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This is a report of a pilot program for laparoscopic sterilization with emphasis on surgical and anesthetic technics. In 1971 the program was developed at the North Carolina Memorial Hospital. Subjects were 129 private patients, mostly white, of middle income with 2 or more children, and from 19 to 47 years of age. Follow up of over 90% indicated high patient satisfaction. Complications were few but may occasionally require surgical management and the method should not be considered a minor procedure. At first patients were handled as inpatients for 1 day preceding surgery. Later an outpatient status was adopted. At an earlier visit a history is taken, instructions given by a nurse, the assigned physician (who may be a physician in training) reviews the history, performs a physical examination, and explains the operation to both the patient and her husband. Laboratory work is performed, operative permits are signed, and patients are asked at this time to agree to sterilization by laparotomy if the laparoscopic approach proves infeasible. On the morning of surgery suitable intravenous medication (Valium 5 mg), fentanyl, and atropine are given and followed by pure oxygen inhalation for 3-5 minutes. Pentothal followed by succinylcholine are given and the patient intubated. Anesthesia is maintained by succinylcholine drip and inhalation of nitrous oxide and oxygen. After surgical preparation with Betadine solution, a combination tenaculum-sound is placed in the cervical canal. Pneumoperitoneum is established with carbon dioxide gas through a Verres needle inserted through a small subumbilical incision. The laparoscopic trocar is introduced by enlarging the same incision. After inspection a second 6 mm trocar is inserted just about the tubes and biopsy forceps introduced. The tenaculum in the cervix is used to position the uterus and tubes. After cauterization tubes are divided with the biopsy forceps and a biopsy specimen obtained if possible without undue action on the tube. After inspection for bleeding or injury to other viscera, the instruments are withdrawn. The procedure can be completed in 15 minutes. After recovery from the anesthesia the patient is removed to the recovery area and then the holding area. After 2 or 3 hours she is seen by a physician and discharged if vital signs are stable. Oral and written instructions for her convalescence are given. Patients are requested to return in 2 weeks or to consult a physician in their home area. 30 patients required postoperative hospital admissions: 15 for non-medical reasons (i.e., distance to travel home) and 15 for observation at the physicians' request. These stayed 14 to 24 hours. Nausea and vomiting were indications in 5. :In one case nosebleed following intubation combined with slight elevation of temperature caused a stay of 48 hours. Retrospectively, only 8 of the 15 hospitalized or 6% of all cases required this extra service. In the initial series there was 1 technical failure due to obesity. The average time to resume normal activities was 3 1/2 days. 115 patients (97.4%) of those responding to a questionnaire stated they would recommend the procedure to a friend. The 3 dissatisfied respondents gave no specific reason. Thorough training of the physicians is urged. Use as an office procedure with local anesthesia is not recommended. Single-puncture technic is being tried. Subsequently over 100 additional procedures have been performed.
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PMID:An outpatient program for laparoscopic sterilization. 426 75

