KEY POINTS

1. CO₂ pneumoperitoneum results in ventilatory and respiratory changes. Pneumoperitoneum decreases thoracopulmonary compliance. PaCO₂ increases (15% to 25%) due to CO₂ absorption from the peritoneal cavity. Capnography reliably reflects this increase, which plateaus after 20 to 30 minutes.
2. In compromised patients, cardiorespiratory disturbances aggravate the increase in PaCO₂ and enlarge the gradient between PaCO₂ and PETCO₂ .
3. Any increase in PETCO₂ larger than 25% and/or occurring later than 30 min after the beginning of peritoneal CO₂ insufflation should suggest CO₂ subcutaneous emphysema, the most frequent respiratory complication during laparoscopy
4. Peritoneal insufflation induces alterations of hemodynamics, characterized by decreases of cardiac output, elevations of arterial pressure, and increases of systemic and pulmonary vascular resistances. Hemodynamic changes are accentuated in high-risk cardiac patients.
5. The pathophysiologic hemodynamic changes can be attenuated or prevented by optimizing preload before pneumoperitoneum and by vasodilating agents, α₂ -adrenergic receptors antagonists, high doses of opioids, and β-blocking agents.
6. Similar pathophysiologic changes occur during pregnancy and in children. Laparoscopy can be safely managed in pregnant women before the 23rd week of pregnancy provided that hypercarbia is prevented. The open laparoscopy approach should be considered to avoid damaging the uterus.
7. Gasless laparoscopy may be helpful to reduce pathophysiologic changes induced by CO₂ pneumoperitoneum but unfortunately increases technical difficulty.
8. Laparoscopy results in multiple postoperative benefits allowing for quicker recovery and shorter hospital stay. These advantages explain the increasing success of laparoscopy, which is proposed for many surgical procedures.
9. Whereas no anesthetic technique has proved to be clinically superior to any other, general anaesthesia with controlled ventilation seems to be the safest technique for operative laparoscopy.
10. Improved knowledge of the intraoperative repercussions of laparoscopy permits safe management of patients with more and more severe cardiorespiratory disease, who may subsequently benefit from the multiple postoperative advantages offered by this technique.