Subcutaneous Emphysema—Beyond the Pneumoperitoneum
Identifieur interne : 000932 ( Pmc/Checkpoint ); précédent : 000931; suivant : 000933Subcutaneous Emphysema—Beyond the Pneumoperitoneum
Auteurs : Douglas E. OttSource :
- JSLS : Journal of the Society of Laparoendoscopic Surgeons [ 1086-8089 ] ; 2014.
Abstract
New additional risks factors that may act to increase the risk of subcutaneous emphysema include total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces.
Url:
DOI: 10.4293/108680813X13693422520882
PubMed: 24680136
PubMed Central: 3939322
Affiliations:
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Subcutaneous Emphysema—Beyond the Pneumoperitoneum</title><author><name sortKey="Ott, Douglas E" sort="Ott, Douglas E" uniqKey="Ott D" first="Douglas E." last="Ott">Douglas E. Ott</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24680136</idno><idno type="pmc">3939322</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939322</idno><idno type="RBID">PMC:3939322</idno><idno type="doi">10.4293/108680813X13693422520882</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">002092</idno><idno type="wicri:Area/Pmc/Curation">002092</idno><idno type="wicri:Area/Pmc/Checkpoint">000932</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Subcutaneous Emphysema—Beyond the Pneumoperitoneum</title><author><name sortKey="Ott, Douglas E" sort="Ott, Douglas E" uniqKey="Ott D" first="Douglas E." last="Ott">Douglas E. Ott</name></author></analytic><series><title level="j">JSLS : Journal of the Society of Laparoendoscopic Surgeons</title><idno type="ISSN">1086-8089</idno><idno type="eISSN">1938-3797</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>New additional risks factors that may act to increase the risk of subcutaneous emphysema include total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Vilos, G" uniqKey="Vilos G">G Vilos</name></author><author><name sortKey="Ternamian, A" uniqKey="Ternamian A">A Ternamian</name></author><author><name sortKey="Dempster, J" uniqKey="Dempster J">J Dempster</name></author><author><name sortKey="Laberge, P" uniqKey="Laberge P">P Laberge</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ott, D" uniqKey="Ott D">D Ott</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ott, De" uniqKey="Ott D">DE Ott</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kuntz, C" uniqKey="Kuntz C">C Kuntz</name></author><author><name sortKey="Wunsch, A" uniqKey="Wunsch A">A Wunsch</name></author><author><name sortKey="Bodeker, C" uniqKey="Bodeker C">C Bodeker</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Menes, T" uniqKey="Menes T">T Menes</name></author><author><name sortKey="Spivak, H" uniqKey="Spivak H">H Spivak</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lacy, A" uniqKey="Lacy A">A Lacy</name></author><author><name sortKey="Blanch, X" uniqKey="Blanch X">X Blanch</name></author><author><name sortKey="Visa, J" uniqKey="Visa J">J Visa</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Niedzielski, A" uniqKey="Niedzielski A">A Niedzielski</name></author><author><name sortKey="Gizewski, J" uniqKey="Gizewski J">J Gizewski</name></author><author><name sortKey="Staraczewski, A" uniqKey="Staraczewski A">A Staraczewski</name></author><author><name sortKey="Rozewiski, S" uniqKey="Rozewiski S">S Rozewiski</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nunn, J" uniqKey="Nunn J">J Nunn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Grzegorzewska, A" uniqKey="Grzegorzewska A">A Grzegorzewska</name></author><author><name sortKey="Antoniewicz, K" uniqKey="Antoniewicz K">K Antoniewicz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, M" uniqKey="Kim M">M Kim</name></author><author><name sortKey="Lofthouse, J" uniqKey="Lofthouse J">J Lofthouse</name></author><author><name sortKey="Flessner, M" uniqKey="Flessner M">M Flessner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mcallister, J" uniqKey="Mcallister J">J McAllister</name></author><author><name sortKey="D Altorio, R" uniqKey="D Altorio R">R D'Altorio</name></author><author><name sortKey="Synder, A" uniqKey="Synder A">A Synder</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sharma, Kc" uniqKey="Sharma K">KC Sharma</name></author><author><name sortKey="Kabinoff, G" uniqKey="Kabinoff G">G Kabinoff</name></author><author><name sortKey="Ducherne, Y" uniqKey="Ducherne Y">Y Ducherne</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Batra, M" uniqKey="Batra M">M Batra</name></author><author><name sortKey="Driscoll, J" uniqKey="Driscoll J">J Driscoll</name></author><author><name sortKey="Coburn, W" uniqKey="Coburn W">W Coburn</name></author><author><name sortKey="Marks, W" uniqKey="Marks W">W Marks</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fitzgerald, Sd" uniqKey="Fitzgerald S">SD Fitzgerald</name></author><author><name sortKey="Andrus, Hc" uniqKey="Andrus H">HC Andrus</name></author><author><name sortKey="Baudendistel, Lj" uniqKey="Baudendistel L">LJ Baudendistel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rittenmeyer, H" uniqKey="Rittenmeyer H">H Rittenmeyer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Herati, A" uniqKey="Herati A">A Herati</name></author><author><name sortKey="Atalla, M" uniqKey="Atalla M">M Atalla</name></author><author><name sortKey="Rais Bahrami, S" uniqKey="Rais Bahrami S">S Rais-Bahrami</name></author><author><name sortKey="Andonian, S" uniqKey="Andonian S">S Andonian</name></author><author><name sortKey="Vira, M" uniqKey="Vira M">M Vira</name></author><author><name sortKey="Kavoussi, L" uniqKey="Kavoussi L">L Kavoussi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Herati, A" uniqKey="Herati A">A Herati</name></author><author><name sortKey="Andonian, S" uniqKey="Andonian S">S Andonian</name></author><author><name sortKey="Rais Bahrami, S" uniqKey="Rais Bahrami S">S Rais-Bahrami</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hillelsohn, J" uniqKey="Hillelsohn J">J Hillelsohn</name></author><author><name sortKey="Friedlander, J" uniqKey="Friedlander J">J Friedlander</name></author><author><name sortKey="Bagadiya, N" uniqKey="Bagadiya N">N Bagadiya</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Celik, H" uniqKey="Celik H">H Celik</name></author><author><name sortKey="Cremins, A" uniqKey="Cremins A">A Cremins</name></author><author><name sortKey="Jones, K" uniqKey="Jones K">K Jones</name></author><author><name sortKey="Harmanli, O" uniqKey="Harmanli O">O Harmanli</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horstmann, M" uniqKey="Horstmann M">M Horstmann</name></author><author><name sortKey="Horton, K" uniqKey="Horton K">K Horton</name></author><author><name sortKey="Kurz, M" uniqKey="Kurz M">M Kurz</name></author><author><name sortKey="Padevit, C" uniqKey="Padevit C">C Padevit</name></author><author><name sortKey="John, H" uniqKey="John H">H John</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wahba, R" uniqKey="Wahba R">R Wahba</name></author><author><name sortKey="Tessler, M" uniqKey="Tessler M">M Tessler</name></author><author><name sortKey="Keiman, S" uniqKey="Keiman S">S Keiman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abe, H" uniqKey="Abe H">H Abe</name></author><author><name sortKey="Bandai, Y" uniqKey="Bandai Y">Y Bandai</name></author><author><name sortKey="Ohtomo, Y" uniqKey="Ohtomo Y">Y Ohtomo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wittigen, Cm" uniqKey="Wittigen C">CM Wittigen</name></author><author><name sortKey="Andrus, Hc" uniqKey="Andrus H">HC Andrus</name></author><author><name sortKey="Fitzgerald, Sd" uniqKey="Fitzgerald S">SD Fitzgerald</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Leighton, T" uniqKey="Leighton T">T Leighton</name></author><author><name sortKey="Pianim, N" uniqKey="Pianim N">N Pianim</name></author><author><name sortKey="Liu, Sy" uniqKey="Liu S">SY Liu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kent, Rb" uniqKey="Kent R">RB Kent</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Holzman, M" uniqKey="Holzman M">M Holzman</name></author><author><name sortKey="Sharp, K" uniqKey="Sharp K">K Sharp</name></author><author><name sortKey="Richards, W" uniqKey="Richards W">W Richards</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hall, D" uniqKey="Hall D">D Hall</name></author><author><name sortKey="Goldstein, A" uniqKey="Goldstein A">A Goldstein</name></author><author><name sortKey="Tynan, E" uniqKey="Tynan E">E Tynan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Marshall, R" uniqKey="Marshall R">R Marshall</name></author><author><name sortKey="Jebsen, P" uniqKey="Jebsen P">P Jebsen</name></author><author><name sortKey="Davie, I" uniqKey="Davie I">I Davie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kelman, G" uniqKey="Kelman G">G Kelman</name></author><author><name sortKey="Swapp, G" uniqKey="Swapp G">G Swapp</name></author><author><name sortKey="Smith, I" uniqKey="Smith I">I Smith</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pearce, D" uniqKey="Pearce D">D Pearce</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Santana, A" uniqKey="Santana A">A Santana</name></author><author><name sortKey="Crausman, R" uniqKey="Crausman R">R Crausman</name></author><author><name sortKey="Dubin, H" uniqKey="Dubin H">H Dubin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nezhat, C" uniqKey="Nezhat C">C Nezhat</name></author><author><name sortKey="Nezhat, F" uniqKey="Nezhat F">F Nezhat</name></author><author><name sortKey="Nezhat, C" uniqKey="Nezhat C">C Nezhat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Murdock, C" uniqKey="Murdock C">C Murdock</name></author><author><name sortKey="Wolff, A" uniqKey="Wolff A">A Wolff</name></author><author><name sortKey="Van Geem, T" uniqKey="Van Geem T">T Van Geem</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kalhan, S" uniqKey="Kalhan S">S Kalhan</name></author><author><name sortKey="Reaney, J" uniqKey="Reaney J">J Reaney</name></author><author><name sortKey="Collins, R" uniqKey="Collins R">R Collins</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kent, R" uniqKey="Kent R">R Kent</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wolf, J" uniqKey="Wolf J">J Wolf</name></author><author><name sortKey="Monk, T" uniqKey="Monk T">T Monk</name></author><author><name sortKey="Mcdougall, E" uniqKey="Mcdougall E">E McDougall</name></author><author><name sortKey="Mcclennan, B" uniqKey="Mcclennan B">B McClennan</name></author><author><name sortKey="Clayman, R" uniqKey="Clayman R">R Clayman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Waisbren, S" uniqKey="Waisbren S">S Waisbren</name></author><author><name sortKey="Herz, B" uniqKey="Herz B">B Herz</name></author><author><name sortKey="Ducheine, Y" uniqKey="Ducheine Y">Y