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Auswirkungen des CO2-Pneumoperitoneums auf die Leber-und Lungenperfusion — Vergleich zweier Abdominaldrucke

Effect of the CO2-pneumoperitoneum on the hepatic and pulmonary perfusion — comparison of two abdominal pressures

  • Chirurgische Forschung
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Zusammenfassung

Grundlagen: Laparoskopische Eingriffe unter Verwendung eines CO2-Pneumoperitoneums (PP) haben einen Einfluß auf den System- und Lungenkreislauf und die Splanchnikusperfusion. Um einen „sicheren“ Abdominaldruck (IAP) für laparoskopische Operationen zu finden, wurde der hämodynamische und metabolische Effekt des PP untersucht.

Methodik: An 6 Schweinen wurde jeweils für 30 min ein IAP von 7 und 13 mm Hg angelegt. Die statistische Auswertung wurde mittels Varianzanalyse und Bonferroni-Holm-Korrektur durchgeführt.

Ergebnisse: In direkter Abhängigkeit von der Höhe des IAP stiegen Rechtsvorhofdruck (RAP: 13 ± 2 vs. 8 ± 1,5, p<0,002), mittlerer pulmonalarterieller Druck (MPAP: 37 ± 5 vs. 26 ± 3, p<0,05) und Portalvenendruck (Pvp, p<0,002; alle nach Bonferroni-Holm). Die transmuralen Drucke von RAP, MPAP, PCWP und Pvp waren erniedrigt als Ausdruck der geringeren Gefäßfüllung. Aortenfluß (Qaorta: 1,3 ± 0,4 vs. 1,5 ± 0,5 l/min, n.s.) und Portalvenenfluß (Qvp: 511 ± 117 vs. 589 ± 127 ml/min, n.s.) sanken nur tendenziell (p=0,02 ohne Bonferroni-Holm), während mittlerer arterieller Druck (MAP), Herzzeitvolumen (HZV) und Leberarterienfluß (Qha) unverändert blieben. Während die arterielle Sauerstoffsättigung mit der Höhe des IAP fiel, blieb die portalvenöse Sauerstoffsättigung trotz gesenktem Qvp unverändert.

Schlußfolgerungen: Der Effekt des CO2-Pneumoperitoneums vor allem auf die Gefäßabschnitte im Niederdruckbereich war bei 7 mm Hg IAP angedeutet und bei 13 mm Hg IAP deutlich ausgeprägt. Mit einem Abfall des Portalvenenflusses ist bei höheren Intraabdominaldrucken zu rechnen. Es ist ratsam, den Abdominaldruck für laparoskopische Operationen so gering wie möglich zu halten, und wenn es die Sicht und chirurgische Bewegungsfreiheit erlauben, nicht über 10 mm Hg einzustellen.

Summary

Background: CO2-pneumoperitoneum has numerous hemodynamic and metabolic effects. In order to get a "safe" abdominal pressure (IAP) for laparoscopic procedures the systemic and pulmonary circulation and the splanchnic perfusion during CO2-pneumoperitoneum was investigated.

Methods: In 6 pigs (31 ± 7 kg) an IAP of 7 and 13 mm Hg was installed for a period of 30 min at each pressure.

Results: In parallel with the increase in IAP the right atrial pressure (RAP, p<0.002), mean pulmonary artery pressure (MPAP, p<0.05), pulmonary capillary wedge pressure (PCWP), and portal pressure (Pvp, p<0.002) increased. However, the transmural pressures of RAP, MPAP, PCWP and Pvp decreased because of decreased filling of the vein and the gradient from the portal vein to the right atrium increased as an indicator of increased venous resistance. Cardiac output (CO), and hepatic arterial flow (Qha) were unchanged, whereas aortic (Qaorta: 1.3 ± 1.4 vs. 1.5 ± 0.5 l/min, n.s.), and portal flow (Qvp: 511 ± 117 vs. 589 ± 127 ml/min, n.s.) decreased slightly (p=0.02 without Bonferroni-Holm). Arterial pressure and heart rate were constant during pneumoperitoneum. Arterial O2-saturation decreased in parallel with IAP, but portal O2-saturation remained constant.

Conclusions: At 7 mm Hg IAP, the hemodynamic effects on the low flow — low pressure conduits were moderate, whereas they were pronounced at 13 mm Hg IAP. Liver perfusion decreases with increased intraabdominal pressure. We conclude that the abdominal pressure for laparoscopic procedures should be kept at lower limits, possibly not exceeding 10 mm Hg.

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Authors and Affiliations

  1. Zentrum für Biomedizinische Forschung, Universität, Währinger Gürtel 18-20, A-1090, Wien, Austria

    Ursula Windberger, R. Auer & U. Losert

  2. Universitätsklinik für Chirurgie, Wien, Austria

    F. Längle

  3. Universitäts-Frauenklinik, Wien, Austria

    R. Wenzl

  4. Institut für Medizinische Computerwissenschaften der Universität Wien, Austria

    G. Heinze

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  1. Ursula Windberger
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  2. R. Auer
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  3. F. Längle
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  4. R. Wenzl
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  5. G. Heinze
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  6. U. Losert
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Correspondence to Ursula Windberger.

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Windberger, U., Auer, R., Längle, F. et al. Auswirkungen des CO2-Pneumoperitoneums auf die Leber-und Lungenperfusion — Vergleich zweier Abdominaldrucke. Acta Chir Austriaca 30, 46–50 (1998). https://doi.org/10.1007/BF02619855

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  • DOI: https://doi.org/10.1007/BF02619855

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