Pneumoperitoneum

Artificial pneumoperitoneum is the introduction of gas into the abdominal cavity to limit the mobility of the diaphragm.

In phthisiology, the method is used to treat pulmonary tuberculosis; in phthisiosurgery, it is used for temporary correction of the volume of the pleural cavity after extensive lung resection.

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Indications for pneumoperitoneum

The main indications for the use of artificial pneumoperitoneum (according to I.A. Shaklein):

• Infiltrative tuberculosis of the lung with the lesion localized below the level of the clavicle;
• disseminated subacute tuberculosis;
• pneumonic phase of primary pulmonary tuberculosis;
• fibrous-cavernous tuberculosis with root localization of cavities;
• pulmonary hemorrhage.

Sometimes artificial pneumoperitoneum is used in combination with unilateral artificial pneumothorax as an alternative to phrenic alcoholization.

Artificial pneumoperitoneum enhances the effect of chemotherapeutic drugs, increases the frequency of closure of cavities with elastic walls, especially in the middle and lower parts of the lungs, accelerates the resorption of extensive infiltrative-pneumonic changes, aspiration pneumonia. In combination with specific chemotherapy, this method is effective in inflammation of the lung lobe, hematogenous-disseminated process, cavernous tuberculosis (regardless of the location of the cavity). This version of collapse therapy is used when chemotherapy is ineffective due to drug intolerance or drug resistance of mycobacterium tuberculosis.

Preparation for pneumoperitoneum

Artificial pneumoperitoneum is applied on an empty stomach. Before introducing gas into the abdominal cavity, the patient must empty the bladder.

Mechanisms of the therapeutic effect of artificial pneumoperitoneum

Mechanical - a decrease in the elastic tension of the lung and partial convergence of the walls of the cavity.

Neuroreflexive - decreased tone of elastic and smooth muscle elements of the lung. This contributes.

• redistribution of microcirculation;
• the development of relative hypoxia, which inhibits the growth of Mycobacterium tuberculosis;
• the development of lymphostasis and slowing down the absorption of toxins.

Air introduced into the abdominal cavity prevents tuberculosis inflammation by limiting diaphragm movements, reducing the volume of lung tissue and reducing the elastic tension of the lung. Raising the diaphragm by 2 cm reduces the volume of the lungs by approximately 700 ml. Raising the dome of the diaphragm to the level of the 4th rib is considered optimal. Introduction of gas into the abdominal cavity causes a viscero-visceral reflex; collapse of the lung, elevation of the diaphragm, increased costal-diaphragmatic breathing, increased lymph flow, improved blood circulation, increased oxidative processes, arterialization of the blood.

Pneumoperitoneum technique

A needle for creating artificial pneumothorax or a longer (6-10 cm) needle is used. The patient is placed on his back; a cushion is placed under the lower sections of the chest. The skin of the abdomen is treated with a 5% alcohol solution of iodine or a 70% ethyl alcohol solution. The abdominal wall is punctured two transverse fingers below and to the left of the navel along the outer edge of the rectus abdominis muscle, the needle is cleaned with a mandrel. Air is introduced into the abdominal cavity through a needle connected to an apparatus for creating artificial pneumothorax.

Unlike artificial pneumothorax, when pneumoperitoneum is imposed, the manometer does not register pressure fluctuations. Only at the moment of gas introduction into the abdominal cavity are small positive fluctuations noted, the pressure value fluctuates from +2 to +10 cm H2O. Indicators of the correct position of the needle: free flow of air into the abdominal cavity, the appearance of a characteristic percussion sound (tympanitis at the site of liver dullness), rapid equalization of the fluid level in the manometer after the gas flow into the abdominal cavity ceases.

During the first insufflation, 400-500 ml of gas is administered, after 24 hours - 400-500 ml, after 3-4 days (depending on the rate of air absorption) - 600-700 ml, less often - 800 ml. Subsequently, insufflations are performed once every 7-10 days. Sometimes up to 1000 ml of gas is administered.

When the body is in a vertical position, the gas moves to the upper abdominal cavity, lifting the diaphragm, pushing the liver, stomach and spleen downwards. To achieve a therapeutic effect, it is sufficient to lift the dome of the diaphragm to the anterior sections of the IV-V ribs.

Contraindications to pneumoperitoneum

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General contraindications:

• extreme degree of exhaustion (weakness of the anterior abdominal wall, presence of hernias);
• concomitant diseases of the abdominal organs;
• previous operations on abdominal organs;
• severe concomitant diseases;
• respiratory failure grade II-III.

Special contraindications:

• common forms of fibro-cavernous or cirrhotic pulmonary tuberculosis:
• subpleural localization of cavities above the level of the third rib;
• caseous pneumonia.

Complications of pneumoperitoneum

• damage to the intestinal wall (up to 1%);
• subcutaneous or mediastinal emphysema (3-5%);
• development of adhesions in the abdominal cavity (30-40%);
• pneumoperitonitis (2-8%);
• air embolism (up to 0.01%).

Treatment with pneumoperitoneum in combination with anti-tuberculosis drugs is continued for 6-12 months. Elimination of pneumoperitoneum is usually carried out without difficulty: the doses of administered gas are gradually reduced, and within 2-3 weeks the gas bubble is completely absorbed.

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