Techniques of Pneumoperitoneum
Pneumoperitoneum is a simple procedure, but one with enormous potential for improving the outcome of treatment of massive incisional hernias. The necessary equipment is minimal and consists of drainage bottles, tubing, antiseptic solutions, Intracath need
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Pneumoperitoneum is a simple procedure, but one with enonnous potential for improving the outcome of treatment of massive incisional hernias. 1- 7 The necessary equipment is minimal and consists of drainage bottles, tubing, antiseptic solutions, Intracath needles, and a syringe with a two-way stopcock. At all times, pneumoperitoneum should be created aseptically (mask, gloves, skin preparation), with or without local anesthesia. A spot should be marked, preferably on the left side of the abdomen, along a line joining the umbilicus to the anterior superior iliac spine, 2 to 3 cm medial to the latter. The needle will go through two layers of resistance-the "give" sensation corresponds to the external oblique aponeurosis and the peritoneum. When the needle is in place, a syringe must be used to aspirate and confirm, through the absence of aspirated liquid or air, that no viscus has been entered. If liquid should be in the aspirate, the needle must be removed and the procedure suspended, usually without complications, until the following day. If not, the easy introduction of air, with the syringe, confinns the good intraperitoneal location of the needle.
Techniques
dominal cavity, slowly and comfortably (Fig. 46.2). When the higher bottle is empty and the lower filled, the tubes are clamped, the bottles are exchanged, and the process is started anew.
Fractionated Injection A thick needle may be used, or a needle that allows the introduction of a plastic catheter into the abdominal cavity. Air is injected as tolerated (abdominal, subcostal, shoulder pain, and/or light nausea). Excess air, which creates pain, may be released through a simple secondary puncture (Fig. 46.3).
Complications Technical failure may provoke subcutaneous or retroperitoneal emphysema, which may be localized or generalized. There may be crepitations, temporary defonnation, but no serious consequences. Other manifestations of air tracking have been neck distension, a change in the voice, air cysts within intestinal loops, and dissection of a gallbladder from its bed.
Pump Technique One bottle is filled with diluted antiseptic solution and connected to a second bottle by a rubber tube. A Richardson pump is connected to the filled bottle to displace the solution into the empty bottle, thus forcing air through a catheter and needle into the abdominal cavity (Fig. 46.1).
Continuous Drip Technique Diluted antiseptic solution is allowed to drip from a higher bottle into a lower one, displacing air from the lower bottle into the ab-
R. Bendavid et al. (eds.), Abdominal Wall Hernias © Springer Science+Business Media New York 2001
Recommendations The results of pneumoperitoneum can be gauged by palpation of the flanks, which become soft, or by normalization of pulmonary function studies. Pneumolysis of intraperitoneal intervisceral adhesions may be achieved with pneumoperitoneum within a few days. Replacement of visceral contents into the abdominal cavity proper requires pneumoperitoneum for at least 15 days. Maximum benefit will be derived from no l
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