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Joris
Joris
Laparoscopic Cholecystectomy
Jean L. Joris, MD, Didier P. Noirot, MD, Marc J. Legrand, MD, Nicolas J. Jacquet, MD,
and Maurice L. Lamy, MD,
Departments of Anesthesiology and Abdominal Surgery, CHU of Liege, Domaine du Sart Tilman, B-4000 Liege, Belgium
load and caused further reduction of CI. Peritoneal insufflation resulted in a significant increase (235%) of
mean arterial pressure, a significant reduction (220%)
of CI, and a significantincreaseof systemic (265%)and
pulmonary (290%)vascular resistances.The combined
effect of anesthesia, head-up tilt, and peritoneal insufflation produced a 50% decrease in CI. Administration
of increasing concentrations of isoflurane, via its
vasodilatory activity, may have partially blunted
these hemodynamic changes. These results demonstrate that laparoscopy for cholecystectomyin head-up
position results in significanthemodynamicchanges in
healthy patients, particularly at the induction of
pneumoperitoneum.
(Anesth Analg 1993;76:1067-71)
Methods
Fifteen fully informed patients scheduled for elective
laparoscopic cholecystectomy gave consent to be included in this study after the approval of the ethics
committee at our institution. Inclusion criteria were
body weight less than 20% more than ideal weight, age
between 18 and 70 yr, no acute cholecystitis, and no
cardiorespiratory disease or medications. All patients
were premedicated with hydroxyzine 50-75 mg by
Anesth Analg 1993;76:1067-71
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ANESTH ANALG
1993;76:1067-71
JORIS ET AL.
HEMODYNAMICS DURING LAPAROSCOPY
? \EM
48.9 k 3.7
4/11
66.8 f 3.0
165 ? 1
62.9 ? 4.6
(20-69)
(55-85)
(152-175)
(35-105)
and (range)
Results
Demographic characteristics of the patients are represented in Table 1. After the induction of anesthesia,
MAP and cardiac index (CI) decreased (Table 2). After
tilting to the head-up position, RAP and PCWP decreased and a further reduction of CI and MAP was
observed. From T1 to T3, a linear relationship linked
MAP and CI (MAP = 16.9 CI + 36.7; Y = 0.94, P < 0.05).
After peritoneal insufflation (T4), this relationship
changed. Indeed, whereas MAP increased (35%), CI
significantly decreased (20%). Peritoneal insufflation
also resulted in a significant increase of systemic and
pulmonary vascular resistances (SVR, 65% and PVR,
90%) (Table 2). RAP and PCWP increased significantly
during insufflation and did not change significantly
from T4 to T6. Deepening of anesthesia by the administration of increasing concentrations of isoflurane
(Table3) allowed partial correction of the changes of CI,
SVR, and PVR which, however, remained significantly
different from preoperative values during CO, insufflation (Table 2). No significant changes of heart rate
and Paco2 were noted during surgery (Tables 2 and 3).
The combined effects of anesthesia, the head-up tilt,
and increased intraabdominal pressure produced a significant decrease (50%) of CI (Table 2). After insufflation, peak and plateau Paw as well as intrathoracic
pressure significantly increased (Table 3). Thirty minutes after exsufflation, all hemodynamic variables had
returned to preoperative values.
JORIS ET AL.
HEMODYNAMICS DURING LAPAROSCOPY
ANESTH ANALG
1993;76:3067-71
1069
T1
before
induction
T2
after
induction
T3
head-up
MAP, mm Hg
HR, beats/ min- '
RAP, mm Hg
PCWP, mm Hg
CI, L.rnin-'.rn-,
SVR, dynes.s.cm-'
PVR, dynes.s.cm-'
96 f 13
79 f 4
8f1
9f1
3.6 0.1
1139 f 49
229 f 21
87 f 3
83 + 4
8+1
9f1
2.7 f 0.2t
1389 + 108
292 f 31
71 f 2 t
76 t 4
5+1
7f1
2.2 0.2t
1452 k 111
272 f 28
T5
T6
5 min
15 min
30 min
T7
after
surgery
97 f 5$
79 f 4
11 f 1$
14 f 2t,$
1.8 f O.lt,$
2367 f 251t,$
521 + 55t,$
102 + 5$
81 + 5
10 f 1$
14 f It,$
2.4 t O . l t
1777 f 146t
423 f 36tJ
93 f 5$
81 f 5
10 f 2$
12 f It,$
2.3 f 0.2t
1676 f 120t
397 f 35t,$
105 f 5$
78 f 4
8+1
9+1
3.4 f 0.3
1365 f 96
291 f 3 2
Pneumoperitoneum
Hemodynamic changes were measured or calculated before the induction of anesthesia (Tl), 10 min after the induction of anesthesia (T2), 10 min after tilting
into 10" head-up position (T3), 5 min (T4), 15 min (TS), and 30 min (T6) after the beginning of insufflation, and 30 min after exsufflation (T7).
Results are mean ? SEM.
* Abbreviations used are: MAP, mean arterial pressure; HR, heart rate; RAP, right atrial pressure; PCWP, pulmonary capillary wedge pressure; CI, cardiac index;
SVR, systemic vascular resistance; PVR, pulmonary vascular resistance.
t P < 0.05 as compared with TI; $ P < 0.05 a s compared with T3.