Experience gained in performing 3615 laparoscopic sterilizations in India over a 10-year period is reported. A simplified technique was developed for performing sterilization under local anesthesia without neuroleptanalgesia, avoiding uterine manipulators, performing direct trocar insertion without prior pneumoperitoneum, and using air for pneumoperitoneum. Beginning in 1973 laparoscopic sterilizations were performed using monopolar electrocoagulation and Hulka clips. The first 100 cases were done under local anesthesia with neuroleptanalgesia (75 mg meperidine, .6 mg atropine intravenously), using uterine manipulators and creating pneumoperitoneum with a Cerres needle and CO2. In 1974, neuroleptanalgesia was no longer used and air was used instead of CO2 for penumoperitoneum (3515 cases). The patients did not fast but were allowed to have liquids and given a glucose drink just prior to survery. The air was insufflated with a sigmoidoscopy bulb or a fish tank minicompressor. Since 1977 the trocar cannula has been inserted directly, without creating a pneumoperitoneum (1035 cases). Since 1980 the semilithotomy position and uterine manipulators are no longer used. A simple supine position with knees bent at right angles and a 30 degree Trendelenburg position was used in the last 435 cases. Of the 3515 cases performed under local anesthesia without neuroleptanalgesia, only 12 (.34%) needed medication during surgery. 20 patients developed vasovagal attacks and required atropine. None needed general anesthesia. Of the 3515 cases in which air was used for pneumoperitoneum, none developed air embolism. When preperitoneal (8 cases), omental (3 cases), and mediastinal (1 case) emphysema developed, it took 3-4 days to subside because the air was absorbed slowly. Postoperative shoulder pain persisted in 1038 cases (29.5%), but it was more of an annoyance than a complication. Of the 1035 cases of direct trocar insertion, there was no injury to the bowel or a blood vessel. In 14 cases (1.3%) the trocar was found to be extraperitoneal and reinserted for correct placement. Pneumoperitoneum with a Verres or spinal needle was created in 21 technically difficult cases (2%), which included obesity, previous scars, and a bulky postpartum uterus. A uterine manipulator wwas used in 9 technically difficult cases (2.07%).
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PMID:Development of a simplified laparoscopic sterilization technique. 623 98

In recent years, laparoscopic surgery has gained popularity in clinical practice. The key element in laparoscopic surgery is creation of pneumoperitoneum and carbon dioxide is commonly used for insufflation. This pneumoperitoneum perils the normal cardiopulmonary system to a considerable extent. Every laparoscopic surgeon should understand the consequences of pneumoperitoneum; so that its untoward effects can be averted. Pneumoperitoneum increases pressure on diaphragm, leading to its cephalic displacement and thereby decreasing venous return, which can be aggravated by the position of patient during surgery. There is no absolute contraindication of laparoscopic surgery, though we can anticipate some problems in conditions like obesity, pregnancy and previous abdominal surgery. This review discusses some aspects of the pathophysiology of carbon dioxide induced pneumoperitoneum, its consequences as well as strategies to counteract them. Also, we propose certain guidelines for safe laparoscopic surgery.
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PMID:Secrets of safe laparoscopic surgery: Anaesthetic and surgical considerations. 2112 64

Pneumoperitoneum for laparoscopic surgery is known to stiffen the chest wall and respiratory system, but its effects on resting pleural pressure in humans are unknown. We hypothesized that pneumoperitoneum would raise abdominal pressure, push the diaphragm into the thorax, raise pleural pressure, and squeeze the lung, which would become stiffer at low volumes as in severe obesity. Nineteen predominantly obese laparoscopic patients without pulmonary disease were studied supine (level), under neuromuscular blockade, before and after insufflation of CO2 to a gas pressure of 20 cmH2O. Esophageal pressure (Pes) and airway pressure (Pao) were measured to estimate pleural pressure and transpulmonary pressure (Pl = Pao - Pes). Changes in relaxation volume (Vrel, at Pao = 0) were estimated from changes in expiratory reserve volume, the volume extracted between Vrel, and the volume at Pao = -25 cmH2O. Inflation pressure-volume (Pao-Vl) curves from Vrel were assessed for evidence of lung compression due to high Pl. Respiratory mechanics were measured during ventilation with a positive end-expiratory pressure of 0 and 7 cmH2O. Pneumoperitoneum stiffened the chest wall and the respiratory system (increased elastance), but did not stiffen the lung, and positive end-expiratory pressure reduced Ecw during pneumoperitoneum. Contrary to our expectations, pneumoperitoneum at Vrel did not significantly change Pes [8.7 (3.4) to 7.6 (3.2) cmH2O; means (SD)] or expiratory reserve volume [183 (142) to 155 (114) ml]. The inflation Pao-Vl curve above Vrel did not show evidence of increased lung compression with pneumoperitoneum. These results in predominantly obese subjects can be explained by the inspiratory effects of abdominal pressure on the rib cage.
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PMID:Respiratory mechanical effects of surgical pneumoperitoneum in humans. 2521 41