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Anestesia para cirugía robótica laparoscópica y

abdominal en adultos
AUTOR: Girish P Joshi, MB, BS, MD, FFARCSI
EDITOR DE SECCIÓN: Stephanie B Jones, MD
EDITOR ADJUNTO: Mariana Crowley, MD

Todos los temas se actualizan a medida que hay nueva evidencia disponible y nuestro proceso de revisión por pares se
completa.

Revisión de la literatura vigente hasta: septiembre de 2023.

Este tema se actualizó por última vez: 21 de octubre de 2022.

INTRODUCCIÓN

El abordaje laparoscópico se ha convertido en un estándar de atención para muchos

procedimientos quirúrgicos abdominales. En comparación con la laparotomía, la laparoscopia
permite incisiones más pequeñas, reduce la respuesta al estrés perioperatorio, reduce el dolor
posoperatorio y da como resultado un tiempo de recuperación más corto. La cirugía robótica
abdominal se realiza por vía laparoscópica y se utiliza con mayor frecuencia para cirugía
ginecológica y urológica, aunque su uso se está expandiendo a otras especialidades.

Las preocupaciones anestésicas de los pacientes sometidos a cirugía laparoscópica y robótica

difieren de las de los pacientes sometidos a cirugía abdominal abierta. La laparoscopia requiere
la insuflación de gas intraperitoneal o extraperitoneal, generalmente dióxido de carbono (CO 2 ),
para crear espacio para la visualización y las maniobras quirúrgicas.

Los efectos fisiológicos del neumoperitoneo, la absorción de CO 2 y la posición requerida para la

cirugía pueden influir en la atención y los resultados intraoperatorios. Además, algunos
procedimientos laparoscópicos/robóticos tardan más que la alternativa abierta.

Este tema discutirá el manejo anestésico de pacientes sometidos a cirugía abdominal

laparoscópica y robótica. Las ventajas y desventajas de la laparoscopia y la cirugía robótica, los
aspectos técnicos de estas técnicas y las complicaciones quirúrgicas se analizan por separado.
(Ver "Laparoscopia asistida por robot" y "Complicaciones de la cirugía laparoscópica" e
"Instrumentos y dispositivos utilizados en la cirugía laparoscópica" y "Colecistectomía
laparoscópica" .)

TÉCNICAS QUIRÚRGICAS

Laparoscopy requires creation of a pneumoperitoneum by insufflation of gas, usually carbon

dioxide (CO2), to open space in the abdomen for visualization and surgical manipulation. CO2
insufflation can be performed blindly using a Veress needle or by placement of a port under
direct vision through a small subumbilical incision. The gas source is connected to the needle or
port; intraabdominal pressure (IAP) is monitored as gas is insufflated, aiming for a pressure ≤15
mmHg to minimize physiologic effects. For laparoscopic prostatectomy, which is performed in
steep Trendelenburg position, the European Association for Endoscopic Surgery recommends
IAP below 12 mmHg [1].

After insufflation, a port is placed, and the laparoscope is inserted. Under direct intraabdominal
vision, further instrument ports are placed. The surgeon uses a video monitor connected to the
laparoscope to see intraabdominal contents and perform the procedure.

In some cases, laparoscopy is used to assist dissection, after which an incision is made to
complete the procedure. In others, a larger port is placed to allow the surgeon to insert one
hand to assist the procedure.

The most commonly used robotic system occupies a lot of space in the operating room, and
consists of a surgeon's control console, a tower holding the optical system, and patient-side cart
with robotic arms ( figure 1). For robotic surgery, once the pneumoperitoneum is created,
multiple ports are placed for insertion of the camera and robotic arms, which are connected to
the patient-side cart. The surgeon operates the camera and the robotic arms from the control
console, remote from the patient, while an assistant is at the patient's side for suctioning,
retraction, and passage of suture or sponges in and out of the abdomen.

