Surgeons working in the abdomen must learn to insufflate before they operate, but the importance of creating an adequate pneumoperitoneum can get lost when the surgical team's focus shifts inside the body's cavity. Looking past the basic first step of all laparoscopic procedures, however, can put patients in jeopardy. Follow these tips to improve insufflation performance and promote abdominal surgery safety.

1. Read the directions
What do you do the first time you boot up a new computer or turn on your smartphone? If you're like most of us, you toss aside user manuals and figure out how they work by trial and error. It's no surprise, then, that our research revealed surgeons rarely read the manufacturers' instructions before using insufflation systems, even though the manuals detail how the systems are properly activated, their safety features, ways to use them in order to maximize their performances and guidance for troubleshooting common operational issues.

2. Keep the flow going
Pumping CO2 into the abdomen continues to be the insufflation method of choice in most ORs. The CO2 flow rate relies on the smallest diameter of the components linking the insufflator unit to the abdomen; increasing or decreasing the diameter of a system's lumen will impact its flow rate and resistance exponentially. Without diving too deep into the laws of physics, you want systems that boast large diameter tubing to keep the gas flowing, the system working effectively and insufflation performing to its capacity.

Keep in mind that the gas flow can be limited by the size of the trocar sheath (not the diameter of the trocar's outer cannula) and Luer lock connectors. Single-use sheaths, which typically have smaller diameters than reusable versions, and Luer locks with diameters smaller than the insufflation tubing they're connected to create significant flow resistance, which limits the performance of the entire system. Consider systems with hoses that attach directly to the sheath without Luer locks, which will greatly reduce flow resistance.

Consider the size of the trocar sheath if the optic scope and insufflation tubing are placed through the same port. For example, when a 10mm scope and insufflation tubing need to function in 1 trocar, use an 11mm or 12mm sheath to limit flow-rate resistance. That will leave enough room for adequate insufflation pressure maintenance and re-establishment during cases involving numerous instrument changes. You can also perform insufflation through a separate port to maintain the pneumoperitoneum when you anticipate exchanging instruments often during a procedure.

Address these potential flow-resistance issues before investing in a high-flow insufflator; the gas flow problems are more than likely related to the working components of the system you have, not to the maximum capacity of the insufflator unit.

3. View insufflation as a unit
Like most surgical professionals, you're likely more focused on maintaining schedule efficiencies than insufflation performance when gathering and connecting a system's components between cases. While you may grab whatever equipment is available at the time when setting up a room for laparoscopy procedures, consider that insufflation systems are only as effective as their weakest links. To ensure a system operates at maximum gas flow — which, again, is limited by the diameter of the smallest component in the system — view it as an entire unit calibrated to work as a whole instead of a collection of interchangeable parts.

4. Flush the system of room air
While exceedingly rare, gas embolism can occur during the start of insufflation if room air — which is 5 times less soluble in blood than CO2 — remains in the tubing when the system is activated. To avoid having room air accidentally enter the bloodstream, flush the system with CO2 for several seconds before attaching the hose to the insufflation trocar. Even though room air increases gas embolism risks, prolonged exposure to CO2 could also put patients in danger, something your anesthesia providers should know and monitor.

5. Avoid cross-contamination
Insufflation systems contain single-use CO2 filters between the insufflator unit and gas tank and trocar that prevent harmful bacteria and debris from reaching the patient. Never use these disposable filters for more than 1 case in an effort to be economical. Ignoring patient safety is never acceptable. Reusing single-use filters to save a few pennies would be even more egregious.

Always place the unit on the laparoscopic tower, above the plane of the surgical surface to prevent blood and irrigation fluid from flowing back through the hose, which could contaminate the unit and increase cross-contamination risks. Turning the unit on and off during a case causes negative insufflation pressure, which could pull gas or body fluids back into the unit, so always disconnect the hose before powering down or up.

In addition, closely monitor CO2 levels in the system's tank and replace it before it empties. Empty tanks interrupt CO2 flow, decrease intra-abdominal pressure and cause positive and negative pressure peaks throughout the system, which increases the likelihood that blood and irrigation fluids flow back into the insufflator. Make the exchange in the downtime between procedures. Waiting to replace near-empty tanks during cases wastes valuable OR minutes and, more importantly, puts patients at risk while surgeons wait until intra-abdominal pressure — and their visualization of the surgical cavity — is restored.

6. Treat the gas
Heating and humidifying the insufflation gas helps maintain the body's core temperature and stave off laparoscopic hypothermia. The heating of the gas should occur as close to the patient as possible, as gas heated in the insufflator unit cools to room temperature when it travels through the hose. Single-use and reusable devices are available that attach to trocars and heat and humidify the CO2 delivered to the patient's abdomen. Using them helps lessen post-op pain and reduce optic scope fogging, which eliminates the need for repeated efficiency-sapping cleanings throughout the procedure.

7. Limit intra-abdominal pressure
Delivering more than 12mmHg of insufflation pressure to maintain CO2 pneumoperitoneum can negatively impact a patient's blood flow and ventilation, but intra-abdominal pressure can inadvertently exceed that safe threshold due to insufflator regulation disturbances — even on units set to 12mmHg — that cause occasional over-pressure peaks. To avoid these potential complications, work with maximum pressure settings less than 12mmHg whenever possible. In addition, take advantage of over-pressure release valve features included on many insufflation units that limit the occurrence and duration of these excessive pressure peaks.

Never lean on the patient's abdomen during a procedure. Doing so decreases the patient's blood flow to the heart as well as his ability to ventilate. Also be sure adequate amounts of anesthesia are delivered so patients don't stir or react to pain, which could manifest as slight contractions of the abdominal muscles. Those contractions increase pressure within the abdominal cavity, which negatively impacts a patient's blood circulation, insufflation efficacy and ventilation.