Ducheine</name></author><author><name sortKey="Yang, H" uniqKey="Yang H">H Yang</name></author><author><name sortKey="Karanfilian, R" uniqKey="Karanfilian R">R Karanfilian</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wolf, J" uniqKey="Wolf J">J Wolf</name></author><author><name sortKey="Clayman, R" uniqKey="Clayman R">R Clayman</name></author><author><name sortKey="Monk, T" uniqKey="Monk T">T Monk</name></author><author><name sortKey="Mcclennan, B" uniqKey="Mcclennan B">B McClennan</name></author><author><name sortKey="Mcdougal, E" uniqKey="Mcdougal E">E McDougal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, D" uniqKey="Lee D">D Lee</name></author><author><name sortKey="Kim, M" uniqKey="Kim M">M Kim</name></author><author><name sortKey="Lee, Y" uniqKey="Lee Y">Y Lee</name></author><author><name sortKey="Lee, H" uniqKey="Lee H">H Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horak, S" uniqKey="Horak S">S Horak</name></author><author><name sortKey="Blecharz, A" uniqKey="Blecharz A">A Blecharz</name></author><author><name sortKey="Rzempoluch, J" uniqKey="Rzempoluch J">J Rzempoluch</name></author><author><name sortKey="Blochal, S" uniqKey="Blochal S">S Blochal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mcalister, J" uniqKey="Mcalister J">J McAlister</name></author><author><name sortKey="D Altonio, R" uniqKey="D Altonio R">R D'Altonio</name></author><author><name sortKey="Synder, A" uniqKey="Synder A">A Synder</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bard, P" uniqKey="Bard P">P Bard</name></author><author><name sortKey="Chen, L" uniqKey="Chen L">L Chen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Klopfenstein, C" uniqKey="Klopfenstein C">C Klopfenstein</name></author><author><name sortKey="Gaggero, G" uniqKey="Gaggero G">G Gaggero</name></author><author><name sortKey="Mamie, C" uniqKey="Mamie C">C Mamie</name></author><author><name sortKey="Morel, P" uniqKey="Morel P">P Morel</name></author><author><name sortKey="Forster, A" uniqKey="Forster A">A Forster</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Perko, G" uniqKey="Perko G">G Perko</name></author><author><name sortKey="Fernandes, A" uniqKey="Fernandes A">A Fernandes</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chui, P" uniqKey="Chui P">P Chui</name></author><author><name sortKey="Gin, T" uniqKey="Gin T">T Gin</name></author><author><name sortKey="Chang, S" uniqKey="Chang S">S Chang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abbott, D" uniqKey="Abbott D">D Abbott</name></author><author><name sortKey="Dunkley, A" uniqKey="Dunkley A">A Dunkley</name></author><author><name sortKey="Roberts, F" uniqKey="Roberts F">F Roberts</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lindsey, S" uniqKey="Lindsey S">S Lindsey</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ahmad, G" uniqKey="Ahmad G">G Ahmad</name></author><author><name sortKey="Duffy, J" uniqKey="Duffy J">J Duffy</name></author><author><name sortKey="Phillips, K" uniqKey="Phillips K">K Phillips</name></author><author><name sortKey="Watson, A" uniqKey="Watson A">A Watson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agresta, F" uniqKey="Agresta F">F Agresta</name></author><author><name sortKey="De Simone, P" uniqKey="De Simone P">P De Simone</name></author><author><name sortKey="Ciardo, L" uniqKey="Ciardo L">L Ciardo</name></author><author><name sortKey="Bedin, N" uniqKey="Bedin N">N Bedin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rudston Brown, B" uniqKey="Rudston Brown B">B Rudston-Brown</name></author><author><name sortKey="Maclennan, D" uniqKey="Maclennan D">D MacLennan</name></author><author><name sortKey="Warriner, C" uniqKey="Warriner C">C Warriner</name></author><author><name sortKey="Phang, P" uniqKey="Phang P">P Phang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ahn, Y" uniqKey="Ahn Y">Y Ahn</name></author><author><name sortKey="Leach, J" uniqKey="Leach J">J Leach</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cunningham, A" uniqKey="Cunningham A">A Cunningham</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rosenthal, R" uniqKey="Rosenthal R">R Rosenthal</name></author><author><name sortKey="Friedman, R" uniqKey="Friedman R">R Friedman</name></author><author><name sortKey="Phillips, E" uniqKey="Phillips E">E Phillips</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gomel, V" uniqKey="Gomel V">V Gomel</name></author><author><name sortKey="Taylor, P" uniqKey="Taylor P">P Taylor</name></author><author><name sortKey="Yuzpe, A" uniqKey="Yuzpe A">A Yuzpe</name></author><author><name sortKey="Rioux, J" uniqKey="Rioux J">J Rioux</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wetter, P" uniqKey="Wetter P">P Wetter</name></author><author><name sortKey="Kavic, M" uniqKey="Kavic M">M Kavic</name></author><author><name sortKey="Levinson, C" uniqKey="Levinson C">C Levinson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hulka, J" uniqKey="Hulka J">J Hulka</name></author><author><name sortKey="Reich, H" uniqKey="Reich H">H Reich</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Whelan, J" uniqKey="Whelan J">J Whelan</name></author><author><name sortKey="Fleshman, J" uniqKey="Fleshman J">J Fleshman</name></author><author><name sortKey="Fowler, D" uniqKey="Fowler D">D Fowler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kalhan, S" uniqKey="Kalhan S">S Kalhan</name></author><author><name sortKey="Reaney, J" uniqKey="Reaney J">J Reaney</name></author><author><name sortKey="Collins, R" uniqKey="Collins R">R Collins</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lew, J" uniqKey="Lew J">J Lew</name></author><author><name sortKey="Gin, T" uniqKey="Gin T">T Gin</name></author><author><name sortKey="Oh, T" uniqKey="Oh T">T Oh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Muller, N" uniqKey="Muller N">N Muller</name></author><author><name sortKey="Nelems, B" uniqKey="Nelems B">B Nelems</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pascual, J" uniqKey="Pascual J">J Pascual</name></author><author><name sortKey="Baranda, M" uniqKey="Baranda M">M Baranda</name></author><author><name sortKey="Tarrero, M" uniqKey="Tarrero M">M Tarrero</name></author><author><name sortKey="Gutierrez, M" uniqKey="Gutierrez M">M Gutierrez</name></author><author><name sortKey="Garrido, I" uniqKey="Garrido I">I Garrido</name></author><author><name sortKey="Errasti, C" uniqKey="Errasti C">C Errasti</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Whiston, R" uniqKey="Whiston R">R Whiston</name></author><author><name sortKey="Eggers, K" uniqKey="Eggers K">K Eggers</name></author><author><name sortKey="Morris, R" uniqKey="Morris R">R Morris</name></author><author><name sortKey="Stamatakis, J" uniqKey="Stamatakis J">J Stamatakis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Shah, P" uniqKey="Shah P">P Shah</name></author><author><name sortKey="Ramakantan, R" uniqKey="Ramakantan R">R Ramakantan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Herrerias, J" uniqKey="Herrerias J">J Herrerias</name></author><author><name sortKey="Ariza, A" uniqKey="Ariza A">A Ariza</name></author><author><name sortKey="Garrido, M" uniqKey="Garrido M">M Garrido</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Richard, H" uniqKey="Richard H">H Richard</name></author><author><name sortKey="Stancato Pasik, A" uniqKey="Stancato Pasik A">A Stancato-Pasik</name></author><author><name sortKey="Salky, B" uniqKey="Salky B">B Salky</name></author><author><name sortKey="Mendelson, D" uniqKey="Mendelson D">D Mendelson</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">JSLS</journal-id><journal-id journal-id-type="iso-abbrev">JSLS</journal-id><journal-id journal-id-type="hwp">jsls</journal-id><journal-id journal-id-type="pmc">jsls</journal-id><journal-id journal-id-type="publisher-id">JSLS</journal-id><journal-title-group><journal-title>JSLS : Journal of the Society of Laparoendoscopic Surgeons</journal-title></journal-title-group><issn pub-type="ppub">1086-8089</issn><issn pub-type="epub">1938-3797</issn><publisher><publisher-name>Society of Laparoendoscopic Surgeons</publisher-name><publisher-loc>Miami, FL</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24680136</article-id><article-id pub-id-type="pmc">3939322</article-id><article-id pub-id-type="publisher-id">JSLS-D-13-00102</article-id><article-id pub-id-type="doi">10.4293/108680813X13693422520882</article-id><article-categories><subj-group subj-group-type="heading"><subject>Scientific Papers</subject></subj-group></article-categories><title-group><article-title>Subcutaneous Emphysema—Beyond the Pneumoperitoneum</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Ott</surname><given-names>Douglas E.</given-names></name><degrees>MD, MBA</degrees><aff>Biomedical Engineering, Mercer University, Macon, GA, USA.</aff></contrib></contrib-group><author-notes><corresp>Address correspondence to: Douglas E. Ott, MD, MBA, <addr-line>109 Preston Court, Macon GA 31210</addr-line>. Telephone: <phone>(478) 477-8996</phone>, E-mail: <email>gabiomed@mindspring.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jan-Mar</season><year>2014</year></pub-date><volume>18</volume><issue>1</issue><fpage>1</fpage><lpage>7</lpage><permissions><copyright-statement>© 2014 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.</copyright-statement><copyright-year>2014</copyright-year><copyright-holder>Society of Laparoendoscopic Surgeons, Inc.</copyright-holder><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/us/">http://creativecommons.org/licenses/by-nc-nd/3.0/us/</ext-link>), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.</license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="jls00114000001.pdf"></self-uri><abstract abstract-type="precis"><p>New additional risks factors that may act to increase the risk of subcutaneous emphysema include total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces.</p></abstract><abstract><sec><title>Background:</title><p>Subcutaneous emphysema and gas extravasation outside of the peritoneal cavity during laparoscopy has consequences. Knowledge of the circumstances that increase the potential for subcutaneous emphysema is necessary for safe laparoscopy.</p></sec><sec><title>Methods:</title><p>A literature review and a PubMed search are the basis for this review.</p></sec><sec><title>Conclusions:</title><p>The known risk factors leading to subcutaneous emphysema during laparoscopy are multiple attempts at abdominal entry, improper cannula placement, loose fitting cannula/skin and fascial entry points, use of >5 cannulas, use of cannulas as fulcrums, torque of the laparoscope, increased intra-abdominal pressure, procedures lasting >3.5 hours, and attention to details. New additional risk factors acting as direct factors leading to subcutaneous emphysema risk and occurrence are total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces. Recognizing this spectrum of factors that leads to subcutaneous emphysema will yield greater patient safety during laparoscopic procedures.