Ann Thorac Surg 2004;77:1469-1471
© 2004 The Society of Thoracic Surgeons
How to do it
A novel technique for creation of adjustable pneumoperitoneum
M. Matej Puc, MDa,
Francis J. Podbielski, MDa,
A. Alan Conlan, MDa*
a Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
Accepted for publication June 3, 2003.
* Address reprint requests to Dr Conlan, Division of Thoracic Surgery, University of Massachusetts Medical Center, 67 Belmont Ave, Worcester, MA, USA 01605-2657
e-mail: conlana{at}ummhc.org
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Abstract
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Creation of a pneumoperitoneum has been demonstrated to be a useful maneuver to help eliminate postresection spaces and air leaks. However, a single instillation of air intraoperatively may not be adequate, and postoperative transabdominal administration of air is uncomfortable and potentially hazardous to the patient. We describe a simple technique that allows repeated administration of pneumoperitoneum and even provides the ability to adjust the amount of air within the abdomen. Our technique is performed at the time of the initial pulmonary resection and enables easy postoperative management of an adjustable pneumoperitoneum.
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Introduction
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Pneumoperitoneum is a well-documented technique to treat postresection pleural spaces or prolonged air leaks, or both [1–6]. The method is especially useful with lower postresection pleural spaces and associated air leakage, which are much more difficult to diminish, control, and close. Pneumoperitoneum requires the instillation of subphrenic air at the time of surgery or later during the postoperative period.
Various techniques for the establishment of pneumoperitoneum at the time of pulmonary resection include blind transdiaphragmatic needle puncture or placement of air under direct vision through the diaphragm. Postoperative techniques have included transcutaneous instillation of air by blind needle placement, the use of a Veres needle [1], or a peritoneal dialysis catheter [3]. All of these techniques have their potential disadvantages. For example, Blalock described the occurrence of a fatal air embolism during transdiaphragmatic needle puncture [6]. This complication, which unfortunately has been reported, occurs with the inadvertent injection of air into the liver. In addition, the single instillation of air at the time of the pulmonary resection does not allow for repeated placement of subdiaphragmatic air without an invasive procedure, or removal of air if the patient does not tolerate the pneumoperitoneum. The postoperative maneuvers usually require a return to the operating room and expose the patient to another invasive procedure with its potential complications.
The technique we have developed can be performed safely and quickly at the time of the initial pulmonary resection. It has the benefit of being able to add more air at a later time and also to remove air, if deemed necessary. Therefore, there is greater flexibility in managing the pneumoperitoneum postoperatively with a minimal additional morbidity to the patient.
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Technique
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Intraoperatively, the decision for pneumoperitoneum must be established. Initially, a purse-string stitch is placed in the lateral portion of the diaphragm with an absorbable suture. Under direct visualization, a 1-cm incision is made through the middle of the purse-string into the subphrenic space. A catheter is then advanced medially into the abdomen and secured in place by tying the purse-string (Fig 1).
We use an 8F feeding tube with an roentgenogram opaque line (Kendall Argyle, Mansfield, MA) along with a three-way stopcock (Medex, Hilliard, OH) attached to the externalized end. The purse-string should not be overly tight, so as not to occlude or impede the removal of the catheter. At the same time, the purse-string needs to be secure enough to prevent the pneumoperitoneum from escaping into the pleural space. Any alternative flexible tubing can be used but should be at least 8F in size and should have an opaque line for identification on chest radiographs.
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Fig 1. Intraoperative placement of the transdiaphragmatic catheter for creation of a pneumoperitoneum. The single arrow shows air insufflated into the peritoneal cavity via the transdiaphragmatic catheter. The multiple arrows illustrate diaphragmatic excursion cephalad to obliterate or minimize the thoracic space.
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The catheter is tunneled through the eighth or ninth intercostal space and secured with a nonabsorbable suture along the midaxillary line. Generally, air is placed into the subphrenic space through the catheter while still in the operating room to confirm its patency and also to visualize appropriate elevation of the diaphragm. Concomitant phrenic nerve block with 0.25% bupivacaine enhances diaphragmatic elevation. This added maneuver is self-limited and potentiates the pneumoperitoneum by producing a lax diaphragm.
