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Gentili A, Iannnettone CM, Pigna A et al. Paediatric Anaesthesia 2000; 10:399-406.

Review: This study investigated the cardiovascular effects of intra-abdominal insufflation during laparoscopy in 20 children, 2-11 years of age. Patients were ASA physical status I or II and did not have any signs of cardiorespiratory disease. In addition to routine monitors, transthoracic echocardiography was employed to evaluate left ventricular end diastolic volume (EDV), endsystolic volume (ESV), fractional shortening (LVFS), and ejection fraction (LVEJ). During the laparoscopic procedures, intra-abdominal pressure was maintained at 10 mmHg. Heart rate, LVFS, and LVEJ did not change significantly during intra-abdominal insufflation. However, significant increases were observed in both systolic and diastolic blood pressure as well as in EDV and ESV. Peak and mean airway pressure and end-tidal CO2 also increased. Deflation resulted in a decrease in all elevated variables. No patient exhibited any cardiovascular or respiratory problems during the procedures.

Commentary: The authors attributed the observed changes in cardiovascular variables to increased venous return and increased aortic impedence produced by the elevation of intra-abdominal pressure. Myocardial function did not increase in response to an increase in preload, however, probably due to the parallel increase in afterload coupled with the myocardial depressant effect of sevoflurane. Elevation of intra-abdominal pressure above 20 mmHg has previously been shown in adults to compromise venous return and cardiac output. The authors of this study conclude that laparoscopy can be performed safely in children with normal cardiac function but caution that children with cardiac disease may exhibit unpredictable responses to alterations in preload and afterload. Videolaparoscopy offers significant postoperative benefits to patients with cardiorespiratory disorders who must undergo major operations, e.g., Nissen fundoplication. Further elucidation of the impact of laparoscopic procedures in children with cardiac disease is needed.

Reviewed by: John T. Algren, MD
Vanderbilt Children's Hospital, Nashville, TN