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Dear Sir,
In this paper and a sequel paper in another journal, the authors state the safety of room air pneumoperitoneum, despite the increased postoperative patient discomfort and wound infections when compared with conventional carbon dioxide pneumoperitoneum (Ikechebelu et al. Citation2005; Ikechebelu et al. Citation2008). The safety of un-sterile, room air insufflations however, should be reconsidered.
In the early years of laparoscopy, several gasses have been proposed for insufflation of the abdominal cavity (Uhlich Citation1982). The presence of oxygen containing gas mixtures, as room air, during pneumoperitoneum has been demonstrated to promote combustion during electrocoagulation. Even some reports of intraperitoneal explosions have been described (Greilich et al. Citation1995; Gunatilake Citation1978; Robinson et al. Citation1979). This problem has been highlighted in the paper and is solved by using room air exclusively for diagnostic laparoscopies. However, in laparoscopy one could never exclude unexpected events in which electrocoagulation might be required.
Another issue is the possibility of gas embolisms during room air pneumoperitoneum. Fatal carbon dioxide embolisms during laparoscopy are rare. Nevertheless, subclinical carbon dioxide embolisms seem to occur in the majority of laparoscopies, many of them even in the beginning of insufflation (Derouin et al. Citation1996; Thio and Teichert Citation1994). As the solubility of room air into blood is about 20 times lower than the solubility of carbon dioxide (Austin et al. Citation1963), the risk of dangerous gas embolism in room air pneumoperitoneum is increased. It has been calculated that the lethal dose of an intravenous gas embolus for carbon dioxide is about 1 litre, whereas for room air this is only 200 ml (Graff et al. Citation1959; Kunkler and King Citation1959).
Thus, promoting the use of room air as insufflating agent for pneumoperitoneum is dangerous. In the early years of laparoscopy the pitfalls of a room air pneumoperitoneum had been demonstrated repeatedly, thereafter it was abandoned promptly.
In the paper, no information about cardiorespiratory events during the procedures was given and no mention of the possible problem of air embolisms was made. From a medicolegal point of view it would be inadvisable to expose patients to the potential danger of room air pneumoperitoneum, especially in centres where carbon dioxide is available.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Editor's Comment: The authors of this paper, published by our journal in 2005, were informed of this correspondence but no response was received.
References
- Austin W H, Lacombe E, Rand P W, Chatterjee M. Solubility of carbon dioxide in serum from 15–38°C. Journal of Applied Physiology 1963; 18: 301–304
- Derouin M, Couture P, Boudreault D, Girard D, Gravel D. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy. Anesthesia and Analgesia 1996; 82: 119–124
- Graff T D, Arbegast N R, Phillips O C, Harris L C, Frazier T M. Gas embolism: a comparative study of air and carbon dioxide as embolic agents in systemic venous system. American Journal of Obstetrics and Gynecology 1959; 78: 259–265
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