ANESTHESIA FOR LAPAROSCOPIC SURGERIES

Prepared & Presented By:

Dr. ROSHANA MALLAWAARACHCHI
 AIMS
 To review the history of laparoscopic surgeries.

 To discuss, briefly, the basic principles of laparoscopic

surgeries.

 To discuss the physiological consequences of laparoscopic

surgeries.

 To discuss the complications (management) of laparoscopic

surgeries.

 To discuss the anesthetic management of laparoscopic surgery.

HITORICAL NOTES
 1980: Patrick Steptoe (UK): started laparoscopic
procedures.

 1983: Semm (German gynecologist): performed the first

laporoscopic appendectomy.

 1985: Erich Muhe (Germany): 1st reported lapaorscopic

cholecystectomy.

 1987: Ger: lap repair of inguinal hernia.

HISTORICAL NOTES (…CONTD.)
 1987: Phillipe Mouret (France): 1st Laparoscopic
Cholecystectomy using video technique

 1988: Harry Reich: laparoscopic lymphadenectomy for t/t of

ovarian cancer.

 1989: Harry Reich: first laparoscopic hysterectomy using bipolar

dissection.

 1990: Bailey and Zucker (USA): laparoscopic anterior highly

selective vagotomy with posterior truncal vagotomy.
ADVANTAGES OF LAPAROSCOPIC SURGERY

 Less postoperative pain

 Less postoperative pulmonary impairment

 Less incidence of postoperative ileus

 Shorter hospital stay

 Earlier ambulation

 Smaller surgical scars

LAPAROSCOPIC PROCEDURES (GENERAL)
 Cholecystectomy  Pancreatectomy
 Vagotomy  Bariatric surgery
 Appendectomy  Nissen fundoplication
 Colectomy  Para-esophageal hernia
 Inguinal hernia repair repair
 Adrenalectomy  Splenectomy
 Nephrectomy  Liver resection
 Prostatectomy  Cystectomy with ileal
conduit
LAPAROSCOPIC PROCEDURES (GYNECOLOGIC)

 Ectopic pregnancy  Myomectomy

 Ovarian cystectomy  Sacrocolpopexy
 Reversal of ovarian  Lymphadenectomy
torsion  Lymphadenectomy,
 Salpingo- staging
oophorectomy  Ablation of
 Hysterectomy endometriosis
SURGICAL STEPS

 Introduction of ‘Veress Needle’

 Creation of
pneumoperitoneum

 Electrocautery dissection
 GASES USED TO CREATE
PNEUMOPERITONEUM: WHY IS CO2
PREFERRED??
 Helium
Insoluble, gas embolism
 Argon

 N2O: Supports combustion, diffuses into the bowel, PONV

 CO2:
 Soluble in blood, Risk of gas embolus is reduced.
 Safe during electrocautery (Non-flammable)
 Can be easily eliminated through the lungs
 Rapidly absorbed into the bloodstream
 Inexpensive
PROPERTIES OF IDEAL GAS FOR INSUFFLATION

 Colorless

 Limited systemic absorption across the peritoneum

 Limited systemic effects when absorbed.

 Rapid excretion if absorbed

 Incapable of supporting combustion.

 High solubility in blood.

 Limited physiological effects with intravascular systemic embolism

PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY

Minimally invasive surgery is not minimally stressful!

MAJOR FACTORS RESPONSIBLE FOR ALTERATION IN
PHYSIOLOGY

 Pneumoperitoneum

 Positioning

 Systemic absorption of Carbon dioxide

EFFECT OF PNEUMOPERITONEUM (MECHANICAL EFFECTS)
RESPIRATORY & VENTILATORY CHANGES
Increased Intra-abdominal pressure

Upward displacement of diaphragm/Impaired

diaphragmatic movements

Reduced lung compliance & FRC

Increased airway pressure & barotrauma
V/Q mismatch with hypoxemia & hypercarbia
Compression of basilar lung segments & atelectasis
HEMODYNAMIC CHANGES

↑Intra-abdominal Pressure

↓Venous return & ↑SVR

↓ Cardiac Output & Cardiac Index

CNS

1) ↑ Intrathoracic pressure
2) ↑ PaCO2 & ↑CBF

3) Compression of IVC, ↑ lumbar spinal pressure

&↓ CSF drainage

↑ ICP
HEPATOPORTAL

 ? ↓ Gastrointestinal (Splanchnic) blood flow

 Mechanical compression
 ADH  Superior mesenteric artery constriction

 ? Maintained Splanchnic blood flow

 Hypercarbia  Vasodilation
RENAL
 Decrease in renal blood flow when IAP >15
mmHg
 Decrease in GFR
 Decrease in urine output
 Decrease in creatinine clearance
 Decrease in sodium excretion
 Potential for volume overload in the face of excessive
fluid administration.
LOWER LIMB

