. 47. – P. 27-37.

47. Murray A. Clinical Effectiveness and Cost-Effectiveness of Laparoscopic Surgery for Colorectal Cancer: Systematic Reviews and Economic Evaluation /A. Murray, T. Lourenco, R. de Verteuil // Health Technology Assessment. – 2006. – V. 10, № 45. – P. 1-141.

48. Mutoh T. Volume Infusion Produces Abdominal Distension, Lung Compression, and Chest Wall Stiffening in Pigs /T. Mutoh, W. J. Lamm, L. J. Embree //Journal of Applied Physiology. – 1992. – V. 72 (2) . – P. 575-582.

49. Neumann P. Positive End-Expiratory Pressure Prevents Atelectasis during General Anaesthesia Even in the Presence of a High Inspired Oxygen Concentration /P. Neumann, H. U. Rothen, J. E. Berglund //Acta Anaesthesiologica Scandinavica. – 1999. – V. 43, № 3. – P. 295-301.

50. Nguyen N. T. Effects of Pneumoperitoneum on Intraoperative Pulmonary Mechanics and Gas Exchange during Laparoscopic Gastric Bypass /N. T. Nguyen, J. T. Anderson, M. Budd //Surgical Endoscopy And Other Interventional Techniques. – 2004. – V. 18, № 1. – P. 64-71.

51. Nguyen N. T. Evaluation of Intra-Abdominal Pressure after Laparoscopic and Open Gastric Bypass /Nguyen N. T., S. L. Lee, J. T. Anderson // Obesity Surgery. – 2001. – V. 11, № 1. – P. 40-45.

52. Nguyen N. T. The Physiologic Effects of Pneumoperitoneum in the Morbidly Obese /N. T. Nguyen, B. M. Wolfe //Annals of Surgery. – 2005. – V. 241, № 2. – P. 219-226.

53. Oikkonen M. Changes in Respiratory Compliance at Laparoscopy: Measurements Using Side Stream Spirometry /M. Oikkonen, M. Tallgren // Canadian Journal of Anaesthesia. – 1995. – V. 42, № 6. – P. 495-497.

54. Oti C. Anaesthesia for Laparoscopic Surgery /C. Oti, M. Mahendran, N. Sabir //British Journal of Hospital Medicine. – 2016. – V. 77, № 1. – P. 24-28.

55. Park S. J. Effects of Intraoperative Protective Lung Ventilation on Postoperative Pulmonary Complications in Patients with Laparoscopic Surgery: Prospective, Randomized and Controlled Trial /S. J. Park, B. G. Kim, A. H. Oh //Surgical Endoscopy. – 2016. – V. 30, № 10. – P. 4598-4606.

56. Patel B. Laparoscopic Pancreaticoduodenectomy in Brisbane, Australia: An Initial Experience /B. Patel, U. Leung, J. Lee //ANZ Journal of Surgery. – 2018. – V. 88, № 5. – P. 440-44.

57. Pereira S. M. Individual Positive End-Expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis /S. M Pereira., M. R. Tucci, C. Morais // Anesthesiology. – 2018. – V. 129, № 6. – P. 1070-1081.

58. PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology High versus Low Positive End- Expiratory Pressure during General Anaesthesia for Open Abdominal Surgery (PROVHILO Trial): A Multicentre Randomised Controlled Trial /S. Hemmes, M. Gama de Abreu, P. Pelosi //Lancet. – 2014. – V. 384, № 9942. – P. 495-503.

59. Reinius H. Prevention of Atelectasis in Morbidly Obese Patients during General Anesthesia and Paralysis: A Computerized Tomography Study /H. Reinius, L. Jonsson, S. Gustafsson //Anesthesiology. – 2009. – V. 111, № 5. – P. 979-987.

60. Russo A. Positive End-Expiratory Pressure during Laparoscopy: Cardiac and Respiratory Effects /A. Russo, E. D. Stasio, A. Scagliusi //Journal of Clinical Anesthesia. – 2013. – V. 25, № 4. – P. 314-320.

61. Sato H. Low Tidal Volume Ventilation with Low PEEP during Surgery May Induce Lung Inflammation /H. Sato, K. Nakamura, Y. Baba //BMC Anesthesiology. – 2016. – V. 16, № 1. – P. 47.

62. Severgnini P. Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function /P. Severgnini, G. Selmo, C. Lanza //Anesthesiology. – 2013. – V. 118, № 6. – P. 1307-1321.