</p></sec></abstract><kwd-group><kwd>Subcutaneous emphysema</kwd><kwd>Carbon dioxide</kwd><kwd>Gas volume</kwd><kwd>Pneumoperitoneum</kwd><kwd>Laparoscopic safety</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>It is important to know where the gas travels during laparoscopic surgery. Placing trocars through the abdominal wall requires more than skill. A planned approach requires consideration of the patients' topography and habitus; knowledge of the surgical procedure; modifications based on specific circumstances peculiar to the patient, number, placement, angle, and trajectory of the trocars; understanding the instruments and devices being deployed and their intended uses, capabilities, and limitations; alternatives to routines, a “plan B”'; an ability to assess and handle adversity and complications; and overcoming arrogance and overconfidence. The focus of this review is to consider the why, what, where, and who of gas intended to distend the peritoneal cavity extending beyond the intended site and to increase awareness of the conditions that effect extravasation of gas beyond the intra-abdominal cavity confines during laparoscopy.</p><sec><title>Choices, Decisions, Consequences</title><p>The potential for subcutaneous emphysema starts with the physician's preparation, knowledge, and experience. A decision regarding the strategy of trocar placement appropriate for the planned procedure precedes an incision. The access incision is followed by a series of events affecting how and where the gas goes and its eventual clinical consequences. The incision(s) (number and size), trocar(s) (number and size), incision/size relationship to trocar size, trocar placement and angle (skin and fascia relationship), fulcrum effect, torque, gas pressure, flow rate and end-point pressure setting, gas volume used, and abdominal wall compliance all influence the appropriateness, completeness, and status of a pneumoperitoneum (<bold><xref ref-type="table" rid="T1">Table 1</xref></bold>).</p><table-wrap id="T1" position="float"><label>Table 1.</label><caption><p>Factors Leading to Subcutaneous Emphysema</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Insufflator (high gas flow and high gas pressure setting)</td></tr><tr><td align="left" rowspan="1" colspan="1">Intra-abdominal pressure >15 mm Hg</td></tr><tr><td align="left" rowspan="1" colspan="1">Multiple attempts at the abdominal entry</td></tr><tr><td align="left" rowspan="1" colspan="1">Veress needle or cannula not placed in the peritoneal cavity</td></tr><tr><td align="left" rowspan="1" colspan="1">Skin/fascial fit/seal around the cannulas is not snug</td></tr><tr><td align="left" rowspan="1" colspan="1">Use of >5 cannulas</td></tr><tr><td align="left" rowspan="1" colspan="1">Laparoscope used as a lever</td></tr><tr><td align="left" rowspan="1" colspan="1">Cannula acting as a fulcrum</td></tr><tr><td align="left" rowspan="1" colspan="1">Long arm of the laparoscope is a force multiplier</td></tr><tr><td align="left" rowspan="1" colspan="1">Tissue integrity compromised by repetitive movements</td></tr><tr><td align="left" rowspan="1" colspan="1">Structural weakness caused by repetitive movements</td></tr><tr><td align="left" rowspan="1" colspan="1">Improper cannula placement, causing stressed angulation</td></tr><tr><td align="left" rowspan="1" colspan="1">Soft tissue dissection and fascial extension</td></tr><tr><td align="left" rowspan="1" colspan="1">Gas dissection leading to more dissection</td></tr><tr><td align="left" rowspan="1" colspan="1">Procedures lasting >3.5 hours</td></tr><tr><td align="left" rowspan="1" colspan="1">Positive end-tidal CO<sup>2</sup> >50 mm Hg</td></tr></tbody></table></table-wrap><p>Carbon dioxide (CO<sub>2</sub>) is listed in the United States Pharmacopeia and is sold with the following labeling: “WARNING! Administration of Carbon Dioxide may be hazardous or contraindicated. For use only by or under the supervision of a licensed practitioner who is experienced in the use and administration of Carbon Dioxide and is familiar with the indications, effects, dosages, methods and frequency and duration of administration, and with the hazards, contraindications, and side effects and the precautions to be taken.” The volume of gas consumed during laparoscopy is important missing data that must be charted along with pressure settings and flow rate. The length of time an operation takes is an important data point, as is the length of anesthesia administration and the type, strength, amount, and volume of drugs used for inhalation or other therapeutic reasons (eg, analgesia, cardiac or blood pressure), but it is not the same as the CO<sub>2</sub> gas volume used during laparoscopy.</p></sec><sec><title>Gas Volume and Flow Rate</title><p>Insufflator flow rate and pressure settings allow gas to be forced from a high-pressure gas system to a low-pressure container (insufflator to abdomen), expanding the cavity. If the entry site is appropriate in size (snug fit), there is no tear in the peritoneum other than trocar penetration, and the trocar extends beyond the peritoneum, gas dissection outside the peritoneal cavity is unlikely and gas is pumped into the intra-abdominal space until back-pressure resistance stops expansion at the predetermined pressure set point. Once a sufficient intra-abdominal space is secured for the surgical procedure, gas flow should be discontinued, even if it is below the pressure set point. Gas insufflation into the peritoneal cavity without increased distention increases intra-abdominal pressure (IAP) and does not increase operating space. Each increase in pressure in the abdomen (in mm Hg) is transmitted against the inner abdominal wall and transmitted to tissues, resulting in decreased perfusion, hypoxia, increased gas absorption, and increased likelihood of tissue dissection and subcutaneous emphysema. The “safe” range of pneumoperitoneum IAP is 0 to 20 mm Hg, although 12 to 14 mm Hg is recommended. It would be best to try to operate at the lowest IAP possible with the lowest flow rate to accomplish the planned surgery and not use arbitrary numbers because they may exceed safety limits in a particular patient.<sup><xref rid="B1" ref-type="bibr">1</xref><xref ref-type="bibr" rid="B2">–</xref><xref rid="B3" ref-type="bibr">3</xref></sup></p><p>IAP causes a mechanical event regardless of the chemical formula of the gas(es) involved. The safety profile of CO<sub>2</sub> favors its use and has chemical effects separate from the generalized mechanical effects of any pneumoperitoneum. Any gas(es) used for a pneumoperitoneum creates an increase in pressure and causes varying degrees of peripheral pooling, vena cava compression, increased venous resistance leading to decreased venous return, decreased cardiac output, and fluctuation in arterial pressure; increased intrathoracic pressure; peritoneal receptor stimulation with neurohumoral factor release of vasopressin, catechols, and renin; and increased vascular resistance of intra-abdominal organs, which increases systemic vascular resistance, acidosis, hypercarbia, hypoxia, and oxidative stress, and—if the gas dissects into surrounding tissues—pneumothorax, pneumomediastinum, and subcutaneous emphysema (<bold><xref ref-type="table" rid="T2">Table 2</xref></bold>).<sup><xref rid="B4" ref-type="bibr">4</xref></sup></p><table-wrap id="T2" position="float"><label>Table 2.</label><caption><p>Recognizable Changes Seen with Subcutaneous Emphysema</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Crepitus</td></tr><tr><td align="left" rowspan="1" colspan="1">Insufflation problems (flow and pressure)</td></tr><tr><td align="left" rowspan="1" colspan="1">Hypercarbia (monitor end-tidal CO<sub>2</sub>)</td></tr><tr><td align="left" rowspan="1" colspan="1">Acidosis (monitor partial pressure of CO<sub>2</sub> in arterial blood and rule out malignant hyperthermia)</td></tr><tr><td align="left" rowspan="1" colspan="1">Change in lung compliance</td></tr><tr><td align="left" rowspan="1" colspan="1">Cardiac arrhythmias, sinus tachycardia, and hypertension</td></tr><tr><td align="left" rowspan="1" colspan="1">Intraoperative increase in partial pressure of end-tidal CO<sub>2</sub> >50 mm Hg</td></tr></tbody></table></table-wrap><p>The ideal gas for pneumoperitoneum insufflation is nontoxic, colorless, readily soluble in the blood, easily expelled from the body or expired through the lungs, nonflammable, and inexpensive. CO<sub>2</sub> best satisfies these characteristics. Oxygen and air are not readily absorbed through the peritoneum and can result in air embolism. Nitrous oxide (NO) has unpredictable absorption. Helium (He) is relatively insoluble in blood compared with CO<sub>2</sub>. Argon (Ar) has a more significant depressant effect on hemodynamics than CO<sub>2</sub>. Oxygen and NO, if mixed with methane, support combustion and are dangerous. The best elements of safety, utility, and cost favor the use of CO<sub>2</sub>.<sup><xref rid="B5" ref-type="bibr">5</xref>,<xref rid="B6" ref-type="bibr">6</xref></sup> The rate of CO<sub>2</sub> absorption through the peritoneum during laparoscopy ranges between 14 and 48 mL/min<sup><xref rid="B7" ref-type="bibr">7</xref></sup> based on peritoneal cavity gas clearance estimates and on peritoneal blood flow being between 2% and 7% of cardiac output, to be ∼100 mL/min (<bold><xref ref-type="table" rid="T3">Table 3</xref></bold>).<sup><xref rid="B8" ref-type="bibr">8</xref><xref ref-type="bibr" rid="B9">–</xref><xref rid="B10" ref-type="bibr">10</xref></sup></p><table-wrap id="T3" position="float"><label>Table 3.</label><caption><p>Intraoperative Causes and Risk Factors for Hypercarbia During Laparoscopy</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Integrity of the anesthesia circuit</td></tr><tr><td align="left" rowspan="1" colspan="1">Position and function of the endotracheal tube</td></tr><tr><td align="left" rowspan="1" colspan="1">Inadequate respiratory exchange</td></tr><tr><td align="left" rowspan="1" colspan="1">Exclude causes other than CO<sub>2</sub> for acidosis</td></tr><tr><td align="left" rowspan="1" colspan="1">Underlying obstructive lung disease</td></tr><tr><td align="left" rowspan="1" colspan="1">Age >65 years</td></tr><tr><td align="left" rowspan="1" colspan="1">Type of surgery (Nissen fundoplication)</td></tr></tbody></table></table-wrap><p>The incidence of subcutaneous emphysema varies from isolated and confined in a small space to extravasation outside of the abdominal cavity extending into the labia, scrotum, legs, chest, head, and neck. The literature range is 0.43% to 2.3% for grossly detectable subcutaneous emphysema. It has been shown in postoperative computed tomography scans from laparoscopic cholecystectomy patients that there was a 56% rate of grossly undetectable or clinical subcutaneous emphysema 24 hours after the procedure.