title: Evaluation of intra-abdominal pressures and gas embolism during laparoscopic partial nephrectomy in a porcine model.
abstract: OBJECTIVE
  Gas embolization is a well documented complication of laparoscopic surgery. We evaluated the association of gas embolization with increased intra-abdominal pressure (IAP) in the porcine model during laparoscopic partial nephrectomy with real-time transesophageal echocardiography.
  
  
  METHODS
  Eight domestic pigs weighing 143 to 162 pounds underwent unilateral transperitoneal laparoscopic heminephrectomy with renal artery clamping with varied IAPs. The renal vein was not clamped, allowing the exposure of venous tributaries to the pneumoperitoneum. IAP was increased in 5 mm Hg increments in 4 pigs each by 1) insufflation pressure adjustment to a maximum of 30 mm Hg and 2) intermittent application of an argon beam coagulator (ABC) to the cut kidney surface. Transesophageal echocardiography was used to monitor embolism.
  
  
  RESULTS
  None of the 4 animals subjected to increased CO2 insufflation pressure (maximum 30 mm Hg) demonstrated gas embolization during partial nephrectomy. The ABC caused gas embolization during partial nephrectomy at an IAP of 30 to 50 mm Hg in 4 animals. The volume of embolized gas was 4 to 20 ml. None of the animals showed intraoperative hemodynamic compromise.
  
  
  CONCLUSIONS
  Gas embolization was not seen during laparoscopic partial nephrectomy with typical insufflation pressures. The ABC can rapidly increase IAP and cause argon embolization at IAPs greater than 30 mm Hg. Prophylactic maneuvers to prevent gas embolization, such as intra-abdominal venting or renal vein clamping, should be considered when applying the ABC.
authors.affiliation: Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Weld
authors.forename: Caroline D
authors.initials: CD
authors.lastname: Ames
authors.forename: Jaime
authors.initials: J
authors.lastname: Landman
authors.forename: Kevin
authors.initials: K
authors.lastname: Morrissey
authors.forename: Thomas
authors.initials: T
authors.lastname: Connor
authors.forename: Greg
authors.initials: G
authors.lastname: Hruby
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
authors.forename: Sam B
authors.initials: SB
authors.lastname: Bhayani
mesh_terms: D000818:Animals; D001128:Argon; D017548:Echocardiography, Transesophageal; D004618:Embolism, Air / Q000000981:diagnostic imaging / Q000209:etiology*; D007327:Insufflation; D010535:Laparoscopy / Q000009:adverse effects*; D023421:Models, Animal; D009392:Nephrectomy / Q000009:adverse effects*; D011028:Pneumoperitoneum, Artificial; D011312:Pressure; D013552:Swine
chemical_list: D001128:Argon