laparoscopy..missed hazards

It is theoretically sound to avoid N2O during laparoscopy for at least two reasons:

First, it diffuses into the abdominal cavity in concentrations sufficient to support combustion of intestinal gas.1

second, it will diffuse into CO2 bubbles and emboli,increasing their size and potenial for an obstructive event.

Adequate muscle relaxation is required during laparoscopy so that:

Spontaneous respiratory effort does not impair the surgical procedure or risk increasing the gradient for embolic gas to enter the central circulation

Most studies but not all report a decrease in left ventricular function and cardiac output (cardiac output decreased 7–24%).

In addition, with assumption of the reverse Trendelenburg position, cardiac index may decrease by 50% of preanesthesia and preinsufflation values.

Venous stasis of the lower extremities also occurs, with attendant concerns for embolic phenomenon 3,4

Relatively small CO2 emboli have been detected by transesophageal echocardiography in 69% of patients, classified by the American Society of Anesthesiologists as physical status ASA1 to ASA3, who undergo laparoscopic cholecystectomy.5

Fatal massive CO2 embolism has been reported, including a report of death from delayed CO2 embolism associated with gas trapping in the portal circulation .6

1-Diemunsch PA, Torp KD, Van Dorsselaer T et al. Nitrous oxide fraction in the carbon dioxide pneumoperitoneum during laparoscopy under general inhaled anesthesia in pigs. Anesth Analg. 2000;90:951–3.

2-Neukman GG. Laparoscopy explosion hazards with nitrous oxide. Anesthesiology 1993;78:875.

3-Celli BR, Rodriques KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing
pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984;130:12.

4-Millard JA, Hill BB, Cook PS, et al. Intermittent sequential pneumatic compression in prevention of venous stasis associated with pneumoperitoneum during
laparoscopic cholecystectomy. Arch Surg 1993;128:914.

5-Derouin M, Couture P, Boudreault D,et al. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy.

Anesth Analg 1996;82:119.

6-Lantz PE, Smith JD. Fatal carbon dioxide embolism complicating attempted laparoscopic cholecystectomy: case report and literature review.

J Forensic Sci 1994;39:1468.