<sup><xref rid="B11" ref-type="bibr">11</xref></sup></p><p>Pneumothorax caused by extension of insufflated gas through diaphragmatic congenital channels into the pleural cavities is reported as 0.03%.<sup><xref rid="B12" ref-type="bibr">12</xref><xref ref-type="bibr" rid="B13">–</xref><xref rid="B14" ref-type="bibr">14</xref></sup> Subcutaneous emphysema, pneumomediastinum, and retroperitoneal extravasation without pneumothorax have also been described during laparoscopic surgery with CO<sub>2</sub> insufflation and may be associated with prolonged hypercarbia.<sup><xref rid="B15" ref-type="bibr">15</xref></sup> Recent articles citing use of a valveless trocar and dynamic pressure system (AirSeal; SurgiQuest, Milford, CT) showed a 19.1% rate of subcutaneous emphysema over 7 times the reported rate, a 3.9% rate of pneumomediastinum 2 times the reported rate, and a 1.2% complication rate of masked pneumothorax a rate 3 times the reported rate for a 24.2% total overall complication rate or 9 times the total reported rate.<sup><xref rid="B16" ref-type="bibr">16</xref><xref ref-type="bibr" rid="B17">–</xref><xref rid="B20" ref-type="bibr">20</xref></sup> Because of these dangers and increased rates of occurrence, it is important that physicians who perform laparoscopy and the postoperative treatment of these patients be familiar with these complications, their natural history, and their management.</p><p>The clinical significance of subcutaneous emphysema is development of hypercarbia and acidosis. The increased risk of hypercarbia is caused by the large peritoneal surface tissue area exposed to CO<sub>2</sub>.<sup><xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B22" ref-type="bibr">22</xref></sup></p><p>Hypercarbia and acidosis are the most commonly recognized complications. A combination of factors contribute to increased arterial partial pressure of CO<sub>2</sub> in arterial blood: rapid absorption of CO<sub>2</sub>, reduced diaphragmatic movement, a decrease in residual functional capacity, and decreased pulmonary CO<sub>2</sub> excretion, leading to ventilation-perfusion mismatch.<sup><xref rid="B23" ref-type="bibr">23</xref>,<xref rid="B24" ref-type="bibr">24</xref></sup> Cardiovascular compromise can be caused by mechanical factors from increased intra-abdominal pressure, affecting ventilation and venous return and with accumulation of CO<sub>2</sub> in the circulation, leading to acidosis and cardiopulmonary system compromise.<sup><xref rid="B25" ref-type="bibr">25</xref></sup> Hypercarbia increases heart rate, systemic blood pressure, central venous pressure, cardiac output, and stroke volume, and it decreases peripheral vascular resistance because of the release of epinephrine and norepinephrine.<sup><xref rid="B26" ref-type="bibr">26</xref><xref ref-type="bibr" rid="B27">–</xref><xref rid="B31" ref-type="bibr">31</xref></sup></p><p>Factors associated with subcutaneous emphysema during laparoscopic pneumoperitoneum are methods of laparoscopy (video assisted or robotic),<sup><xref rid="B32" ref-type="bibr">32</xref></sup> insufflator settings for pressure and flow, actual IAP, actual flow rate, number of abdominal entry sites, size and geometry of fascial incision to trocar size of entry site, snugness of fit between trocar and fascia, number of times the entry site is entered, amount of torqueing and pressure on entry sites, vectoring of the laparoscope, fulcrum effect between laparoscope and fascia, length of procedure, volume of gas used, patient age, patient BMI, coexisting metabolic diseases, tissue integrity, type of trocar used, and purposeful extraperitoneal dissection. The total amount of gas used may or may not be related to the length of time of the procedure and may be more important than the length of time of the procedure. Insufflator settings for pressure and flow rate influence insufflation dynamics, the amount of gas absorption or extraperitoneal extravasation with higher pressures, and flow rates contributing to the increased incidence of gas extravasation, noted as <italic>subcutaneous emphysema</italic> (<bold><xref ref-type="table" rid="T4">Table 4</xref></bold>).</p><table-wrap id="T4" position="float"><label>Table 4.</label><caption><p>Factors Associated with Increased Likelihood of Subcutaneous Emphysema, Pneumothorax, or Pneumomediastinum</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Improper placement of gas</td></tr><tr><td align="left" rowspan="1" colspan="1">Repeated attempts to create a pneumoperitoneum</td></tr><tr><td align="left" rowspan="1" colspan="1">Improper placement of the trocar</td></tr><tr><td align="left" rowspan="1" colspan="1">Loose trocar fascia entry</td></tr><tr><td align="left" rowspan="1" colspan="1">Number of trocars >4</td></tr><tr><td align="left" rowspan="1" colspan="1">Size of trocars is ≥10 mm</td></tr><tr><td align="left" rowspan="1" colspan="1">Torqueing with traumatic expansion of the fascia</td></tr><tr><td align="left" rowspan="1" colspan="1">Longer surgery time</td></tr><tr><td align="left" rowspan="1" colspan="1">Volume of gas (must be recorded and part of the record)</td></tr><tr><td align="left" rowspan="1" colspan="1">Flow rate and pressure (high flow rate and high pressure)</td></tr><tr><td align="left" rowspan="1" colspan="1">Lack of external visualization during robotic procedures</td></tr><tr><td align="left" rowspan="1" colspan="1">Lack of haptic feedback during robotic procedures</td></tr><tr><td align="left" rowspan="1" colspan="1">Increased mechanical advantage without recognition during robotic surgery</td></tr></tbody></table></table-wrap></sec><sec><title>Forces, Fulcrum, and Leverage</title><p>How and to what extent a tissue is dissected by gas depends on its structure, integrity, composition, architecture, morphology, tensile strength, and adherence to underlying structures. These tissue characteristics are affected by the pressure settings, pressure drop, volume, duration, and resistance to gas flow. Peritoneal separation can occur because of multiple repetitive movements of the laparoscope acting through a cannula. The cannula acts as a fulcrum for the laparoscope (lever arm) to act as a class-one lever and force multiplier. The pivot point is the fascial entry site. The resulting mechanical advantage can extend the original peritoneal penetration site, allowing gas extravasation into planes outside of the abdomen. During robotic surgery, instrument manipulation occurs without the surgeon's ability to sense or appreciate these forces because of lack of haptic feedback and the inability to see the relationship of the length of the laparoscope to the abdominal entry point. Separation of the surgeon at a console from the patient removes the ability to see the results of their hand movements and how this effects trocar angle and amount of stress and torqueing of the peritoneal entry site, because there is little to no haptic feedback (tactile) to alert the surgeon of overstressing the port entry sites. Attention of the assistant at the operating table is important for monitoring not only the robotic instruments but also the entry sites and robotic movements that may compromise the port sites.</p><p>A laparoscope or instrument placed through the abdominal wall into the peritoneal cavity acts as a class-one lever with the fulcrum pivot point as the trocar and fascia. The laparoscope is the movable bar pivoting at the fixed point of the trocar and fascia. Because distance from the fulcrum equals force × distance, this becomes leverage and thus mechanical advantage. The laparoscope becomes a force multiplier. A small force a long distance from the fulcrum can produce a significant effect. The laparoscopy through the cannula also creates torque and a vector pressure by fulcrum effect on all tissue structures in that path. Torque is the force causing an object to rotate about an axis, fulcrum, or pivot. The laparoscope rotates about an axis or pivot point as it passes through the cannula, penetrating the abdominal wall. The distance from the pivot point to the point where the force acts is the moment arm, creating a vector that can increase the size of the peritoneal entry defect.</p><p>Torque pressure sensation can be appreciated during traditional straight laparoscopic procedures but is not felt during robotic procedures, because there is a loss of force feedback and haptic awareness. During robotic procedures, force feedback related to angulation of instruments and trocars and lack of direct visualization of the cannula by the operating surgeon increases the potential for overstressing tissues and loss of tissue layer integrity, which leads to gas extravasation tissue dissection and subcutaneous emphysema.</p></sec><sec><title>Literature Review of Subcutaneous Emphysema and Laparoscopy</title><p>A search of PubMed for “subcutaneous emphysema” and “laparoscopy” identified 175 citations.<sup><xref rid="B7" ref-type="bibr">7</xref>,<xref rid="B33" ref-type="bibr">33</xref><xref ref-type="bibr" rid="B34">–</xref><xref rid="B65" ref-type="bibr">65</xref></sup> Major contributors to the occurrence of subcutaneous emphysema include surgical entry technique leading to preperitoneal insufflation, improper trocar placement, gas flow rate and pressure setting, number of trocars, length of procedure, and total amount of gas used.<sup><xref rid="B33" ref-type="bibr">33</xref><xref ref-type="bibr" rid="B34">–</xref><xref rid="B39" ref-type="bibr">39</xref></sup></p><p>The reported incidence rate of known subcutaneous emphysema ranges from 0.43% to 2.34%.<sup><xref rid="B7" ref-type="bibr">7</xref>,<xref rid="B33" ref-type="bibr">33</xref>,<xref rid="B40" ref-type="bibr">40</xref></sup> It is reported that as much as 77% of laparoscopy patients have grossly undetectable subcutaneous emphysema but 20% have findings on postoperative chest radiograph of pneumomediastinum.<sup><xref rid="B36" ref-type="bibr">36</xref><xref ref-type="bibr" rid="B37">–</xref><xref rid="B38" ref-type="bibr">38</xref></sup> Computed tomography scans taken within 24 hours of laparoscopic cholecystectomy show 56% of patients with undetectable subcutaneous emphysema.<sup><xref rid="B41" ref-type="bibr">41</xref></sup> Prolonged operative time, increased age, increased end tidal carbon dioxide, and increased number of operative ports are significantly associated with subcutaneous emphysema.