- The commonest structure that can be injured by the laparoscope is the distended stomach. So pass a nasogastric tube and aspirate the stomach contents especially if the induction has involved prolonged bag and mask ventilation.
- Regurgitation of gastric contents can happen
- Pulmonary oedema from fluid infusions and the head-down position
- Insufflation is the most hazardous phase; A demonstrable gas embolism can occur in 1 out of 2000 patients; so watch for high insufflating pressures and low flow. Signs of gas embolism include arrhythmia, hypotension, cyanosis and cardiac arrest. The safest technique is to use CO2 for the pneumoperitoneum rather than N2O, because CO2 is more soluble and if an embolism occurs, it will resolve faster. Watch the indicators on the insufflating machine continuously during inflation. Pressure over 3 kPa or total volume insufflated exceeding 5 litres are hazardous. Caval compression and reduced venous return, with lowered cardiac output, may be a consequence of intra-abdominal pressure exceeding 4 kPa.
- The pressure effect of the insufflating gas will also splint the diaphragm and impede the mechanism of breathing.
- Avoid excessive head down tilt, and always be prepared for laparotomy.
- The end-tidal CO2 will rise during the course of a prolonged procedure and minute volume should be adjusted to compensate.
- Pneumothorax and surgical emphysema have been described, associated with prolonged surgery.
- Shoulder-tip pain, from diaphragmatic irritation, is a common postoperative problem.
The Lay Medical Man 