1. Flow rate - speed of insufflation
2. Flow volume - quantity of gas insufflated from the start of case to present
3. Flow pressure - pressure exerted back on the gas insufflation from the contained space

1. Gas will flow once abdominal access and insufflation is attached to a trochar
2. Flow rate may be limited based on diameter of insufflation mechanism
3. Vagal reaction (stretching of peritoneum) during insufflation may cause extreme bradycardia → desufflate → glycopyrrolate/atropine may be necessary
   1. Dehydrated + high flow → Tachycardia
   2. Elderly/CAD pt + high flow → increased myocardial O2 demand → ischemia
4. Some choose to insufflate with low flow to avoid vagal reaction → increase flow rate after 1 L of insufflation
5. Several liters of CO2 will be instilled before 15 mmHg is reached
6. Pressures should usually not exceed 12-15 mmHg

1. Loss of pneumoperitoneum: pt is contracting muscles (light), gas port is blocked or disconnected, excessive suction
2. High pressure, no flow: occurs on access, tipe of needle or port is in the abdominal wall rather than the abdomen
3. Loss of flow: gas tank empty → switch tanks, check all connections

1. Ideal insufflation gas balances pain/irritation with safety
2. CO2 has strong safety profile
   1. Gas can be used with electrocautery because it is non-combustible
   2. Low risk of air embolism because it is water soluble
   3. CO2 does cause peritoneal irritation → retained gas can cause abdominal pain
3. Other gases:
   1. Air - inert, non-combustible, not water soluble, no peritoneal irritation
   2. Helium - inert, non-combustible, not water soluble, no peritoneal irritation

1. Electrosurgical (monopolar, bipolar), ultrasonic energy devices, electrosurgical tissue sealers (bipolar)
2. Electrosurgical are least expensive and most widely available
3. Ultrasonic devices and electrosurgical tissue sealers are associated with higher costs but have versatility and control of larger vessels. Can be used as graspers for tissue manipulation and have less thermal spread than monopolar electrosurgical devices. Interchangeable depending on preference.

1. No tissue effect - ensure a complete circuit for electrosurgical device. Pt must have a dispersive electrode attached and active electrode must also be attached to the machine
2. Power setting - use lowest power setting to achieve the appropriate result to avoid injury
3. Unintended tissue damage - careful of direct and capacitive coupling and insulation failure
   1. Direct coupling occurs when the tip of the electrode comes in contact with another metal instrument or conducting material and the energy is then transferred to unintended tissues → damage
   2. Capacitive coupling is when a capacitor is created between an electrode and a metal cannula → discharged into surrounding tissues
   3. Insulation failure occurs when the shaft of the instrument becomes damaged or uncovered, exposed the current to surrounding tissues, often off camera
4. Caution - devices such as the ultrasonic energy devices are frequently hot after use and require cooling of the active blade to avoid thermal injury to future grasped tissues

1. Injury to intra-abdominal structures such as solid organs, bowel, mesentery, and retroperitoneal vessels
2. MC injury is SB (regardless of technique - Hasson, Veress)
3. Conversion to open if injury is catastrophic to life

Veress Needle

1. uses a blunt needle with pressure-deployed sharp needle

2. Place pt in Trendelenburg (head down 10-20 degrees)

3. Needle insertion is typically infraumbilical/supraumbilical through a stab incision

4. 2 points of resistance: fascia and peritoneum (often a click is heard once the peritoneum is traversed)

5. Confirm placement

   1. Aspirate - not return of blood, bowel contents, or urine
   2. Instill saline - flow without difficulty and should not aspirate back
   3. Remove syringe and watch for saline to freely fall through the needle into the abdominal cavity → Positive drop test
   4. Attach insufflator - pressure should be <10 mmHg, flow should be noted

6. Remove the needle and reattempt insertion if the above is not met or clearly demonstrated

7. As the abd insufflates, dullness to percussion is lost and tympany gained

8. Dec insufflation pressure → Troubleshoot

   1. Empty gas tank or disconnected CO2 line

   

Hasson technique

1. Avoids blind insertion of the trocar or needle
2. Hasson cannulas have 2 struts for affixing fascial sutures to create and adquate seal for pneumoperitoneum
3. Steps
   1. Incision is made, subcutaneous tissue and fat are spread away from the underlying fascia
   2. Fascia grasped with a clamp and cut/incised. 2 stay sutures are placed on either side of the incision
   3. After preperitoneal fat is sept away from the underlying peritoneum, final layer is grasped with a hemostat or fine clamp. Peritoneum is opened with a sharp tool
   4. Finger is then inserted into the abdomen to confirm entrance and absence of scar tissue to facilitate trocar insertion

Optical trocar

1. Abdominal access utilizing the clear bottom trocar with the laparoscope inserted during placement
2. Allows for visualized entry through the abdominal wall layers into the abdomen
3. Optimal viewing is with a 0-degree scope
4. Downward pressure is adjusted based on tissue resistance to obtain a smooth, controlled insertion
5. This allows recognition of the different abdominal wall layers → subcutaneous tissue/fat, muscle, preperitoneal fat, peritoneum
6. Use of veress needle insufflation prior to optical insertion is a method that can potentially decrease injury to viscera below the trocar; however, selectively practiced

Previous abdominal operations

Complications