Pneumoperitoneum

Artificial pneumoperitoneum - 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 is used to temporarily correct the volume of the pleural cavity after extensive lung resection.

[1], [2], [3], [4], [5], [6], [7]

Indications for pneumoperitoneum

The main indications for the use of artificial pneumoperitoneum (according to IA Shaklein):

• Infiltrative pulmonary tuberculosis with lesion localization below the clavicle level;
• disseminated subacute tuberculosis;
• pneumonic phase of primary pulmonary tuberculosis;
• fibro-cavernous tuberculosis with a radical localization of caverns;
• pulmonary hemorrhage.

Sometimes an artificial pneumoperitoneum is used in combination with a one-sided artificial pneumothorax as an alternative to frenicoalcoholization.

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 lung, speeds up the resorption of extensive infiltrative-pneumonic changes, aspiration pneumonia. In combination with specific chemotherapy, this method is effective in inflammation of the lung, hematogenically disseminated process, cavernous tuberculosis (regardless of the location of the cavity). This option of collapsotherapy is used when the chemotherapy is ineffective due to drug intolerance or drug resistance of mycobacterium tuberculosis.

Preparation for pneumoperitoneum

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

Mechanisms of therapeutic action of artificial pneumoperitoneum

Mechanical - reducing the elastic stress of the lung and partial approach of the walls of the cavity.

Neuroreflex - a decrease in the tone of the 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;
• development of lymphostasis and slowing the absorption of toxins.

The air introduced into the abdominal cavity prevents tubercular inflammation due to limitation of diaphragm movements, reduction of the volume of the lung tissue and reduction of the elastic tension of the lung. Raising the diaphragm by 2 cm reduces the volume of the lungs by approximately 700 ml. Optimal consider the rise of the dome of the diaphragm to the level of the IV rib. Introduction into the abdominal cavity of the gas causes a viscer-visceral reflex; a decrease in the lung, a rise in the diaphragm, an increase in the rib and diaphragmatic respiration, an increase in the lymph flow, an improvement in blood circulation, an increase in oxidative processes, and blood arterialization.

Methods of pneumoperitoneum

Apply a needle to apply artificial pneumothorax or a longer (6-10 cm) needle. The patient is laid on his back; under the lower sections of the chest put a roller. The skin of the stomach is treated with a 5% solution of iodine alcohol or 70% ethanol. The abdominal wall is pierced into two transverse fingers below and to the left of the navel along the outer edge of the rectus abdominis muscle, and the needle is cleaned with a mandrone. Air into the abdominal cavity is injected through a needle connected to an apparatus for applying an artificial pneumothorax.

Unlike artificial pneumothorax, when a pneumoperitoneum is applied, the manometer does not detect pressure fluctuations. Only at the moment of introducing gas into the abdominal cavity, small positive fluctuations are noted, the pressure varies from +2 to +10 cm of water. Indicators of the correct position of the needle: free entry of air into the abdominal cavity, the appearance of a characteristic percussion sound (tympanitis at the place of liver stupidity), rapid leveling of the liquid level in the manometer after the gas supply to the abdominal cavity has ceased.

At the first insufflation, 400-500 ml of gas are injected, in a day - 400-500 ml, after 3-4 days (depending on the speed of air resorption) - 600-700 ml. Less often - 800 ml. Further insufflation is carried out 1 time in 7-10 days. Sometimes inject up to 1000 ml of gas.

With the vertical position of the body, the gas moves to the upper abdominal cavity, lifting the diaphragm, pushing the liver, stomach and spleen downwards. To obtain the therapeutic effect, the diaphragm dome lifts up to the front segments of the IV-V ribs.

Contraindications to pneumoperitoneum

[8], [9], [10], [11], [12], [13],

General contraindications:

• extreme degree of exhaustion (weakness of anterior abdominal wall, presence of hernias);
• associated diseases of the abdominal cavity;
• the transferred operations on organs of an abdominal cavity;
• severe co-morbidities;
• respiratory insufficiency II-III degree.

Special contraindications:

• widespread forms of fibrous-cavernous or cirrhotic pulmonary tuberculosis:
• subpleural cavern localization above level III of the 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 continues for 6-12 months. The elimination of pneumoperitoneum is usually carried out without difficulty: gradually reduce the dose of the introduced gas, and within 2-3 weeks the gas bubble completely resolves.

[14], [15], [16], [17], [18], [19], [20]