<sup><xref rid="B32" ref-type="bibr">32</xref></sup> None of the articles reviewed evaluated, screened for, measured, or mentioned total gas volume as a consideration regarding correlation or association with subcutaneous emphysema occurrence. Of course, the gas is necessary for the occurrence so gas volume is a necessary component and important factor. Overlooking or disregarding total gas volume is a disregard for completeness and appreciation of the laparoscopic process: this is a critical flaw in the assessment of the activity. Historically, there is little to no appreciation of the interaction, correlation or lack of correlation, causation, or association and the relationship between the amounts of gas used during laparoscopy, length of time of insufflation exposure, or the IAP during the surgery. The relationship of gas volume and subcutaneous emphysema occurrence is the interaction of gas volume used, insufflation exposure time, gas flow rate, and IAP. Subcutaneous emphysema is caused by the constellation of these factors. There is at least a matrix of 16 possibilities. It could be low gas volume, increased surgery time, high sustained intra-abdominal pressure and high gas flow, or high total gas volume, long surgery time, high IAP and low gas flow rate, or large gas volume, short exposure, high IAP, and high gas flow rate, etc. Based on the literature, the contribution of these factors is unknown. The data point of CO<sub>2</sub> volume for laparoscopic procedures is mostly ignored, poorly monitored, and rarely recorded or reported. Not paying attention to this is folly and sloppy, and it disregards a factor that has an impact on and consequences for the patient. The question is how much gas exposure, along with other factors, causes extravasation? Insufflation time is usually noted on the anesthesia record; pressure and volume settings may or may not be charted, but total gas exposure volume is universally <italic>not</italic> recorded. It is suspected that the factors of gas flow, length of gas exposure, IAP, and gas volume used affect the patient and the occurrence of gas extravasation and subcutaneous emphysema (<bold><xref ref-type="table" rid="T5">Table 5</xref></bold>).</p><table-wrap id="T5" position="float"><label>Table 5.</label><caption><p>Actions to Initiate When Subcutaneous Emphysema Is Suspected or Noticed</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Evaluate for a pneumothorax</td></tr><tr><td align="left" rowspan="1" colspan="1">Check end-tidal CO<sub>2</sub> and arterial CO<sub>2</sub></td></tr><tr><td align="left" rowspan="1" colspan="1">Increase ventilation rate and tidal volume</td></tr><tr><td align="left" rowspan="1" colspan="1">Increase oxygen to 100%</td></tr><tr><td align="left" rowspan="1" colspan="1">CO<sub>2</sub> absorber in the circuit</td></tr><tr><td align="left" rowspan="1" colspan="1">Decreased IAP</td></tr><tr><td align="left" rowspan="1" colspan="1">Discontinue NO because it rapidly enters the area of tissue emphysema</td></tr><tr><td align="left" rowspan="1" colspan="1">Assess airway to ensure there is no compression before extubation</td></tr></tbody></table></table-wrap><p>To reduce the likelihood of subcutaneous emphysema, the following are recommended: awareness of its potential; physician vigilance; attention to detail regarding abdominal entry; monitoring insufflator settings for pressure, flow rate, and volume of gas with alarm settings; quickness, but not rushing, to complete the procedure (because length of procedure and gas consumption relate to the condition); reduce the number of attempts to enter the abdomen; have a snug trocar skin condition; test for correct placement by initial IAP assessment; and monitor end tidal CO<sub>2</sub> (<bold><xref ref-type="table" rid="T6">Table 6</xref></bold>).</p><table-wrap id="T6" position="float"><label>Table 6.</label><caption><p>How to Prevent Subcutaneous Emphysema</p></caption><table frame="hsides" rules="groups"><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">Awareness</td></tr><tr><td align="left" rowspan="1" colspan="1">Vigilance</td></tr><tr><td align="left" rowspan="1" colspan="1">Observation</td></tr><tr><td align="left" rowspan="1" colspan="1">Technique</td></tr><tr><td align="left" rowspan="1" colspan="1">Low gas flow and pressure settings</td></tr><tr><td align="left" rowspan="1" colspan="1">Low IAP</td></tr><tr><td align="left" rowspan="1" colspan="1">Cannulas that fit snugly</td></tr><tr><td align="left" rowspan="1" colspan="1">Gentle handling of trocars intraoperatively</td></tr><tr><td align="left" rowspan="1" colspan="1">CO<sub>2</sub> gas monitoring (respiratory and blood)</td></tr><tr><td align="left" rowspan="1" colspan="1">Reduced torqueing and fulcrum effect</td></tr><tr><td align="left" rowspan="1" colspan="1">Performing quickly, but not rushing</td></tr><tr><td align="left" rowspan="1" colspan="1">Attention to detail, attention to detail, attention to detail</td></tr></tbody></table></table-wrap></sec></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>See <bold><xref ref-type="table" rid="T1">Tables 1</xref><xref ref-type="table" rid="T2"></xref><xref ref-type="table" rid="T3"></xref><xref ref-type="table" rid="T4"></xref><xref ref-type="table" rid="T5"></xref>–<xref ref-type="table" rid="T6">6</xref>.</bold> Factors that should alert surgeons and anesthesiologists to the potential for subcutaneous emphysema are the use of four or more trocars, trocars that are not tight fitting with slippage, prolonged increases of IAP, increased operating time, and increased volume of gas. It is necessary to be prepared for less than optimal occurrences during laparoscopy, have a plan, be vigilant, be cautious, know how to use and set the insufflator, record the volume of CO<sub>2</sub> gas used, use the fewest number of cannulas to perform the surgery, make the cannula skin/fascia entry a tight/snug fit, use the lowest flow rate and IAP that allows the planned surgery to be performed safely, know the limitations of the instruments and how they can be misused, place cannulas at angles appropriate for the surgery planned, be aware that the laparoscopy can act as a lever with mechanical advantage, keep IAP <15 mm Hg, monitor end-expiratory CO<sub>2</sub>, look at and feel the skin around the cannula insertion sites, perform the surgery quickly but not hurried, and, finally—attention to detail, attention to detail, attention to detail.</p></sec></body><back><ref-list><title>References:</title><ref id="B1"><label>1.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vilos</surname><given-names>G</given-names></name><name><surname>Ternamian</surname><given-names>A</given-names></name><name><surname>Dempster</surname><given-names>J</given-names></name><name><surname>Laberge</surname><given-names>P</given-names></name></person-group><article-title>Laparoscopic entry: a review of techniques, technologies, and complications</article-title>. <source>J Obstet Gynaecol Can</source>. <year>2007</year>;<volume>29</volume>:<fpage>433</fpage>–<lpage>465</lpage><pub-id pub-id-type="pmid">17493376</pub-id></mixed-citation></ref><ref id="B2"><label>2.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ott</surname><given-names>D</given-names></name></person-group><article-title>Laparoscopy and adhesion formation, adhesions and laparoscopy</article-title>. <source>Sem Reprod Med</source>. <year>2008</year>;<volume>26</volume>:<fpage>322</fpage>–<lpage>330</lpage></mixed-citation></ref><ref id="B3"><label>3.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Ott</surname><given-names>DE</given-names></name></person-group><article-title>The pneumoperitoneum</article-title>. In: <person-group person-group-type="editor"><name><surname>Schollmeyer</surname><given-names>T</given-names></name><name><surname>Mettler</surname><given-names>L</given-names></name><name><surname>Alkatout</surname><given-names>I</given-names></name></person-group>, eds <source>The Practical Manual for Laparoscopic and Hysteroscopic Gynaecological Surgery</source>. <publisher-loc>New Delhi</publisher-loc>: <publisher-name>Jaypee Brothers Medical Publishers</publisher-name>; <year>2012</year></mixed-citation></ref><ref id="B4"><label>4.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kuntz</surname><given-names>C</given-names></name><name><surname>Wunsch</surname><given-names>A</given-names></name><name><surname>Bodeker</surname><given-names>C</given-names></name></person-group><article-title>Effect of pressure and gas type on intraabdominal, subcutaneous, and blood pH in laparoscopy</article-title>. <source>Surg Endosc</source>. <year>2000</year>;<volume>14</volume>:<fpage>367</fpage>–<lpage>371</lpage><pub-id pub-id-type="pmid">10790557</pub-id></mixed-citation></ref><ref id="B5"><label>5.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Menes</surname><given-names>T</given-names></name><name><surname>Spivak</surname><given-names>H</given-names></name></person-group><article-title>Laparoscopy: searching for the proper insufflation gas</article-title>. <source>Surg Endosc</source>. <year>2000</year>;<volume>14</volume>:<fpage>1050</fpage>–<lpage>1056</lpage><pub-id pub-id-type="pmid">11116418</pub-id></mixed-citation></ref><ref id="B6"><label>6.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Lacy</surname><given-names>A</given-names></name><name><surname>Blanch</surname><given-names>X</given-names></name><name><surname>Visa</surname><given-names>J</given-names></name></person-group><article-title>Alternative gases in laparoscopic surgery</article-title>. In: <person-group person-group-type="editor"><name><surname>Rosenthal</surname><given-names>R</given-names></name><name><surname>Friedman</surname><given-names>R</given-names></name><name><surname>Phillips</surname><given-names>E</given-names></name></person-group> eds. <source>The Pathophysiology of Pneumo-peritoneum</source>. <publisher-loc>Berlin Heidelberg</publisher-loc>: <publisher-name>Springer</publisher-name>; <year>1998</year>:<fpage>7</fpage>–<lpage>17</lpage></mixed-citation></ref><ref id="B7"><label>7.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Niedzielski</surname><given-names>A</given-names></name><name><surname>Gizewski</surname><given-names>J</given-names></name><name><surname>Staraczewski</surname><given-names>A</given-names></name><name><surname>Rozewiski</surname><given-names>S</given-names></name></person-group><article-title>Nineteen years of laparoscopy in the gynecology clinic IPGPAM</article-title>. <source>Ginekol Pol</source>. <year>1992</year>;<volume>63</volume>:<fpage>596</fpage>–<lpage>599</lpage><pub-id pub-id-type="pmid">1305576</pub-id></mixed-citation></ref><ref id="B8"><label>8.