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Anestez in Laparoscopic Surg PDF
Anestez in Laparoscopic Surg PDF
Anestez in Laparoscopic Surg PDF
Laparoscopic techniques offer major benefits to and systemic infections demonstrated after
Key points
the patient such as minimized incision size and laparoscopic surgery.2
Laparoscopic surgery has trauma with reduced postoperative discomfort, These benefits are particularly useful in
many benefits for patients,
shortened recovery rates, and a lower incidence several patient groups. Laparoscopic surgery is
including reduced
of postoperative wound infections. These useful in obese patients in whom open pro-
postoperative pain and
fewer wound-related factors all contribute to shorter in-patient stay cedures would be technically very challenging
complications. and reduced perioperative morbidity. and who are particularly susceptible to wound
Consequently, many major procedures that infections after operation. An example of this is
Table 1 Risks and benefits of laparoscopic surgery with cephalad movement of the lungs, the tracheal tube may
Benefits Risks migrate endobronchially.
One rare but devastating complication of prolonged surgery in
Reduced wound infection Visceral and vascular damage the steep Trendelenburg position is the onset of ‘well leg compart-
Faster recovery Complications associated with extremes of positioning
Reduced morbidity Acute kidney injury
ment syndrome’ induced by the combination of impaired arterial
Reduced pain Cardiocerebral vascular insufficiency perfusion to raised lower limbs, compression of venous vessels by
Pulmonary atelectasis lower limbs supports, and reduced femoral venous drainage due to
Venous gas embolism
‘Well leg compartment syndrome’
the pneumoperitoneum. The resultant compartment syndrome of
the lower limbs presents after operation with disproportionate
lower limb pain, rhabdomyolysis, and potentially
patient must be balanced between the risk of complications due to myoglobin-associated acute renal failure leading to significantly
the position, duration, degree of carbon dioxide (CO2) absorption, increased morbidity and mortality.
and physiological effects of pneumoperitoneum for a particular Risk factors include surgery .4 h duration, muscular lower
laparoscopic procedure vs the shortened postoperative recovery limbs, obesity, peripheral vascular disease, hypotension, and steep
Trendelenburg positioning.5 Risks may be mitigated by avoiding
178 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
Anaesthesia for laparoscopic surgery
the inferior vena cava, and compression of pulmonary parenchyma to an open procedure considered when choosing the anaesthetic
which increases pulmonary vascular resistance, further reducing technique.
cardiac output.
Reverse Trendelenburg positioning may also result in hypoten- Perioperative management
sion due to the reduction in preload by venous pooling in the
lower limbs and pelvis which in turn is exacerbated by reduced Airway
femoral venous flow secondary to raised IAP. The most common technique for airway management involves pla-
cement of a cuffed oral tracheal tube (COTT), neuromuscular
relaxation, and positive pressure ventilation. This protects against
Respiratory effects gastric acid aspiration, allows optimal control of CO2, and facili-
Respiratory changes occur due to raised IAP and Trendelenburg tates surgical access. It is recommended that bag and mask venti-
positioning. As the abdomen is distended by CO2, diaphragmatic lation before intubation should be minimized to avoid gastric
excursion is limited resulting in raised intra-thoracic pressure, distension and the insertion of a nasogastric tube may be required
reduced pulmonary compliance, and reduced functional residual to deflate the stomach, not only to improve surgical view but also
capacity which in turn leads to pulmonary atelectasis, altered V/Q to avoid gastric injury on trochar insertion.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011 179
Anaesthesia for laparoscopic surgery
Dexamethasone has also been suggested before induction to reduce operation, particularly in patients with existing respiratory disease
subsequent opiate analgesia requirements in the first 2 h after or those having prolonged surgery.
laparoscopic hysterectomy in addition to its anti-emetic effects.9
Conclusion
Antiemetics
Laparoscopic surgery has a high incidence of postoperative nausea Over the last 30 yr, anaesthesia for laparoscopic surgery has devel-
and vomiting and this can be very distressing, worsen pain, and oped and advanced significantly resulting in a technique that mini-
extend the period of hospital admission for patients. Therefore, mizes many of the risks, complications, and prolonged duration of
prophylaxis is important, particularly in patients with other risk hospital stay of open surgery. The proportion of surgical cases per-
factors. As with open surgery, multi-modal regimes such as ondan- formed laparoscopically will continue to increase and anaesthetists
setron, cyclizine, and dexamethasone seem most effective in must understand and safely manage the specific physiological
addition to general measures such as deflating the stomach, avoid- alterations, risks, and practical challenges that laparoscopy
ing known emetogenic drugs, for example, opiates and ensuring presents.
good quality postoperative analgesia.10
Conflict of interest
180 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011