T1
before
induction
T2
after
induction
T3
head-up
41.2 f 0.9
84 f 3
36.3 f 1.4t
243 + 12t
0.46 f 0.03
34.1 f 0.7t
216 f 13t
0.38 + 0.04
0
14.9 f 1.3
1.2 t 1.3
14.5 f 1.1
10.6 1.2
T5
T6
Pneumoperitoneum
5 min
15 min
30 min
35.8 t 0.9t
234 f 9 t
0.84 f 0.05$
9.4 f 1.1$
21.8 f 1.9$
17.9 + 1.8$
39.1 f 1.0
230 f l l t
1.02 f 0.084
9.6 f 1.0$
22.6 t 1.2$
18.4 f 1.5$
37.5 f 0.8
222 f 10t
0.90 f 0.8$
8.7 +- 0.8$
22.7 f 1.3$
18.4 + 1.2$
T7
after
surgery
43.2
* 1.2$
82.2k 3.1
'Arterial Pcoz (Pam2)and Poz (Path), expired end-tidal concentration of isoflurane, and peak and plateau airway pressure (Paw) were measured 10 min after
the induction of anesthesia (T2), 10 min after tilting into 10' head-up position (T3), 5 min (T4), 15 min (T5). and 30 min (T6) after the beginning of insufflation.
Pacoz and Pa02 also were measured before the induction of anesthesia (TI) and 30 min after exsufflation (T7). Change in intrathoracic pressure (AITP) as compared
to T3 were calculated during pneumoperitoneum.
Results are mean ? SEM.
t P < 0.05 as compared with T1; $ P < 0.05 as compared with T3.
Discussion
This study demonstrates that peritoneal C 0 2 insufflation to an intraabdominal pressure of 14 mm Hg, necessary for laparoscopic cholecystectomy, induces major
hemodynamic changes in healthy non-obese patients
without cardiac disease. These significant disturbances
are characterized by an increase in MAP, SVR, and PVR,
and a decrease of CI. CI markedly decreased to as much
as 50%of preoperative values 5 min after the beginning
of insufflation. The hemodynamic changes observed in
this study complement the results of recent studies during gynecologic laparoscopy in the head-down position (6,9,10). By using an invasive monitoring in patients in the head-up position, we observed a more
pronounced increase of SVR and PVR.
The pathophysiology of these changes remains unclear. Before insufflation, SVR did not change significantly and a linear relationship linked MAP and CI.
Anesthetic induction drugs depressed the myocardium
and reduced CI and MAP. Tilting the patient to the
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JORIS ET AL.
HEMODYNAMICS DURING LAPAROSCOPY
ANESTH ANALG
1993;761067-71
increased sympathetic activity in response to the decreased CO (9). Indeed, vasodilation by the administration of increasing concentrations of isoflurane improved CO although RAP did not change. Finally, the
concentrations of isoflurane used in this study do not
depress the normal myocardium (16). The effect of increased IAP and ITP on myocardial contractility can
not, however, be determined from this study. Transesophageal echocardiography should be helpful in assessing contractility and venous return. Thus, during
laparoscopy, the decrease in CO can be explained by a
reduction in venous return and/or an increase of SVR.
It seems that the normal heart, which tolerates an increase of afterload very easily in normal conditions,
becomes sensitive to changes in afterload much like a
decompensated heart (21), when this normal heart has
to face the artificial conditions of pneumoperitoneum
under general anesthesia.
These results indicate the need for caution in patients
with impaired cardiac function, anemia, or hypovolemia scheduled for laparoscopy. Such situations may occur during laparoscopy in patients with ruptured ectopic pregnancies, or diagnostic laparoscopy in patients with blunt and penetrating injuries to the abdomen and in patients with peritonitis. These results bear
a particular significance in cases of laparoscopy in older
patients, such as for gastrointestinal surgical procedures; these patients are more likely to have known or
latent cardiac disease. Hemodynamic consequences of
pneumoperitoneum have not been explored in patients
with cardiac disease. However, indirect data suggest
that hemodynamics may be more altered in these patients than in ASA Class I patients (22). In all these
cases, it would seem prudent to reduce the rate of insufflation and limit abdominal inflating pressures to a
minimum. The trend to readily propose the laparoscopic approach for patients with impaired cardiac
function because of easier and smoother postoperative
recovery should be tempered by the risks related to the
intraoperative hemod ynamic changes induced by peritoneal insufflation. The anesthetic management of laparoscopy is beyond the scope of this paper. However,
anesthetics with vasodilating action should be favored,
and anesthetics that directly depress the heart should
be avoided. Pure vasodilator and cardiotonic drugs
may be necessary in patients with compromised cardiac function. Finally, it should be noted that the usual
intraoperative cardiovascular monitoring (blood pressure, heart rate, capnography, pulse oximetry) gives no
accurate information on the increase of SVR and the
reduction of CO.
In conclusion, these results highlight the fact
that laparoscopy induces significant hemod ynamic
changes even in healthy patients and creates increases
of SVR and PVR, an increase of MAP, and a reduction
of CO. These disturbances could be mediated both
ANESTH ANALG
1993;76:1067-71
mechanically and humorally. Whereas these cardiovascular changes should not be hazardous in healthy patients, special care and monitoring are mandatory for
patients with impaired cardiac function. In these patients postoperative benefits of laparoscopy should be
balanced against intraoperative risks.
References
1 . Dubois F, Icard P, Bertholet G, Levard H. Coelioscopic cholecys-
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HEMODYNAMICSDURING LAPAROSCOPY
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