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Nunn</surname><given-names>J</given-names></name></person-group><article-title>Carbon dioxide</article-title>. In: <source>Applied Respiratory Physiology</source>. <publisher-loc>London</publisher-loc>: <publisher-name>Butterworth</publisher-name>; <year>1987</year>:<fpage>207</fpage>–<lpage>234</lpage></mixed-citation></ref><ref id="B9"><label>9.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Grzegorzewska</surname><given-names>A</given-names></name><name><surname>Antoniewicz</surname><given-names>K</given-names></name></person-group><article-title>Effective peritoneal blood flow and patient characteristics</article-title>. In: <person-group person-group-type="editor"><name><surname>Khanna</surname><given-names>R</given-names></name></person-group>, ed. <source>Adv Perit Dial</source>. <year>1994</year>;<volume>10</volume>:<fpage>27</fpage>–<lpage>29</lpage><pub-id pub-id-type="pmid">7999843</pub-id></mixed-citation></ref><ref id="B10"><label>10.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kim</surname><given-names>M</given-names></name><name><surname>Lofthouse</surname><given-names>J</given-names></name><name><surname>Flessner</surname><given-names>M</given-names></name></person-group><article-title>A method to test blood flow limitation of peritoneal-blood solute transport</article-title>. <source>J Am Soc Nephrol</source>. <year>1997</year>;<volume>8</volume>:<fpage>471</fpage>–<lpage>474</lpage><pub-id pub-id-type="pmid">9071716</pub-id></mixed-citation></ref><ref id="B11"><label>11.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>McAllister</surname><given-names>J</given-names></name><name><surname>D'Altorio</surname><given-names>R</given-names></name><name><surname>Synder</surname><given-names>A</given-names></name></person-group><article-title>CT findings after uncomplicated percutaneous laparoscopic cholecystectomy</article-title>. <source>J Comput Assist Tomogr</source>. <year>1991</year>;<volume>15</volume>:<fpage>770</fpage>–<lpage>772</lpage><pub-id pub-id-type="pmid">1832177</pub-id></mixed-citation></ref><ref id="B12"><label>12.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sharma</surname><given-names>KC</given-names></name><name><surname>Kabinoff</surname><given-names>G</given-names></name><name><surname>Ducherne</surname><given-names>Y</given-names></name></person-group><article-title>Laparoscopic surgery and its potential for medical complications</article-title>. <source>Heart Lung</source>. <year>1977</year>;<volume>26</volume>:<fpage>52</fpage>–<lpage>67</lpage><pub-id pub-id-type="pmid">9013221</pub-id></mixed-citation></ref><ref id="B13"><label>13.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Batra</surname><given-names>M</given-names></name><name><surname>Driscoll</surname><given-names>J</given-names></name><name><surname>Coburn</surname><given-names>W</given-names></name><name><surname>Marks</surname><given-names>W</given-names></name></person-group><article-title>Evanescent nitrous oxide pneumothorax after laparoscopy</article-title><source>Anesth Analg</source>. <year>1983</year>;<volume>62</volume>:<fpage>1121</fpage>–<lpage>1123</lpage><pub-id pub-id-type="pmid">6228171</pub-id></mixed-citation></ref><ref id="B14"><label>14.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Fitzgerald</surname><given-names>SD</given-names></name><name><surname>Andrus</surname><given-names>HC</given-names></name><name><surname>Baudendistel</surname><given-names>LJ</given-names></name><etal></etal></person-group><article-title>Hypercarbia during carbon dioxide pneumoperitoneum</article-title>. <source>Am J Surg</source>. <year>1992</year>;<volume>163</volume>:<fpage>186</fpage>–<lpage>190</lpage><pub-id pub-id-type="pmid">1733368</pub-id></mixed-citation></ref><ref id="B15"><label>15.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rittenmeyer</surname><given-names>H</given-names></name></person-group><article-title>Carbon dioxide toxicity related to a laparoscopic procedure</article-title>. <source>J Post Anesth Care</source>. <year>1994</year>;<volume>9</volume>:<fpage>157</fpage>–<lpage>161</lpage></mixed-citation></ref><ref id="B16"><label>16.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Herati</surname><given-names>A</given-names></name><name><surname>Atalla</surname><given-names>M</given-names></name><name><surname>Rais-Bahrami</surname><given-names>S</given-names></name><name><surname>Andonian</surname><given-names>S</given-names></name><name><surname>Vira</surname><given-names>M</given-names></name><name><surname>Kavoussi</surname><given-names>L</given-names></name></person-group><article-title>A new valve-less trocar for urologic laparoscopy: initial evaluation</article-title>. <source>J Endourlol</source>. <year>2009</year>;<volume>23</volume>:<fpage>1535</fpage>–<lpage>1539</lpage></mixed-citation></ref><ref id="B17"><label>17.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Herati</surname><given-names>A</given-names></name><name><surname>Andonian</surname><given-names>S</given-names></name><name><surname>Rais-Bahrami</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Use of the valveless trocar system reduces carbon dioxide absorption during laparoscopy when compared with standard trocars</article-title>. <source>Urology</source>. <year>2011</year>;<fpage>77;1126</fpage>–<lpage>1132</lpage><pub-id pub-id-type="pmid">21094989</pub-id></mixed-citation></ref><ref id="B18"><label>18.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hillelsohn</surname><given-names>J</given-names></name><name><surname>Friedlander</surname><given-names>J</given-names></name><name><surname>Bagadiya</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Masked pneumothorax: risk of valveless trocar systems</article-title>. <source>J Urol</source><year>2013</year><comment>[Epub ahead of print]</comment></mixed-citation></ref><ref id="B19"><label>19.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Celik</surname><given-names>H</given-names></name><name><surname>Cremins</surname><given-names>A</given-names></name><name><surname>Jones</surname><given-names>K</given-names></name><name><surname>Harmanli</surname><given-names>O</given-names></name></person-group><article-title>Massive subcutaneous emphysema in robotic sacrocolpopexy</article-title>. <source>JSLS</source>. <year>2013</year>; <volume>17</volume>:<fpage>245</fpage>–<lpage>248</lpage><pub-id pub-id-type="pmid">23925018</pub-id></mixed-citation></ref><ref id="B20"><label>20.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horstmann</surname><given-names>M</given-names></name><name><surname>Horton</surname><given-names>K</given-names></name><name><surname>Kurz</surname><given-names>M</given-names></name><name><surname>Padevit</surname><given-names>C</given-names></name><name><surname>John</surname><given-names>H</given-names></name></person-group><article-title>Prospective comparison between the AirSeal System valve-less Trocar and a standard Versaport Plus V2 Trocar in robotic-assisted radical prostatectomy</article-title>. <source>J Endourol</source>. <year>2013</year>; <volume>27</volume>:<fpage>579</fpage>–<lpage>582</lpage><pub-id pub-id-type="pmid">23186377</pub-id></mixed-citation></ref><ref id="B21"><label>21.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wahba</surname><given-names>R</given-names></name><name><surname>Tessler</surname><given-names>M</given-names></name><name><surname>Keiman</surname><given-names>S</given-names></name></person-group><article-title>Acute ventilator complications during laparoscopic upper abdominal surgery</article-title>. <source>Can J Anaesth</source>. <year>1996</year>;<volume>43</volume>:<fpage>77</fpage>–<lpage>83</lpage><pub-id pub-id-type="pmid">8665641</pub-id></mixed-citation></ref><ref id="B22"><label>22.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Abe</surname><given-names>H</given-names></name><name><surname>Bandai</surname><given-names>Y</given-names></name><name><surname>Ohtomo</surname><given-names>Y</given-names></name></person-group><article-title>Extensive subcutaneous emphysema and hypercapnia during laparoscopic cholecystectomy: two case reports</article-title>. <source>Surg Laparosc Endosc</source>. <year>1995</year>;<volume>5</volume>:<fpage>183</fpage>–<lpage>187</lpage><pub-id pub-id-type="pmid">7633643</pub-id></mixed-citation></ref><ref id="B23"><label>23.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wittigen</surname><given-names>CM</given-names></name><name><surname>Andrus</surname><given-names>HC</given-names></name><name><surname>Fitzgerald</surname><given-names>SD</given-names></name><etal></etal></person-group><article-title>Analysis of hemodynamics and ventilation during laparoscopic cholecystectomy</article-title>. <source>Arch Surg</source>. <year>1991</year>;<volume>126</volume>:<fpage>997</fpage>–<lpage>1001</lpage><pub-id pub-id-type="pmid">1830738</pub-id></mixed-citation></ref><ref id="B24"><label>24.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Leighton</surname><given-names>T</given-names></name><name><surname>Pianim</surname><given-names>N</given-names></name><name><surname>Liu</surname><given-names>SY</given-names></name><etal></etal></person-group><article-title>Effectors of hypercarbia during experimental pneumoperitoneum</article-title>. <source>Am Surg</source>. <year>1992</year>;<volume>58</volume>:<fpage>717</fpage>–<lpage>721</lpage><pub-id pub-id-type="pmid">1456592</pub-id></mixed-citation></ref><ref id="B25"><label>25.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kent</surname><given-names>RB</given-names><suffix>3rd</suffix></name></person-group><article-title>Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy</article-title>. <source>Arch Surg</source>. <year>1991</year>;<volume>126</volume>:<fpage>1154</fpage>–<lpage>1156</lpage><pub-id pub-id-type="pmid">1834040</pub-id></mixed-citation></ref><ref id="B26"><label>26.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Holzman</surname><given-names>M</given-names></name><name><surname>Sharp</surname><given-names>K</given-names></name><name><surname>Richards</surname><given-names>W</given-names></name></person-group><article-title>Hypercarbia during carbon dioxide gas insufflation for therapeutic laparoscopy: a note of caution</article-title>. <source>Surg Laparosc Endosc</source>. <year>1992</year>;<volume>2</volume>:<fpage>11</fpage>–<lpage>14</lpage><pub-id pub-id-type="pmid">1341494</pub-id></mixed-citation></ref><ref id="B27"><label>27.