Introduction

The introduction of laparoscopic techniques has revolutionised general surgery. This technique has proven successful in decreasing length of hospital stay and reducing patient recovery time. To ease for the abdominal surgeon concerning visibility and accessibility, pneumoperitoneum is often created by the use of carbon dioxide using a Veress needle.
The fast acceptance of laparoscopic surgery, both by patients and surgeons, meant that the technique was introduced without much scientific evidence to support its safety. There are several potential risk factors, among which CO2 embolisation to the cardio-pulmonary circulation and bleeding are considered as two of the most serious

The complexity of liver surgery in general is partially due to the organic structure with a frequent number of venous sinusoids. The risk for gas embolism (GE) during laparoscopic liver surgery could then theoretically be higher than for other organs. Broadened indications for laparoscopic liver surgery have therefore increased the need for prediction and evaluation of CO2 embolisation.

Our group consists of Professor Sten Rubertsson and his Ph.D student Dr. Diddi Fors, both anesthesiologist, and Assistant Professor Dag Arvidsson and his Ph.D student Dr. Kristinn Eiriksson, both surgeons. Dr. Ulf Jersenius, Ph.D., (surgeon) left the group after the dissertation.
The group has so far studied the physiological effects as well as the frequency and severity of CO2 embolism during laparoscopic liver surgery in an animal model. We have focused on whether there is a possibility to influence the GE rate by the use of different surgical and/or anesthesiological techniques.

Publications

Jersenius U, Fors D, Rubertsson S, Arvidsson D. The effects of experimental venous carbon dioxide embolization on hemodynamic and respiratory variables. Acta Anaesthesiol Scand 2006; 50: 156-62

Jersenius U, Fors D, Rubertsson S, Arvidsson D. Laparoscopic parenchymal division of the liver in a porcine model: comparison of the efficacy and safety of three different techniques. Surg Endosc 2007; 21: 315-20

Eiriksson K, Fors D, Rubertsson S, Arvidsson D. Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques. Surg Endosc 2009; 23: 1038-42

Fors D, Eiriksson K, Arvidsson D, Rubertsson S. Gas embolism during laparoscopic liver resection in a pig model: frequency and severity. Br.J.Anaesth. 2010 105(3):282-88





Wednesday, 2 June 2010

With the use of higher intra peritoneal pressure (IAP) during laparoscopic liver resection (LLR) the bleeding is reduced and there is increased gas embolism. On those videos we can show a typical view while doing operation on a pig with 8 mmHg IAP (A) and with 16 mmHg (B).

A left lateral lobectomy was performed with manufactured injury to the left liver vein. The vein was left open for 3 minutes and then closed with metal clips.

With sharp eyes one can see the start of emboli entering the outflow tract on the ultrasound picture (picture in picture (B)). This happens 8 seconds after the vein cut.

A.

B.
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Monday, 29 March 2010

Gas bubbles recorded on TransEsofagealEchocardiogram (TEE)

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Video from a laparoscopic liver lobe resection

This video shows a laparoscopic liver lobe resection. Carbon dioxide was used to create pneumoperitoneum. In the upper left corner the view from the TEE is seen, focused on the right outflow tract of the heart. When the surgeon caused a damage to a vein, bleeding occurred. As the bleeding decreased, carbon dioxide entered the circulatory system and presented as a cluster of white bubbles in the heart. For more details, see the article "Gas embolism during laparoscopic liver resection in a pig model - frequency and severity".

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Sunday, 28 March 2010

Quantifying embolism

To try to quantify the emboli seen on echocardiogram we described those as either grade 1 or grade 2. Grade 2 was defined as filling of the chamber with white dots (bubbles) (see figure). Grade 1 embolization was defined as >5 bubbles seen on the screen but less than filling of the camber. If there were any emboli showing on the screen 10 seconds before and after a defined grade 1 or grade 2 embolization, it was counted with that same embolization event.




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