63. Slutsky S. Basic Science in Ventilator-Induced Lung Injury: Implications for the Bedside //American Journal of Respiratory and Critical Care Medicine. – 2001. – V. 163, № 3. – P. 599-600.

64. Slutsky S. Ventilator-Induced Lung Injury /A. S. Slutsky, V. M. Ranieri //New England Journal of Medicine. – 2013. – V. 369, № 22. – P. 2126-2136.

65. Steier J. Observational Study of the Effect of Obesity on Lung Volumes /J. Steier, A. Lunt, N. Hart // Thorax. – 2014. – V. 69, № 8. – P. 752-759.

66. Sutherasan Y. Protective Mechanical Ventilation in the Non-Injured Lung: Review and Meta-Analysis /Y. Sutherasan, M. Vargas, P. Pelosi // Critical Care. – 2014. – V. 18, № 2. – P. 211.

67. Talmor D. Esophageal and Transpulmonary Pressures in Acute Respiratory Failure /D. Talmor, T Sarge., C. R. O'Donnell //Critical Care Medicine. – 2006. – V. 34, № 5. – P. 1389-1394.

68. Tokics L. Lung Collapse and Gas Exchange during General Anesthesia: Effects of Spontaneous Breathing, Muscle Paralysis, and Positive End-Expiratory Pressure /L. Tokics, G. Hedenstierna, A. Strandberg //Anesthesiology. – 1987. – V. 66, № 2. – P. 157-167.

69. Tremblay L. N. Ventilator-Induced Injury: From Barotrauma to Biotrauma /L. N. Tremblay, A. S. Slutsky //Proceedings of the Association of American Physicians. – 1998. – V. 110, № 6. – P. 482-488.

70. Tremblay L. N. Ventilator-Induced Lung Injury: From the Bench to the Bedside /L. N. Tremblay, A. S. Slutsky //Intensive Care Medicine. – 2006. – V. 32, № 1. – P. 24-33.

71. Tusman G. «Alveolar Recruitment Strategy» Improves Arterial Oxygenation during General Anaesthesia /G. Tusman, S. H. Böhm, G. F. Vazquez de Anda //British Journal of Anaesthesia. – 1999. – V. 82, № 1. – P. 8-13.

72. Twaij A. Laparoscopic vs Open Approach to Resection of Hepatocellular Carcinoma in Patients with Known Cirrhosis: Systematic Review and Meta-Analysis /A. Twaij, Pucher P. H., Sodergren M.H., Gall T., Darzi A., Jiao L.R. // World Journal of Gastroenterology - July 2014 - vol. 20, № 25 - P. 8274–81.

73. Vassiliou M. P. Non-Linear Evaluation of Respiratory Mechanics during Laparoscopic Cholecystectomy /M. P. Vassiliou, L. Rizzoti, V. Laopodis //Hepato-Gastroenterology. – 2003. – V. 50, № 52. – P. 934-938.

74. Veitch S. Minimal Access Surgery /S. Veitch, A. O. Mahendran //General Surgical Operations. – London, 2013. – P. 57-65.

75. Veldkamp R. Laparoscopic Surgery versus Open Surgery for Colon Cancer: Short-Term Outcomes of a Randomised Trial /R. Veldkamp, E. Kuhry, W. Hop //The Lancet Oncology. – 2005. – V. 6, № 7. – P. 477-484.

76. Wahba R. W. Acute Ventilatory Complications during Laparoscopic Upper Abdominal Surgery /R. W. Wahba, M. J. Tessler, S. J. Kleiman //Canadian Journal of Anaesthesia. – 1996. – V. 43, № 1. – P. 77-83.

77. Webb H. H. Experimental Pulmonary Edema Due to Intermittent Positive Pressure Ventilation with High Inflation Pressures. Protection by Positive End-Expiratory Pressure /H. H. Webb, D. F. Tierney //Am. Rev. Respir. Dis. – 1974. – V. 110 (5) . – P. 556-565.

78. Weiser T. G. An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data /T. G. Weiser, S. E. Regenbogen, K. D. Thompson //Lancet. – 2008. – V. 372, № 9633. – P. 139-144.

79. Wongsurakiat P. Changing Pattern of Ventilator Settings in Patients without Acute Lung Injury: Changes over 11 Years in a Single Institution /P. Wongsurakiat, D. J. Pierson, G. D. Rubenfeld // Chest. – 2004. – V. 126, № 4. – P. 1281-1291.