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hall</surname><given-names>D</given-names></name><name><surname>Goldstein</surname><given-names>A</given-names></name><name><surname>Tynan</surname><given-names>E</given-names></name></person-group><article-title>Profound hypercarbia late in the course of laparoscopic choleystectomy</article-title>. <source>Anesthesiology</source>. <year>1993</year>;<volume>79</volume>:<fpage>173</fpage>–<lpage>174</lpage><pub-id pub-id-type="pmid">8342803</pub-id></mixed-citation></ref><ref id="B28"><label>28.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Marshall</surname><given-names>R</given-names></name><name><surname>Jebsen</surname><given-names>P</given-names></name><name><surname>Davie</surname><given-names>I</given-names></name><etal></etal></person-group><article-title>Circulatory effect of carbon dioxide insuflation of the peritoneal cavity for laparoscopy</article-title>. <source>Br J Anaesth</source>. <year>1972</year>;<volume>44</volume>:<fpage>680</fpage>–<lpage>682</lpage><pub-id pub-id-type="pmid">4262614</pub-id></mixed-citation></ref><ref id="B29"><label>29.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kelman</surname><given-names>G</given-names></name><name><surname>Swapp</surname><given-names>G</given-names></name><name><surname>Smith</surname><given-names>I</given-names></name></person-group><article-title>Cardiac output and arterial blood gas tension during laparoscopy</article-title>. <source>Br J Anesth</source>. <year>1972</year>;<volume>44</volume>:<fpage>1155</fpage>–<lpage>1162</lpage></mixed-citation></ref><ref id="B30"><label>30.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Pearce</surname><given-names>D</given-names></name></person-group><article-title>Respiratory acidosis and subcutaneous emphysema during laparoscopic cholecystectomy</article-title>. <source>Can J Anaesth</source>. <year>1994</year>;<volume>4</volume>:<fpage>314</fpage>–<lpage>316</lpage><pub-id pub-id-type="pmid">8004738</pub-id></mixed-citation></ref><ref id="B31"><label>31.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Santana</surname><given-names>A</given-names></name><name><surname>Crausman</surname><given-names>R</given-names></name><name><surname>Dubin</surname><given-names>H</given-names></name></person-group><article-title>Late onset of subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy</article-title>. <source>Chest</source>. <year>1999</year>;<volume>115</volume>:<fpage>1468</fpage>–<lpage>1471</lpage><pub-id pub-id-type="pmid">10334176</pub-id></mixed-citation></ref><ref id="B32"><label>32.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nezhat</surname><given-names>C</given-names></name><name><surname>Nezhat</surname><given-names>F</given-names></name><name><surname>Nezhat</surname><given-names>C</given-names></name></person-group><article-title>Operative laparoscopy (minimally invasive surgery): state of the art</article-title>. <source>J Gynecol Surg</source>. <year>1992</year>;<volume>8</volume>:<fpage>111</fpage>–<lpage>141</lpage><pub-id pub-id-type="pmid">10171579</pub-id></mixed-citation></ref><ref id="B33"><label>33.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Murdock</surname><given-names>C</given-names></name><name><surname>Wolff</surname><given-names>A</given-names></name><name><surname>Van Geem</surname><given-names>T</given-names></name></person-group><article-title>Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy</article-title>. <source>Obstet Gynecol</source>. <year>2000</year>;<volume>95</volume>:<fpage>704</fpage>–<lpage>709</lpage><pub-id pub-id-type="pmid">10775733</pub-id></mixed-citation></ref><ref id="B34"><label>34.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kalhan</surname><given-names>S</given-names></name><name><surname>Reaney</surname><given-names>J</given-names></name><name><surname>Collins</surname><given-names>R</given-names></name></person-group><article-title>Pneumomediastinum and subcutaneous emphysema during laparoscopy</article-title>. <source>Cleve Clin J Med</source>. <year>1990</year>;<volume>57</volume>:<fpage>639</fpage>–<lpage>642</lpage><pub-id pub-id-type="pmid">2146045</pub-id></mixed-citation></ref><ref id="B35"><label>35.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kent</surname><given-names>R</given-names></name></person-group><article-title>Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy</article-title>. <source>Arch Surg</source>. <year>1991</year>;<volume>126</volume>:<fpage>1154</fpage>–<lpage>1156</lpage><pub-id pub-id-type="pmid">1834040</pub-id></mixed-citation></ref><ref id="B36"><label>36.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wolf</surname><given-names>J</given-names></name><name><surname>Monk</surname><given-names>T</given-names></name><name><surname>McDougall</surname><given-names>E</given-names></name><name><surname>McClennan</surname><given-names>B</given-names></name><name><surname>Clayman</surname><given-names>R</given-names></name></person-group><article-title>The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery</article-title>. <source>J Urol</source>. <year>1995</year>;<volume>154</volume>:<fpage>959</fpage>–<lpage>963</lpage><pub-id pub-id-type="pmid">7637101</pub-id></mixed-citation></ref><ref id="B37"><label>37.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Waisbren</surname><given-names>S</given-names></name><name><surname>Herz</surname><given-names>B</given-names></name><name><surname>Ducheine</surname><given-names>Y</given-names></name><name><surname>Yang</surname><given-names>H</given-names></name><name><surname>Karanfilian</surname><given-names>R</given-names></name></person-group><article-title>Iatrogenic respiratory acidosis during laparoscopic preperitoneal hernia repair</article-title>. <source>J Laparoendosc Surg</source>. <year>1996</year>;<volume>6</volume>:<fpage>181</fpage>–<lpage>183</lpage><pub-id pub-id-type="pmid">8807520</pub-id></mixed-citation></ref><ref id="B38"><label>38.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wolf</surname><given-names>J</given-names></name><name><surname>Clayman</surname><given-names>R</given-names></name><name><surname>Monk</surname><given-names>T</given-names></name><name><surname>McClennan</surname><given-names>B</given-names></name><name><surname>McDougal</surname><given-names>E</given-names></name></person-group><article-title>Carbon dioxide absorption during laparoscopic pelvic operation</article-title>. <source>J Am Coll Surg</source>. <year>1995</year>;<volume>180</volume>:<fpage>555</fpage>–<lpage>560</lpage><pub-id pub-id-type="pmid">7749530</pub-id></mixed-citation></ref><ref id="B39"><label>39.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lee</surname><given-names>D</given-names></name><name><surname>Kim</surname><given-names>M</given-names></name><name><surname>Lee</surname><given-names>Y</given-names></name><name><surname>Lee</surname><given-names>H</given-names></name></person-group><article-title>Does intraabdominal pressure affect development of subcutaneous emphysema at gynecologic laparoscopy?</article-title><source>J Minim Invasive Gynecol</source>. <year>2011</year>;<volume>18</volume>:<fpage>761</fpage>–<lpage>765</lpage><pub-id pub-id-type="pmid">21940220</pub-id></mixed-citation></ref><ref id="B40"><label>40.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horak</surname><given-names>S</given-names></name><name><surname>Blecharz</surname><given-names>A</given-names></name><name><surname>Rzempoluch</surname><given-names>J</given-names></name><name><surname>Blochal</surname><given-names>S</given-names></name></person-group><article-title>Complications of endoscopy in gynecology</article-title>. <source>Ginekol Pol</source>. <year>1992</year>;<volume>63</volume>:<fpage>619</fpage>–<lpage>622</lpage><pub-id pub-id-type="pmid">1305581</pub-id></mixed-citation></ref><ref id="B41"><label>41.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>McAlister</surname><given-names>J</given-names></name><name><surname>D'Altonio</surname><given-names>R</given-names></name><name><surname>Synder</surname><given-names>A</given-names></name></person-group><article-title>CT findings after uncomplicated percutaneous laparoscopic cholecystectomy</article-title>. <source>J Comput Assist Tomogr</source>. <year>1991</year>;<volume>15</volume>:<fpage>770</fpage>–<lpage>772</lpage><pub-id pub-id-type="pmid">1832177</pub-id></mixed-citation></ref><ref id="B42"><label>42.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bard</surname><given-names>P</given-names></name><name><surname>Chen</surname><given-names>L</given-names></name></person-group><article-title>Subcutaneous emphysema associated with laparoscopy</article-title>. <source>Anesth Analg</source>. <year>1990</year>;<volume>71</volume>:<fpage>101</fpage>–<lpage>102</lpage><pub-id pub-id-type="pmid">2141968</pub-id></mixed-citation></ref><ref id="B43"><label>43.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Klopfenstein</surname><given-names>C</given-names></name><name><surname>Gaggero</surname><given-names>G</given-names></name><name><surname>Mamie</surname><given-names>C</given-names></name><name><surname>Morel</surname><given-names>P</given-names></name><name><surname>Forster</surname><given-names>A</given-names></name></person-group><article-title>Laparoscopic extraperitoneal inguinal hernia repair complicated by subcutaneous emphysema</article-title>. <source>Can J Anaesth</source>. <year>1995</year>;<volume>42</volume>:<fpage>523</fpage>–<lpage>525</lpage><pub-id pub-id-type="pmid">7628034</pub-id></mixed-citation></ref><ref id="B44"><label>44.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Perko</surname><given-names>G</given-names></name><name><surname>Fernandes</surname><given-names>A</given-names></name></person-group><article-title>Subcutaneous emphysema and pneumothorax during laparoscopy for ectopic pregnancy removal</article-title>. <source>Acta Anesthesiol Scand</source>. <year>1997</year>;<volume>41</volume>:<fpage>792</fpage>–<lpage>794</lpage></mixed-citation></ref><ref id="B45"><label>45.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Chui</surname><given-names>P</given-names></name><name><surname>Gin</surname><given-names>T</given-names></name><name><surname>Chang</surname><given-names>S</given-names></name></person-group><article-title>Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy</article-title>. <source>Anesthesia</source>. <year>1993</year>;<volume>48</volume>:<fpage>978</fpage>–<lpage>981</lpage></mixed-citation></ref><ref id="B46"><label>46.