title: Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects.
abstract: Laparoscopy has emerged as an alternative to laparotomy in select trauma patients. In animal models, increasing abdominal pressure is associated with an increase in intrathoracic and intracranial pressures. We conducted a prospective trial of human subjects who underwent laparoscopic-assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures.
  
  
  
  Ten patients undergoing lap VPS were recruited. Abdominal insufflation was performed using CO2 to 0, 8, 10, 12 and 15 mmHg. ICP was measured through the ventricular catheter simultaneously with insufflation and with desufflation using a manometer. Peak inspiratory pressures (PIP) were measured through the endotracheal tube. Blood pressure was measured using a noninvasive blood pressure cuff. End-tidal CO2 (ETCO2) was measured for each set of abdominal pressure level. Pressure measurements from all points of insufflation were compared using a two-way ANOVA with a post hoc Bonferroni test. Mean changes in pressures were compared using t test.
  
  
  
  ICP and PIP increased significantly with increasing abdominal pressure (both p < 0.01), whereas cerebral perfusion pressure (CPP) and mean arterial pressure did not significantly change with increasing abdominal pressure over the range tested. Higher abdominal pressure values were associated with decreased ETCO2 values.
  
  
  
  Increased ICP and PIP appear to be a direct result of increasing abdominal pressure, since ETCO2 did not increase. Though CPP did not change over the range tested, the ICP in some patients with 15 mmHg abdominal insufflation reached values as high as 32 cmH2O, which is considered above tolerance, regardless of the CPP. Laparoscopy should be used cautiously, in patients who present with baseline elevated ICP or head trauma as abdominal insufflation affects intracranial pressure.
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Shapiro 3, Boston, MA, 02215, USA.
authors.forename: Tovy Haber
authors.initials: TH
authors.lastname: Kamine
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Shapiro 3, Boston, MA, 02215, USA.
authors.forename: Nassrene Y
authors.initials: NY
authors.lastname: Elmadhun
authors.affiliation: Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Ekkehard M
authors.initials: EM
authors.lastname: Kasper
authors.affiliation: Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Efstathios
authors.initials: E
authors.lastname: Papavassiliou
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Shapiro 3, Boston, MA, 02215, USA. beschnei@bidmc.harvard.edu.
authors.forename: Benjamin E
authors.initials: BE
authors.lastname: Schneider
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D001239:Inhalation / Q000502:physiology*; D007427:Intracranial Pressure / Q000502:physiology*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects*; D011312:Pressure; D011446:Prospective Studies; D035423:Thoracic Cavity / Q000502:physiology*; D017287:Ventriculoperitoneal Shunt
keywords: Intracranial pressure; Intrathoracic pressure; Laparoscopy; Ventriculoperitoneal shunt