The Perimoperitoneium (Pneumoperitoneum)

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Mark Perloe, MD:  “Hi, I’m Dr. Mark Perloe and this is Dr. Douglas Ott.  We’re going to talk about insufflation in laparoscopy which would seem to be something that we really don’t need to be talking about.”

Douglas E. Ott, MD, MPA:  “Yes and no; the answer is we use the gas to go into the abdomen to distend the abdomen but the qualities of the gas have been relatively unknown to us for a while.  One of the things that’s important is that the gas doesn’t have any water vapor in it and the lack of water vapor damages the peritoneum.”

Mark Perloe, MD:  “I’ve always heard that carbon dioxide as it escapes through the needle and expands is also fairly cold, does that chilling effect have any role to play?”

Douglas E. Ott, MD, MPA:  “Yes, as the gas goes into the abdomen the gas is forced through small orifices and then has a nozzeling effect as it goes into the abdomen in that the speed of the gas increases rapidly.  Based on the size of the exiting orifice it can be fairly rapid, and when the dry gas is going in against a wet tissue surface there’s evaporation.  That causes a wind chill effect on the tissue which causes desiccation to the tissue which causes hypothermia and damage to the peritoneal tissue and then inflammation.”

Mark Perloe, MD:  “That sounds like a good theory but are there clinical studies backing up this claim or theory?”

Douglas E. Ott, MD, MPA:  “It has been known by anesthesiologists for a fairly long period of time that on average there’s a lose of three-tenths degrees centigrade per hour use of gas which is about sixty liters of gas, and that’s directly attributable to the gas if they monitor the intraabdominal temperature.  The other is that the damage to the peritoneum has been shown in elegant studies by Larry Demco that by heating the gas while a patient is awake and having awake laparoscopy compared to cold dry gas that the patient is able to get a larger pneumoperitoneum with warm wet gas without complaining and to have no shoulder pain as a result and, therefore, they have decreased amounts of narcotics that they use in the recovery area and they go home quicker.”

Mark Perloe, MD:  “So has that been carried out to patients that you put to sleep and do a routine gynecology laparoscopy, say, for a tubal sterilization?”

Douglas E. Ott, MD, MPA:  “Yes, there’s been studies that have been done in Australia, Europe, and the United States that show the benefits of using humidified gas post-operatively for patients and intraoperatively.  They have less hypothermia, less recovery room time, and use fewer narcotics.  The patient has greater satisfaction and is able to return to normal quicker.”

Mark Perloe, MD:  “Is there any available data on adhesion risks?”

Douglas E. Ott, MD, MPA:  “There is no direct data about adhesion risk but there is indirect evidence that contributes to the idea that by damaging the peritoneum there is increased adhesions.  There are studies that show that tissue desiccation is one of the main factors for adhesion formation, another is when the tissue becomes dry there’s an increased amount of prostaglandins, lymphokines, and cytokines that are released from the tissue as an inflammatory response which are the precursors to adhesion formation.”

Mark Perloe, MD:  “We’ve got this information, is this something that we can use in operating rooms today?”

Douglas E. Ott, MD, MPA:  “Yes, there’s a device that’s manufactured called the Insuflow device which is the only device that heats and humidifies the gas as it goes into the patient’s abdomen.  It attaches to any insufflator and can be used with any system that’s commercially sold.  So it’s not an insufflator; it’s an adaption that hooks between the insufflator and the patient.  What it does is it takes the gas that’s at twenty degrees centigrade and bone dry and as it’s delivered to the patient’s abdomen it creates a temperature of thirty-five degrees centigrade or ninety-six degrees, and it’s moist just like the inside of the abdomen.”

Mark Perloe, MD:  “I’ve asked you to come and speak to me about this here because we started using this at Northside Hospital and, antidotally, I can tell you that my patients are recovering quicker and are more alert in the recovery room.  When you go back after the dictation to talk to the patient, they are seemingly more comfortable so I think it’s exciting to have this.  Have you looked at using a local anesthetic or any other compounds that may have an effect in reducing adhesions further or providing additional analgesia instead of using water in the device?” 

Douglas E. Ott, MD, MPA:  “The device has a FDA regulation on it that it’s just used to deliver humidified gas using water.  There have been people who have used other materials as an off label use for surgery but the company cannot make any claims related to that.  However, intuitively it would seem that by using the gas stream as a vehicle and having any kind of material in the gas stream as a liquid or even as a dried powder would be delivered to the abdomen for whatever purposes whether it be for anesthesia, for prevention of adhesions, delivery of antibiotics, or even for chemotherapeutic agents.  There is technology that the company has that is patent protected for this purpose and there are studies being done outside the United States for this as a drug delivery system.”

Mark Perloe, MD:  “We look forward to seeing some of that data.  Thank you very much for coming and talking with us.”

Douglas E. Ott, MD, MPA:  “Thank you.”