PREOPERATIVE EVALUATION

A medical history and anesthesia-directed physical examination should be performed for all
patients who undergo anesthesia. In anticipation of laparoscopy, we focus the preoperative
evaluation on those medical conditions that may affect the response to physiologic changes
associated with laparoscopy and the surgical procedure. The laparoscopic approach is used for
surgical procedures with a range of risks of perioperative cardiac and pulmonary adverse
events and surgical complications. As examples, diagnostic laparoscopy may be a brief
procedure with minimal tissue trauma, while laparoscopic radical hysterectomy requires
extensive dissection, may take a number of hours, and can result in significant blood loss.

We believe that preoperative evaluation for laparoscopic procedures should be the same as it
would be for the equivalent open procedure. (See "Evaluation of perioperative pulmonary risk"
and "Evaluation of cardiac risk prior to noncardiac surgery".)

PHYSIOLOGIC EFFECTS OF LAPAROSCOPY

Cardiovascular changes — The cardiovascular changes during laparoscopy are variable and
dynamic ( table 1) [2-5]. These effects are generally well tolerated by healthy patients.
However, significant intraoperative cardiac dysfunction can occur in older patients and in those
with cardiopulmonary disease (eg, chronic obstructive pulmonary disease [COPD], congestive
heart failure, pulmonary hypertension, valvular heart disease). Studies of hemodynamic events
during laparoscopy in patients with significant cardiopulmonary disease have reported an
increase in mean arterial pressure (MAP), systemic vascular resistance (SVR), and central venous
pressure (CVP), with decreases in cardiac output (CO) and stroke volume (SV) during peritoneal
insufflation [6-10]. Compared with healthy patients, those with cardiopulmonary disease may
require more pharmacologic interventions and more intensive monitoring to respond to these
changes.

Cardiovascular changes during laparoscopy relate to the increase in intraabdominal pressure

(IAP) associated with carbon dioxide (CO2) insufflation, effects of positioning, and of absorption
of CO2, as follows:

● Effects of pneumoperitoneum – Pneumoperitoneum and the associated increase in IAP

result in neuroendocrine and mechanical effects on cardiovascular physiology.

• Neuroendocrine effects – Increase in IAP results in catecholamine release and

activation of the renin–angiotensin system with vasopressin release [11-13]. This
increases MAP in most patients and may contribute to increases in SVR and pulmonary
vascular resistance (PVR) [14].

Vagal stimulation, from insertion of the Veress needle or peritoneal stretch with gas
insufflation, can result in bradyarrhythmias. Bradycardia is common in this setting,
while atrioventricular dissociation, nodal rhythm, and asystole have been reported [15].
 • Mechanical effects – Mechanical aspects of laparoscopy are dynamic; the resulting
cardiovascular effects depend on the patient's preexisting volume status, insufflation
pressure, and position. Compression of arterial vasculature with pneumoperitoneum
increases SVR and PVR, with variable effects on CO and blood pressure (BP) [11-13].

Hypercarbia caused by CO2 absorption may also increase SVR and PVR; in most cases,
minute ventilation is increased to prevent hypercarbia, but the increase in intrathoracic
pressure that accompanies ventilator adjustments may further increase SVR and PVR.

Cardiovascular effects tend to resolve quickly as pneumoperitoneum is maintained. A

study of hemodynamic data in 38 patients who underwent laparoscopic
cholecystectomy reported decreases in cardiac index, SV, and left ventricular (LV) end-
diastolic volume after insufflation of CO2 to 15 mmHg, with normalization of all values
within 15 minutes [16].

● Effects of positioning – Laparoscopic surgery is often performed in head-up (eg, for

cholecystectomy) or head-down (eg, pelvic surgery) positions to allow the intraabdominal
organs to fall away from the surgical field. Extremes of position can affect cardiovascular
function.

• Head up – The head-up position (ie, reverse Trendelenburg) leads to venous pooling,
tends to reduce venous return to the heart [12,17], and may result in hypotension,
especially in patients who are hypovolemic.

• Head down – The-head down position (ie, Trendelenburg) position increases venous
return and cardiac filling pressures. A study of the hemodynamic effects of laparoscopy
included 16 patients who underwent laparoscopic radical prostatectomy with 12 mmHg
intraabdominal pressure and a 45 degree Trendelenburg position [5]. CVP, mean
pulmonary artery pressure, and pulmonary capillary wedge pressure increased two- to
threefold, and mean arterial BP (ABP) increased by 35 percent, without changes in CO,
heart rate (HR), or SV. Cardiac filling pressures normalized immediately after surgery.

