key: cord-1021730-7rf1arpd
authors: Dalli, Jeffrey; Khan, Mohammad Faraz; Nolan, Kevin; Cahill, Ronan A
title: Laparoscopic Pneumoperitoneum Escape and Contamination during Surgery using the Airseal Insufflation System: Video Vignette
date: 2020-07-09
journal: Colorectal Dis
DOI: 10.1111/codi.15255
sha: e666f469f9c09feb11f204d4cd81ab203db115d4
doc_id: 1021730
cord_uid: 7rf1arpd

Unanticipated behaviours of the Airseal Insufflation and Access System (Conmed, NY, USA), in the public domain since 2017, have been recently restated by the manufacturer in light of the COVID19 pandemic and widespread concerns regarding aerosolization hazards during surgery. The associated video illustrates this device’s tendency for intra‐abdominal gas effluvium to be continually blown into the operating room during use as well as the phenomenon of air entrainment (i.e. the tendency for room air to be sucked into the abdomen) during high pressure intraoperative suctioning. We used a combination of assessment technologies in a high‐fidelity simulation model (fresh porcine cadaver) as well as during clinical surgery to examine gas flow through the Airseal 12mm valve‐less trocar with the Airseal IFS carbon dioxide (CO(2)) insufflator in Airseal mode.

Surgery and Distal Motion, and holds research funding from Intuitive Corporation and with IBM Ireland (from the Irish Government). JD, FZ and KN have no conflicts of interest to declare.

This article is protected by copyright. All rights reserved Unanticipated behaviours of the Airseal Insufflation and Access System (Conmed, NY, USA), in the public domain since 2017 1 , have been recently restated by the manufacturer 2 in light of the COVID19 pandemic and widespread concerns regarding aerosolization hazards during surgery. 3 The associated video illustrates this device's tendency for intra-abdominal gas effluvium to be continually blown into the operating room during use as well as the phenomenon of air entrainment (i.e. the tendency for room air to be sucked into the abdomen) during high pressure intraoperative suctioning.

We used a combination of assessment technologies in a high-fidelity simulation model (fresh porcine cadaver) as well as during clinical surgery to examine gas flow through the Airseal 12mm valve-less trocar with the Airseal IFS carbon dioxide (CO 2 ) insufflator in Airseal mode. Schlieren Imaging (an optical imaging technology that identifies differences in gas densities) as well as a specific near-infrared CO 2 visualisation system (FLIR GF343, Flir Systems Ltd, UK) were used to dynamically visualize gas flow around the trocar. A specific laparoscopic nebulizer (Aeroneb Solo, Aerogen, Galway, Ireland) enabled abdominal gas and droplet egress visualisation by transillumination in a darkened room. 4 A Flowmeter (TSI Series 5000, TSI Inc, MI, USA) measured directional velocity of flow just outside of the trocar.

By these methods, a continuous CO 2 plume flowing at a rate of 1-2L/min is shown arising from the trocar in Airseal mode. This continues, albeit to a lesser extent, with placement of the cap packaged along with the trocar. The nebulization model shows this gas vortex contains unfiltered gas exiting from the peritoneum. This flow reverses with suctioning (whether via a separate port or the Airseal trocar itself) reaching a peak inflow velocity in these tests of 8 L/min. At the same time the pressure of the pneumoperitoneum is relatively maintained without compensatory increase in Airseal insufflation consistent with room air being sucked directly into the abdomen via the valve-less trocar.

The video illustrates a mechanism of direct operating room pollution by intraabdominal gas and associated airborne particles, corroborated by direct clinical observation of the CO 2 flue during live surgery. 5 This accounts for some of the excess CO 2 consumption seen with use of Airseal insufflation. 6 Contamination of the intraabdominal space with non-medical grade air during suctioning dilutes the purity of the CO 2 pneumoperitoneum risking infection, combustion and persistence of gas beyond pure CO 2 timeframes (prolonging interstital emphysema or hollow viscus distension). It may also hazard gas embolism during surgery (including Transanal Total Mesorectal Excision, TaTME 7 ) 8 .

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Huntington TR Safety first: significant risk of air embolism in laparoscopic gasketless insufflation systems

Accepted Article

This article is protected by copyright. All rights reserved Ireland; the TSI series 5000 flowmeter supplied with expertise by Mr John O'Dea, Palliare, Galway, Ireland and the Aeroneb Solo with expertise by Mr Barry Russell, Aerogen, Galway, Ireland.