Harvey J. Sugerman
Laparoscopic surgery has become very popular for the treatment of severe obesity. Obesity can be distributed in either an android fashion, primarily within the abdominal area or centrally as seen primarily in male patients, or in a gynoid manner, in the hips and buttocks, peripherally as seen primarily in female patients. Many of our severely obese female patients have both peripheral and central obesity. We have found that central obesity is associated with a significant increase in intra-abdominal pressure and this pressure is as high or higher than the pressure seen in patients with an "acute abdominal compartment syndrome" (Fig. 5.1). Data support the finding that this increase in intra-abdominal pressure is associated with a number of obesity related co-morbidity problems leading to the development of a "chronic abdominal compartment syndrome". These co-morbidities include obesity hypoventilation syndrome with its high cardiac filling pressures, gastroesophageal reflux disease, venous stasis disease, pseudotumor cerebri, an increased risk of incisional hernia and it is probably the cause of systemic hypertension and the nephrotic syndrome of obesity.
With regards to the specific problems of laparoscopic surgery associated with increased intra-abdominal pressure, there are several issues that need to be discussed. As the abdominal pressure is already elevated, especially in male patients, it may require a greater insufflation pressure than that used in thin patients in order to obtain an adequate pneumoperitoneum for enough visibility to perform the operation.
Animal studies have shown that acutely increased intra-abdominal pressure may lead to a decreased venous return to the heart with a decreased cardiac output primarily due to pressure on the inferior vena cava (Fig. 5.2). Further increases in intra-abdominal pressure can raise intra-thoracic pressure (Fig. 5.3), which will further compromise cardiac function and could cause severe hypotension. Thus, in patients with coronary artery atherosclerosis or carotid stenosis an acutely decreased venous return could lead to cardiovascular collapse, heart failure, myocardial infarction or stroke. Therefore, the surgeon and anesthesiologist need to be very observant of the patient's vital signs during abdominal insufflation. Intermittent pneumatic venous compression boots have been shown to increase venous return and counteract the effects on the lower body venous system. Should the patient become hemo-dynamically unstable, the pneumoperitoneum should be reduced, the patient given
Fig. 5.1. Correlation between urinary bladder pressure and sagittal abdominal diameter in 84 morbidly obese patients and 5 "control" non-obese patients with ulcerative colitis, r = 0.67, p < 0.0001). Reprinted with permission from Sugerman HJ, Windsor ACJ, Bessos MK, Wolfe L. Abdominal pressure, sagittal abdominal diameter and obesity co-morbidity. J Int Med 1997; 241:71-9.
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