● Effects of hypercarbia – Absorption of CO2 during laparoscopy can have direct and
indirect cardiovascular effects. The direct effects of hypercarbia and associated acidosis
include decreased cardiac contractility, sensitization to arrhythmias, and systemic
vasodilation. Indirect effects are the result of sympathetic stimulation, and include
tachycardia and vasoconstriction, which may counteract vasodilation [12]. (See 'Pulmonary
changes' below.)
Pulmonary changes — Pneumoperitoneum with CO2 and surgical positioning are associated
with changes in pulmonary function and gas exchange ( table 2). These changes can result
from increased IAP with pneumoperitoneum and from absorption of CO2.

During laparoscopy, minute ventilation must be increased to compensate for absorption of CO2.
Hyperventilation may be difficult for patients with COPD, asthma, and/or severe obesity,
especially in Trendelenburg position. In patients with COPD and in older patients, end-tidal CO2
(ETCO2) may not accurately reflect arterial partial pressure of CO2; in such patients, arterial
blood gases may be required to monitor ventilation.

The absorption and elimination of CO2 in patients with severe obesity appears to be similar to
patients without obesity [18]. Arterial oxygenation decreases and alveolar–arterial oxygen
gradient increases in anesthetized patients with obesity when placed in Trendelenburg position,
though CO2 insufflation tends to slightly reverse these effects [19].

● Changes in pulmonary mechanics – Pneumoperitoneum causes cephalad displacement

of the diaphragm and mediastinal structures, which reduces functional residual capacity
(FRC) and pulmonary compliance, resulting in atelectasis and increased peak airway
pressures. These effects are exacerbated with steep Trendelenburg positioning (eg, during
pelvic surgery) and are reduced with reverse Trendelenburg positioning (eg, during
cholecystectomy and gastric surgery). The changes in pulmonary compliance may be less
with retroperitoneal insufflation (eg, during renal or adrenal procedures) compared with
intraperitoneal insufflation [20].

● CO2 absorption – CO2 is highly soluble and is rapidly absorbed into the circulation during
insufflation for laparoscopy. CO2 absorption increases quickly and reaches a plateau at
approximately 60 minutes of insufflation [20-22]. Ventilation must be increased to
maintain normal end-tidal and arterial partial pressure of CO2 ( figure 2). (See
'Mechanical ventilation' below.)

Surgical technique may influence the degree of CO2 absorption. Multiple studies have
found that subcutaneous emphysema, a possible complication of laparoscopy, is
associated with increased absorption of CO2 [21-23]. (See 'Subcutaneous emphysema'
below.)

Subcutaneous emphysema may be more common during retroperitoneal insufflation of

CO2 compared with intraperitoneal insufflation, but it is not clear whether the
retroperitoneal approach itself increases CO2 absorption. Findings from studies that
compared CO2 absorption with these two techniques without subcutaneous emphysema
have reported conflicting results [21-24].
 ● Ventilation/perfusion matching – The reduction in FRC and atelectasis associated with
laparoscopy may theoretically lead to shunting and ventilation/perfusion mismatch;
however, in healthy patients, these effects are minimal and well tolerated, even with steep
Trendelenburg positioning [4,5,25].

● Endotracheal tube position – Pneumoperitoneum and Trendelenburg positioning may

cause cephalad movement of the carina, which can result in mainstem endobronchial
migration of the endotracheal tube, hypoxia, and high inspiratory pressure [26,27]. In
addition, endotracheal tube cuff pressure increases in some patients during laparoscopy
[28].

Regional circulatory changes

● Splanchnic blood flow – The mechanical and neuroendocrine effects of

pneumoperitoneum can decrease splanchnic circulation, resulting in reduced total hepatic
blood flow and bowel perfusion. However, hypercapnia can cause direct splanchnic
vasodilatation. Thus, the overall effects on splanchnic circulation are not clinically
significant [29,30].