Approximately 800 to 1000 mL of air is usually required to establish an adequate pneumoperitoneum. It is advisable to place a three-way stopcock on the catheter to allow accurate adjustment of the pneumoperitoneum without releasing the pneumoperitoneum when adding or removing air from the system. The pneumoperitoneum is monitored with daily chest radiographs. Patients are placed on at least negative 10 cm of chest tube suction continuously to keep the pleural space evacuated and the surfaces in contact. With the catheter in place, the pneumoperitoneum can be adjusted as dictated by the clinical situation. For example, the instilled air can translocate to the contralateral diaphragm, so the amount of ipsilateral subphrenic air will need adjusting to prevent further spillage. In addition, posturing the patient with the affected side up when administering the air helps to direct the pneumoperitoneum to its proper location.
Once the pneumoperitoneum is no longer required, the catheter is then simply removed and the remaining air is allowed to reabsorb. In addition, the adjustable pneumoperitoneum can be usefully combined with other techniques to help eliminate residual pleural spaces. We have combined an apical pleural tent with a pneumoperitoneum to eliminate residual pleural spaces (Fig 2).
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Fig 2. Combination of a pneumoperitoneum and an apical pleural tent. The single arrow shows air insufflated into the peritoneal cavity via the transdiaphragmatic catheter. The multiple arrows illustrate diaphragmatic excursion cephalad to obliterate or minimize the thoracic space.
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Comment
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The residual postresection space along with a persistent air leak can lead to significant morbidity. This is especially true of lower pleural spaces. The creation of a pneumoperitoneum is a well-established technique that has helped manage these problems. Our novel technique provides a simple way to establish an adjustable pneumoperitoneum, which allows for greater postoperative control.
Our experience with adjustable pneumoperitoneum has included a study of 21 patients who had extensive resections for inflammatory lung disease. On average the catheters remained in place for 5 days with approximately one to three refills per patient of anywhere between 500 and 1000 mL of additional air. No major or minor complications were identified. We placed all of these patients on suction drainage because of the inflammatory nature of the lung disease. The pneumoperitoneums were effective in reducing the residual pleural spaces with early sealing of air leaks.
The various techniques for creating a pneumoperitoneum can be carried out either intraoperatively or postoperatively. A single intraoperative instillation of air by a transdiaphragmatic approach, however, may not maintain an elevated diaphragm for an adequate amount of time. Also, the addition of air postoperatively in these patients has required a transabdominal approach, which is both painful and potentially hazardous. The establishment of an initial pneumoperitoneum postoperatively carries some of these same risks. Blind transabdominal placement of air carries obvious risk and the air may not reach its destination in the subphrenic area. Other techniques, such as the placement of a Veres needle or a peritoneal dialysis catheter, require an operation, which carries added risk to the patient.
The creation of an adjustable pneumoperitoneum as we have described is a simple and safe technique. It allows for greater control of the pneumoperitoneum such that the air can be added safely to the abdomen, directed accurately into the subphrenic space, and even removed to a level that the patient can tolerate, if so needed. These are unique qualities of the adjustable pneumoperitoneum that are not found with the other previously described techniques.
The decision to create an adjustable pneumoperitoneum at the time of operation requires the foresight that a postresection space will likely develop or a troublesome air leak will persist. Some of the risk factors to help predict the occurrence of a complicated postresection space include inflammatory lung diseases (ie, tuberculosis, bronchiectasis, necrotizing pneumonitis), extensive lung resections, chronic obstructive airway diseases, and pulmonary fibrosis/scarring, to name a few. These particular morbid sequelae are well documented in the literature and need no further mention at this time. Overall, our technique provides a reliable method that should be at the disposal of the thoracic surgeon if a residual space or air leak is envisioned to be a potential problem. This is especially true of lower postresection pleural spaces with air leakage.
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References
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- Cerfolio R.J., Holman W.L., Katholi C.R. Pneumoperitoneum after concomitant resection of the right middle and lower lobes (bilobectomy). Ann Thorac Surg 2000;70:942-947.[Abstract/Free Full Text]
- Conlan A.A. Prophylaxis and management of post lobectomy infected spaces. Int Trends Gen Thorac Surg 1990;6:279-289.
- Handy J.R., Jr, Judson M.A., Zellner J.L. Pneumoperitoneum to treat air leaks and spaces after a lung volume reduction operation. Ann Thorac Surg 1997;64:1803-1805.[Abstract/Free Full Text]
- De Giacomo T., Rendina E.A., Venuta F., et al. Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections. Ann Thorac Surg 2001;72:1716-1719.[Abstract/Free Full Text]
- Miller J.I. Acute and delayed space problems following pulmonary resection. Chest Surg Clin N Am 1996;6:615-621.[Medline]
- Blalock J.B. Pneumoperitoneum after pulmonary resection. Surg Clin North Am 1966;46:1475-1484.[Medline]
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Abstract
Introduction