1) ↓ Femoral venous blood flow

2) Pooling of blood (Reverse Trendelenberg position)

↑DVT
EFFECT OF PNEUMOPERITONEUM ON PHARMACOKINETICS

 Prolonged T1/2 of drugs eliminated by liver

(reduction of hepatic perfusion)

 Reduced Clearance of drugs eliminated through

kidneys (reduced creatinine clearance and urine
flow)
NEUROHUMORAL RESPONSES

 RAA system activation (↑ renin,

↑ angiotensin, and ↑ aldosterone)

 Sympathetic system activation (↑

catecholamines)
EFFECT OF POSITIONING

Friedrich
Trendelenburg
1844-1924
EFFECTS OF POSITIONING
 Position varies according
to the anatomical site of
operation
 Trendelenberg position
 Pelvic procedures
 Reverse Trendelenberg
position
 Supremesocolic procedures
(e.g., Cholecystectomy)
 Associated changes are
related to:
 Degree of head-down/up tilt
 Patient’s age
 Intravascular volume status
 Associated cardiac disease
 Ventilation techniques
 Anesthetic drugs
EFFECTS OF TRENDELENBERG POSITION
 Cardiovascular System
 ↑ CVP & CO
 Baroreceptor reflex  vasodilation and bradycardia
 Usually insignificant in healthy patients

 Patients with coronary heart disease with poor

left ventricular function - ↑ central blood volume,
and pressure changes maybe harmful.
EFFECTS OF TRENDELENBERG POSITION
 Respiratory System
 Facilitates the development of atelectasis
 FRC, total lung volume, and pulmonary compliance is
reduced.

 CNS
 ↑ CBF
↑ ICP
 ↓ Venous return
EFFECTS OF REVERSE TRENDELENBERG POSITION

 Cardiovascular System
 Venous return thus reducing CO and MAP
(compounded by the pneumoperitoneum)
 Venous stasis occurs in the legs

 Respiratory System
 Increased FRC
EFFECTS OF CO2 INSUFFLATION
 Direct Effects:
 Hypercarbia, Acidosis
 Decrease in HR, contractility, and SVR.

 Indirect Effects (stimulation of SNS)

 Increase in HR, contractility, and SVR.

 Premature ventricular contractions

 Bradydysrhythmias

 Asystole
COMPLICATIONS OF LAPAROSCOPY WITH RELEVANCE TO
ANESTHESIA

 Cardiovascular:
 Hypotension, hypertension, tachycardia, bradycardia, dysrhythmias, asystole
 Pulmonary:
 Hypercapnia, hypoxemia, atelectasis, barotrauma
 Related to gas insufflation
 Subcutaneous emphysema, gas embolism, pneumothorax, pneumomediastinum,
pneumopericardium, extreme CO2 absorption
 Surgical
 Hemorrhage, damage to hollow viscera, damage to nerves
 Mechanical
 Damage to nerves or eyes (positioning and draping), dislodgement of ET tube
with endobronchial intubation
 Miscellaneous:
 Hypothermia, nausea and vomiting, hyperkalemia, renal failure, increased risk
of regurgitation
 Foramen Bochdalek
Paraesophageal hiatus
Foramen of Morgagni
SubcutaneousSubcutaneious
Emphysema
Emphysema
GAS EMBOLISM: DETECTION
 Fall in ETCO2
 Dysrhythmias (bradycardia, tachycardia, asystole)
 Hypotension (decreased left ventricular filling)
 Fall in arterial oxygen saturation
 Increased CVP and venous congestion
 ECG evidence of acute right heart strain
 Mill-wheel murmur
 Precordial Doppler, TEE, Transthoracic
echocardiography
GAS EMBOLISM: TREATMENT
 Stop gas insufflations immediately
 Increase inspiratory O2 concentration to 100%
and hyperventilate
 Position patient head down, left lateral decubitus
 Attempt intracardial gas aspiration if CVP present
 Give inotropes to support right ventricle
 Treat severe hypotension with vasopressors
 CPR for asystole
DYSRHYTHMIAS

 Tachycardia, bradycardia, asystole

 Identify the cause

 Stop gas insufflation

 Consider Atropine (may need to give undiluted atropine)

 Don’t delay CPR

ENDOBRONCHIAL INTUBATION

 Carina shifts upwards with creation of

pneumoperitoneum
 Exaggerated by positioning (head down)

 Check tube position frequently

HYPOXEMIA
 Pre-existing conditions: morbid obesity, COPD

 Hypoventilation: positioning, pneumoperitoneum, ET tube

obstruction, bronchospasm, inadequate ventilation, gas embolism.