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Abbott</surname><given-names>D</given-names></name><name><surname>Dunkley</surname><given-names>A</given-names></name><name><surname>Roberts</surname><given-names>F</given-names></name></person-group><article-title>Carbon dioxide pneumothorax occurring during laparoscopic cholecystectomy</article-title>. <source>Anesthesia</source>. <year>1992</year>;<volume>47</volume>:<fpage>587</fpage>–<lpage>588</lpage></mixed-citation></ref><ref id="B47"><label>47.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lindsey</surname><given-names>S</given-names></name></person-group><article-title>Subcutaneous carbon dioxide emphysema following laparoscopic salpingo-oophorectomy: a case report</article-title>. <source>AANA J</source>. <year>2008</year>;<volume>76</volume>:<fpage>282</fpage>–<lpage>285</lpage><pub-id pub-id-type="pmid">18777813</pub-id></mixed-citation></ref><ref id="B48"><label>48.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ahmad</surname><given-names>G</given-names></name><name><surname>Duffy</surname><given-names>J</given-names></name><name><surname>Phillips</surname><given-names>K</given-names></name><name><surname>Watson</surname><given-names>A</given-names></name></person-group><article-title>Laparoscopic entry techniques</article-title>. <source>Cochrane Database Syst Rev</source>. <year>2008</year>;<fpage>16</fpage></mixed-citation></ref><ref id="B49"><label>49.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Agresta</surname><given-names>F</given-names></name><name><surname>De Simone</surname><given-names>P</given-names></name><name><surname>Ciardo</surname><given-names>L</given-names></name><name><surname>Bedin</surname><given-names>N</given-names></name></person-group><article-title>Direct trocar insertion vs Veress needle in non-obese patients undergoing laparoscopic procedures: a randomized prospective single-center study</article-title>. <source>Surg Endosc</source>. <year>2004</year>;<volume>18</volume>:<fpage>1778</fpage>–<lpage>1781</lpage><pub-id pub-id-type="pmid">15809789</pub-id></mixed-citation></ref><ref id="B50"><label>50.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rudston-Brown</surname><given-names>B</given-names></name><name><surname>MacLennan</surname><given-names>D</given-names></name><name><surname>Warriner</surname><given-names>C</given-names></name><name><surname>Phang</surname><given-names>P</given-names></name></person-group><article-title>Effect of subcutaneous carbon dioxide insufflation on arterial pCO2</article-title>. <source>Am J Surg</source>. <year>1996</year>;<volume>171</volume>:<fpage>460</fpage>–<lpage>463</lpage><pub-id pub-id-type="pmid">8651384</pub-id></mixed-citation></ref><ref id="B51"><label>51.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ahn</surname><given-names>Y</given-names></name><name><surname>Leach</surname><given-names>J</given-names></name></person-group><article-title>A comparison of subcutaneous and preperitoneal emphysema arising from gynecologic laparoscopic procedures</article-title>. <source>J Reprod Med</source>. <year>1976</year>;<volume>17</volume>:<fpage>335</fpage>–<lpage>337</lpage><pub-id pub-id-type="pmid">137316</pub-id></mixed-citation></ref><ref id="B52"><label>52.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Cunningham</surname><given-names>A</given-names></name></person-group><article-title>Anesthetic implications of laparoscopic surgery</article-title>. <source>Yale J Biol Med</source>. <year>1998</year>;<volume>71</volume>:<fpage>551</fpage>–<lpage>578</lpage><pub-id pub-id-type="pmid">10604786</pub-id></mixed-citation></ref><ref id="B53"><label>53.</label><mixed-citation publication-type="book"><person-group person-group-type="editor"><name><surname>Rosenthal</surname><given-names>R</given-names></name><name><surname>Friedman</surname><given-names>R</given-names></name><name><surname>Phillips</surname><given-names>E</given-names></name></person-group> eds. <source>Pathophysiology of Pneumoperitoneum</source>. <publisher-loc>Berlin Heidelberg</publisher-loc>: <publisher-name>Springer</publisher-name>; <year>1998</year></mixed-citation></ref><ref id="B54"><label>54.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Gomel</surname><given-names>V</given-names></name><name><surname>Taylor</surname><given-names>P</given-names></name><name><surname>Yuzpe</surname><given-names>A</given-names></name><name><surname>Rioux</surname><given-names>J</given-names></name></person-group><source>Laparoscopy and Hysteroscopy in Gynecologic Practice</source>. <publisher-loc>Chicago</publisher-loc>: <publisher-name>Yearbook Medical Publishers</publisher-name>: <year>1986</year></mixed-citation></ref><ref id="B55"><label>55.</label><mixed-citation publication-type="book"><person-group person-group-type="editor"><name><surname>Wetter</surname><given-names>P</given-names></name><name><surname>Kavic</surname><given-names>M</given-names></name><name><surname>Levinson</surname><given-names>C</given-names></name></person-group> eds. <source>Prevention and Management of Laparoendoscopic Surgical Complications</source>. <publisher-loc>Miami, FL</publisher-loc>: <publisher-name>SLS</publisher-name>; <year>1999</year></mixed-citation></ref><ref id="B56"><label>56.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Hulka</surname><given-names>J</given-names></name><name><surname>Reich</surname><given-names>H</given-names></name></person-group><source>Textbook of Laparoscopy</source>. <edition>2nd ed</edition><publisher-loc>Philadelphia</publisher-loc>: <publisher-name>WB Saunders</publisher-name>; <year>1994</year></mixed-citation></ref><ref id="B57"><label>57.</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Whelan</surname><given-names>J</given-names></name><name><surname>Fleshman</surname><given-names>J</given-names></name><name><surname>Fowler</surname><given-names>D</given-names></name></person-group><source>The SAGES Manual Perioperative Care in Minimally Invasive Surgery</source>. <publisher-loc>NewYork</publisher-loc>: <publisher-name>Springer</publisher-name>; <year>2006</year></mixed-citation></ref><ref id="B58"><label>58.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kalhan</surname><given-names>S</given-names></name><name><surname>Reaney</surname><given-names>J</given-names></name><name><surname>Collins</surname><given-names>R</given-names></name></person-group><article-title>Pneumomediastinum and subcutaneous emphysema during laparoscopy</article-title>. <source>Cleve Clin J Med</source>. <year>1990</year>;<volume>57</volume>:<fpage>639</fpage>–<lpage>642</lpage><pub-id pub-id-type="pmid">2146045</pub-id></mixed-citation></ref><ref id="B59"><label>59.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lew</surname><given-names>J</given-names></name><name><surname>Gin</surname><given-names>T</given-names></name><name><surname>Oh</surname><given-names>T</given-names></name></person-group><article-title>Anaesthetic problems during laparoscopic cholecystectomy</article-title>. <source>Anaesth Intensive Care</source>. <year>1992</year>;<volume>20</volume>:<fpage>91</fpage>–<lpage>92</lpage><pub-id pub-id-type="pmid">1535184</pub-id></mixed-citation></ref><ref id="B60"><label>60.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Muller</surname><given-names>N</given-names></name><name><surname>Nelems</surname><given-names>B</given-names></name></person-group><article-title>Postcoital catamenial pneumothorax: report of a case not associated with endometriosis and successfully treated with tubal ligation</article-title>. <source>Am Rev Respir Dis</source>. <year>1996</year>;<volume>134</volume>:<fpage>803</fpage>–<lpage>804</lpage><pub-id pub-id-type="pmid">2945503</pub-id></mixed-citation></ref><ref id="B61"><label>61.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Pascual</surname><given-names>J</given-names></name><name><surname>Baranda</surname><given-names>M</given-names></name><name><surname>Tarrero</surname><given-names>M</given-names></name><name><surname>Gutierrez</surname><given-names>M</given-names></name><name><surname>Garrido</surname><given-names>I</given-names></name><name><surname>Errasti</surname><given-names>C</given-names></name></person-group><article-title>Subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumopericardium after laparoscopy</article-title>. <source>Endoscopy</source>. <year>1990</year>;<volume>22</volume>:<fpage>59</fpage><pub-id pub-id-type="pmid">2137777</pub-id></mixed-citation></ref><ref id="B62"><label>62.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Whiston</surname><given-names>R</given-names></name><name><surname>Eggers</surname><given-names>K</given-names></name><name><surname>Morris</surname><given-names>R</given-names></name><name><surname>Stamatakis</surname><given-names>J</given-names></name></person-group><article-title>Tension pneumothorax during laparoscopic cholecystectomy</article-title>. <source>Br J Surg</source>. <year>1991</year>;<volume>78</volume>:<fpage>1325</fpage><pub-id pub-id-type="pmid">1836969</pub-id></mixed-citation></ref><ref id="B63"><label>63.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Shah</surname><given-names>P</given-names></name><name><surname>Ramakantan</surname><given-names>R</given-names></name></person-group><article-title>Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy</article-title>. <source>J Post Grad Med</source>. <year>1990</year>;<volume>36</volume>:<fpage>31</fpage>–<lpage>32</lpage></mixed-citation></ref><ref id="B64"><label>64.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Herrerias</surname><given-names>J</given-names></name><name><surname>Ariza</surname><given-names>A</given-names></name><name><surname>Garrido</surname><given-names>M</given-names></name></person-group><article-title>An unusual complication of laparoscopy: pneumopericardium</article-title>. <source>Endoscopy</source>. <year>1980</year>;<volume>12</volume>:<fpage>254</fpage>–<lpage>255</lpage><pub-id pub-id-type="pmid">6448743</pub-id></mixed-citation></ref><ref id="B65"><label>65.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Richard</surname><given-names>H</given-names></name><name><surname>Stancato-Pasik</surname><given-names>A</given-names></name><name><surname>Salky</surname><given-names>B</given-names></name><name><surname>Mendelson</surname><given-names>D</given-names></name></person-group><article-title>Pneumothorax and pneumomediastinum after laparoscopic surgery</article-title>. <source>Clin Imaging</source>. <year>1997</year>;<volume>21</volume>:<fpage>337</fpage>–<lpage>339</lpage><pub-id pub-id-type="pmid">9316753</pub-id></mixed-citation></ref></ref-list></back></pmc><affiliations><list></list><tree><noCountry><name sortKey="Ott, Douglas E" sort="Ott, Douglas E" uniqKey="Ott D" first="Douglas E." last="Ott">Douglas E. Ott</name></noCountry></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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