To paraphrase the article, nobody really knows anything about the pnumoperitoneium vs lift laparoscopy.
Kru where is all your 15 years of research? Not a paper ( cept the bogus one) out of you. You have a completely different agenda dontcha Kru.
Lame try.
Oh so was naming the abdolift when you really should have said lapralift.
Touche' fatboy
____________________
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Much Remains to Be Learned
Steve Eubanks, MD
Approximately 15 years of experience and tens of thousands of cases have led to a
strong knowledge base for advanced laparoscopy. Additionally, decades of gynecologic
laparoscopy led to a large experience with patients who underwent diagnostic or
relatively straightforward therapeutic procedures. Our experience with and understanding
of the effects of carbon dioxide pneumoperitoneum are far from nascent. Nonetheless, a
report in this issue of the Journal provides evidence that although pneumoperitoneum
appears to be well-tolerated by most patients, significant sequelae and complications can
occur in ways not previously recognized.
The deleterious effects of pneumoperitoneum that have been clearly documented
include decreased venous return to the right heart, a hypercoagulable state, increased
systemic vascular resistance, and compression of capillaries potentially leading to reduced
flow in areas such as the renal cortex and surface of the liver.1,2 Attempts to attenuate
some of these effects have used substances such as a nitric oxide-releasing substance.
Some surgeons use routine anticoagulation following splenectomy. Other simple measures
have included working with a lower than normal (normal defined as 15 mm Hg)
intraperitoneal pressure and keeping operative times to a minimum.
Gasless laparoscopy received significant attention in the early 1990s but failed to
receive widespread acceptance.
Many of these negative effects were known but rarely observed by individual surgeons. This situation is somewhat analogous to the time during which deep venous thrombosis (DVT) prophylaxis was less common, and many surgeons would claim hundreds or thousands of cases
performed without witnessing a DVT or pulmonary embolus in any patient. Careful follow
up, objective studies, and published results provided the surgical community with a more
thorough understanding of the magnitude of the problem. This understanding subsequently
led to widespread use of prophylactic measures for patients at risk for DVT.
Ikeda et al present in this issue of Annals of Surgery an article entitled “High
Incidence of Thrombosis of the Portal Venous System After Laparoscopic Splenectomy:
A Prospective Study With Contrast-Enhanced CT.”3 The widely known and previously
published reports of complications of laparoscopic splenectomy rarely mention portal
venous thrombosis. There exist scattered reports of this problem, including the publication
by Winslowe et al reporting portal venous thrombosis after splenectomy in a retrospective
study that included some patients who had undergone laparoscopic splenectomy.4 Other
case reports and small series have mentioned this complication. None report thrombosis
From the Hugh E. Stephenson Department of Surgery, W. Alton Jones Distinguished Professorship in Surgery, Columbia, Missouri.
Reprints: Steve Eubanks, MD, Hugh E. Stephenson Department of Surgery, W. Alton Jones Distinguished Professorship in Surgery, One Hospital Drive, Room
M580-HSC, Columbia, MO 65212. E-mail: eubankssw@health.missouri.edu.
Copyright © 2005 by Lippincott Williams & Wilkins
ISSN: 0003-4932/05/24102-0217
DOI: 10.1097/01.sla.0000152108.66049.87
© 2005 Lippincott Williams & Wilkins 217
rates that approach the magnitude described in this issue of
the journal. However, most prior reports failed to routinely
screen postsplenectomy patients radiographically.
The authors pose several hypotheses for the markedly
higher rate of thrombosis in the laparoscopic patients compared
with open splenectomy patients. These hypotheses
remain to be proven. Furthermore, the operative groups are
not matched regarding diagnoses, which can clearly impact
the rate of postoperative thrombosis. Approximately one third
of the patients in this study experienced clinically significant
thrombosis. Although the absolute number of patients reported
with clinically significant complications is small, the
potential implications are disturbing. This study demonstrates
the need for further evaluation of the specific topic of
postsplenectomy portal venous thrombosis in laparoscopic
patients and prompts us to ask, “What other similar problems
would be detected if all patients were screened postoperatively?”
Would routine computed tomography scans or Doppler
flow studies following laparoscopic nephrectomy reveal a
disturbing incidence of subclinical thrombus formation in the
inferior vena cava? Furthermore, at what point do we subject
patients to the risks associated with anticoagulation for problems
previously unrecognized that are rarely clinically significant?
Our understanding of the impact of pneumoperitoneum
on human physiology requires further investigation. We
should ask if the responses previously investigated are true
for all populations. Are the observed immune responses in
young adults applicable to the elderly or pediatric populations?
We already possess the knowledge that the elimination
of excess carbon dioxide occurs at different rates in the
mother and fetus. However, the clinical significance of this
phenomenon is undetermined. Likewise, does a laparoscopicassociated
hypercoagulable state occur equally in all patient
groups regardless of age or underlying diseases or conditions?
The study by Ikeda et al needs to be confirmed in a
larger cohort before the surgical community commits to
sweeping changes in the perioperative anticoagulation protocols
for laparoscopic patients. Because this study points out
the incomplete nature of our understanding of the potential
sequelae of pneumoperitoneum, its value reaches far beyond
the specific topic reported. One would hope that studies such
as this would inspire clinicians and investigators to pursue a
deeper understanding of an approach that affects several
hundred thousand patients each year. We truly have much yet
to learn.
REFERENCES
1. Larsen JF, Svendsen FM, Pedersen V. Randomized clinical trial of the
effect of pneumoperitoneum on cardiac function and haemodynamics
during laparoscopic cholecystectomy. Br J Surg. 2004;91:848–854.
2. Mertens zur Borg IR, Lim A, Verbrugge SJ, et al. Effects of intraabdominal
pressure elevation and positioning on hemodynamic responses during
carbon dioxide pneumoperitoneum for laparoscopic donor nephrectomy:
a prospective controlled clinical study. Surg Endosc. 2004;18:919 –923.
3. Ikeda M, Sekimoto M, Takiguchi S, et al. High incidence of thrombosis
of the portal venous system after laparoscopic splenectomy: a prospective
study with contrast-enhanced CT scan. Ann Surg. 2004;241.
4. Winslowe ER, Brunt LM, Drebin JA, et al. Portal vein thrombosis after
splenectomy. Am J Surg. 2002;184:631– 636.
