Surgical humidification

Surgical humidification is the conditioning of insufflation gas with water vapour (humidity) and heat
during surgery. Surgical humidification is used to reduce the risk of tissue drying and evaporative
cooling.

Laparoscopic surgery humidification

During laparoscopy (laparoscopic surgery or minimally invasive surgery), it is necessary to insufflate the
abdominal cavity (i.e. inflate the abdomen like a balloon) with medical-grade carbon dioxide (CO2) to
create a viewing and working space for the surgery. The CO2 may be unconditioned, or conditioned with
heat, or with humidification and heat. During insufflation, the peritoneum (an extensive delicate
membrane that lines the abdominal cavity and covers most of the abdominal organs) is exposed to the
CO2.

Unconditioned medical-grade CO2 has virtually no moisture[1] and enters the abdomen at room
temperature (19 to 21 °C).[2] The condition of the gas is dry and cold compared to that of the natural
physiological state of the peritoneum which is immersed in fluid at body temperature (37 °C).
Experimental and clinical investigations have demonstrated that insufflation with unconditioned CO2
causes evaporation of the fluid and drying of the peritoneum, resulting in inflammation and damage to its
cells.[3][4][5] Clinically, peritoneal injury caused by drying has been linked to post-operative pain,[6][7][8]
evaporative cooling resulting in a decrease in core temperature and increased risk of intra-operative
hypothermia,[7][9][10][11][12] as well as adhesion formation.[4][13]

In addition, animal studies have revealed that surgical humidification reduces peritoneal tumor
implantation and tumor load [14][15] suggesting a possible benefit in cancer patients undergoing
abdominal surgery.

Conditioning the CO2 with only heat causes tissue drying.[16] Warmer gas has a greater capacity for
evaporation as the gas can hold more water vapor, therefore the tissues will dry faster than when
unconditioned gas is used, potentially leading to increased adverse consequences.[17][18][19] Conditioning
the CO2 with humidity, in combination with heat, has been shown to decrease peritoneal damage by
reducing the capacity of CO2 to carry moisture away from the tissue.[3][4] Temperature loss during
surgery, due to tissue drying, can be prevented by adequately humidifying and heating the
CO2.[4][6][7][10][13][20]

Open (abdominal) surgery humidification

During open surgery the surgeon exposes the peritoneal cavity to the ambient air. Exposure to ambient air
results in evaporation and cooling. Current studies have shown that the use of surgical humidification
during open abdominal surgery (laparotomy) have warmer core body temperatures and reduced risk of
operative hypothermia.[21][22] As with any operation, maintaining patient normothermia is a critical
process to prevent surgical site infections, additional respiratory distress and surgical bleeding.[23][24]

Respiratory humidification during surgery

Anesthesia causes vasodilatation, which increases blood flow to the surface of the body and thus
increases heat loss from the body. During anesthesia, blood flow to the surface may maintain skin
temperature (which is normally lower than the core temperature), even while the core temperature is
falling.[25] Barring preventive interventions, hypothermia occurs in more than half of all surgical patients
undergoing anesthesia.[26]

The risk of a loss of body temperature and hypothermia increase with the duration of surgery, especially
for surgery that lasts more than one hour. Surgical hypothermia, defined as a core temperature below
36.0 °C, is associated with increased risk of infectious and non-infections complications,[27] longer post-
operative ICU and overall hospital recovery, and more frequent requirement of transfusions.[28][29]
Elderly persons, especially those with lower muscle and body mass are at greater risk of hypothermia.[30]

Respiratory humidification during surgery helps maintain body temperature and normal function of the
respiratory mucosa.[31][32] In the same way that some animals pant to lose excess body heat, heat is lost
through the lungs during mechanical or assisted ventilation. Heated humidification of respiratory gases
during surgery has been demonstrated to reduce the fall in core body temperature, especially in surgeries
lasting longer than one hour. The lungs can be insufflated with respiratory gases that are heated to near
body temperature and humidified to 90 to 100% relative humidity(RH). Normally, air in the lungs is at
core body temperature and at close to 100% RH. Especially when cold dry gases (such as anhydrous
compressed gas from oxygen tanks) are used, it cool and can dry the airway. The body then utilizes
energy to evaporate sufficient water from the lungs to maintain lung gas temperature and humidity. It is
generally estimated that 10 percent of the loss of body heat during surgery is from the respiratory
tract.[33] Especially in open surgery (rather than endoscopic/robotic surgery), respiratory humidification
can be used in concert with forced air warming blankets or gowns, warmed IV, and irrigation fluids to
prevent hypothermia.

References
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