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Abdominal Insufflation for Laparoscopy Increases Intracranial and Intrathoracic Pressure in Human Subjects
Tovy H. Kamine*, Nassrene Y. Elmadhun, Ekkehard M. Kasper, Efstathios Papavassiliou, Benjamin E. Schneider
Surgery, BIDMC, Boston, MA
INTRODUCTION: Laparoscopy has emerged as an alternative to laparotomy in trauma patients. In animal models, case reports and small case series in humans, increasing abdominal pressure is associated with increasing intrathoracic and intracranial pressures. This has not been studied prospectively in human subjects. We present a prospective trial of patients who underwent laparoscopic assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures.
METHODS: Ten patients undergoing Lap VPS were recruited. Abdominal insufflation was performed using CO2 to 0, 8, 10, 12 and 15mmHg. ICP was measured through the ventricular catheter with insufflation and desufflation using a manometer. Inspiratory pressure (PIP) was measured through the endotracheal tube. Blood pressure was measured using a non-invasive blood pressure cuff. End-title CO2 (ETCO2) was measured at each pressure point. Baseline data were obtained including demographics: age, sex; and PMH: HTN, CHF, cancer, cirrhosis, renal failure, BMI, and prior abdominal or cranial surgery. Pressure measurements at all points of insufflation were compared using a 2-way ANOVA with a post-hoc Bonferroni test. Mean changes in pressures were compared using T-Test.
RESULTS: Both intracranial pressure and inspiratory pressure increased significantly with increasing abdominal pressure (both p<0.01). However, cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) did not significantly change with increasing abdominal pressure over the range tested. Higher abdominal pressure values were associated with decreased ETCO2 values. Mean increase in pressures from baseline observed with abdominal insufflation (from 0 to 15 mmHg) were: ICP: +6.15 cmH2O (95% CI 3.29 to 9.01); PIP: +6.80 mmHg (95% CI 5.09 to 8.51); CPP: -1.6mmHg (95% CI -8.7 to 5.4); and MAP: +2.9mmHg (95% CI -3.4 to 9.2).
DISCUSSION: Previous studies in animals and retrospective case reports and small series in humans have raised concern over an increase in ICP during laparoscopy. In this prospective study we have confirmed the presence of the multiple compartment syndrome, i.e., an increase in both the intrathoracic and intracranial pressure with increasing abdominal pressure. However, we have also shown that--despite a significant rise in ICP--cerebral perfusion pressure is not affected by increases in intra-abdominal pressure within the range of insufflation pressures used for laparoscopy. This suggests that in the absence of elevated ICP, laparoscopy is a safe modality for diagnosis and treatment in head or chest injured patients
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