 Intrapulmonary shunting: decreased FRC, endobronchial

intubation, pneumothorax, atelectasis.

 Decreased Cardiac Output: hemorrhage, dysrhythmias,

myocardial depression.

 Technical equipment failure: circuit disconnection, delivery of

hypoxic gas mixture.
HYPERCARBIA
 Excessive absorption of CO2
 Hypoventilation
 Increased dead space
 CO2 embolism
 Pneumothorax, pneumomediastinum,
pneumopericardium
 Subcutaneous emphysema
 Exhausted CO2 absorber
 Malignant hyperthermia
ANESTHESIOLOGICAL CONTRAINDICATIONS OF LAPAROSCOPY

 Congestive heart disease (NYHA II-IV)

 Ischemic heart disease
 Obstructive and restrictive pulmonary diseases
 Morbid obesity
 Pregnancy
 Patent foramen ovale
 Huge organomegaly
 Moderate to severe ascites
 Right-to-left shunt
ABSOLUTE CONTRAINDICATIONS
 Acute or recent MI

 Blood dyscrasias

 Late 2nd trimester of pregnancy

 Uncompensated COPD

 Hiatus hernia
CONDUCT OF ANESTHESIA

 Pre-anesthetic check-up & Pre-op advice

 History, physical examination, risk assessment.

 Premedication: H2-blocker, Anxiolytic

(midazolam/diazepam)
CONDUCT OF ANESTHESIA
 Goals:
 IAP: 12 – 15 mmHg (don’t allow to rise >20 mmHg)
 Airway pressure <40 cmH2O (20 – 30)
 EtCO2 ~ 35 mmHg
 Maintain BP and HR.
 Give attention to
 Prevent Acid Aspiration
 ET tube displacement
 Rhythm changes esp. at the time of gas insufflation
 PONV prophylaxis
 Post-operative pain management
 Patient may be anxious

 Duration may be long

 Trendelenburg position (with pneumoperitoneum) may cause

respiratory compromise and dyspnea in the awake patient

 Muscle relaxation is invariably needed.

 LMA, & spontaneous breathing not recommended.

 Induction: Injection Pethidine 0.5 – 1 mg/kg; then inj Propofol (1.5 – 2
mg/kg) or STP (5 mg/kg); Succinylcholine (vecuronium, rocuronium,
cisatracurium) + Inj Dexamethasone 4 mg iv for PONV prophylaxis

 Intubation: appropriate size cuffed ET tube (LMA not recommended).

NG or OG tube insertion and aspiration of stomach content (air)

 Maintenance: Isoflurane (or TCI of TIVA) + O2 + Muscle relaxant ;

 Ventilation: O2 + IPPV (spontaneous ventilation not recommended)

adjusted to eliminate CO2

 End of the Sx: Give inj ondansetron 4 mg; stop isoflurane when
instruments are removed; slightly reduce ventilation, allow the patient to
breathe spontaneously (but avoid hypoventilation); Reversal agent

 Halothane (+ fentanyl) not recommended.

 Extubation

 Watch for facial edema

 Watch for subcutaneous emphysema

 Inspect oropharynx
POSTOPERATIVE MANAGEMENT
 Issues:

 Pain: wound/ right shoulder

 PONV
PROTOCOL FOR POSTOPERATIVE PAIN RELIEF

 Preoperative administration of a non-opioid

analgesic (e.g. NSAID, Paracetamol)
 Pre-incisional infiltration of trocar insertion sites
with local anesthetics (e.g. 40 ml bupivacaine
0.25%, lidocaine 0.5%)
 Rescue medication with small doses of an opioid
(e.g. morphine)
 Treat postoperative shivering with clonidine or
pethidine.
PONV
 Incidence as high as 42%.

 Inj Dexamethasone 4 mg iv at the time of induction.

 Inj Ondansetron 4 mg iv at the end of surgery.

 Third anti-emetic for rescue therapy.

 Adequate pain control.

Recent Advances
GASLESS LAPAROSCOPY
SINGLE-PORT LAPAROSCOPIC SURGERY

Less postoperative pain, less blood loss,

faster recovery time, and better cosmetic results
Drawbacks - increased operative time
Thank You