● Renal blood flow – The creation of a pneumoperitoneum results in reduction in renal

perfusion and urine output associated with renal parenchymal compression, reduced
renal vein flow, and increased levels of vasopressin [31-33]. When IAP is kept under 15
mmHg, renal function and urine output generally normalize soon after
pneumoperitoneum deflation, without histologic evidence of pathologic changes.

The effects of laparoscopy on renal function for patients with preexisting renal disease
have not been studied. In most cases, we believe that the benefits of a minimally invasive
surgical approach outweigh theoretical concerns about the effect of increased
intraabdominal pressure on renal function.

● Cerebral blood flow – Increased intraabdominal and intrathoracic pressures, hypercarbia,

and Trendelenburg positioning can all increase cerebral blood flow (CBF) and intracranial
pressures (ICP) [34]. In healthy patients undergoing prolonged pneumoperitoneum and
steep Trendelenburg position, cerebral oxygenation and cerebral perfusion remain within
safe limits [35]. In a small study of patients undergoing laparoscopic cholecystectomy,
internal carotid blood flow reduced significantly after induction of anesthesia, positive
pressure ventilation, and pneumoperitoneum [36]. The reduction in internal carotid artery
blood flow was independently associated with reduced CO, despite unchanged MAP, depth
of anesthesia, and end-tidal carbon dioxide levels. However, clinical significance of these
findings in relatively healthy patients remains unclear. In patients with intracranial mass
 lesions or significant cerebrovascular disorders (eg, carotid atherosclerosis and cerebral
aneurysm), the increase in ICP may have clinical consequences. Therefore, in this patient
population, we maintain strict normocapnia during laparoscopy.

● Intraocular pressure – Intraocular pressure (IOP) increases with pneumoperitoneum and

increases further when the patient is positioned in Trendelenburg [37-39]. A prospective
observational study of IOP in patients who underwent robotic laparoscopic prostatectomy
and hysterectomy in steep Trendelenburg position found that IOP increased and lasted
until 45 to 60 minutes after surgery [40]. The clinical implications of this degree of increase
are unknown, though increased IOP may play a role in the rarely reported postoperative
visual loss in patients with prolonged cases. (See 'Complications related to positioning'
below and "Postoperative visual loss after anesthesia for nonocular surgery", section on
'Postoperative ischemic optic neuropathy'.)

ANESTHETIC MANAGEMENT

Choice of anesthetic — In most cases, we perform general anesthesia for laparoscopy and
robotic surgery. For procedures performed in Trendelenburg position, general anesthesia with
endotracheal intubation allows optimal ventilatory control and support [41].

Others use spinal or epidural anesthesia for short procedures in the supine or head-up position
(eg, diagnostic laparoscopy, laparoscopic cholecystectomy) [42-44]. A sensory level of T4 to T6 is
required for adequate neuraxial anesthesia.

Monitoring and intravenous access — As for any anesthetic, standard American Society of
Anesthesiologists (ASA) monitors (eg, blood pressure [BP], electrocardiography, oxygen
saturation, capnography, and temperature) are applied prior to laparoscopy. Further
monitoring (eg, continuous intraarterial pressure) should be added as required by the patient's
medical condition, the expected blood loss, and the duration of surgery. (See "Basic patient
monitoring during anesthesia".)

All patients require placement of at least one venous catheter for anesthesia. The need for
additional or high-capacity venous access should be dictated by the expected blood loss.

Many robotic procedures and some laparoscopic procedures are performed with the patient's
arms tucked at the sides, limiting access for blood sampling, placement of an arterial catheter,
or additional venous access during the procedure.
Induction of anesthesia — A variety of medications and techniques can be used for induction
of anesthesia and are chosen based on patient factors. For most adults, intravenous (IV)
induction is performed. (See "Induction of general anesthesia: Overview".)

After induction, the eyes should be closed and covered (ie, with tape or adhesive transparent
dressing) to avoid corneal damage. An orogastric tube should be placed and suctioned to
decompress the stomach prior to needle or trocar insertion and to minimize stomach injury.

Choice of airway device — We place an endotracheal tube for airway management for
laparoscopy, rather than a supraglottic airway (SGA), to provide optimal control of ventilation
for elimination of carbon dioxide (CO2) and to protect against aspiration. A cuffed endotracheal
tube allows the use of positive end expiratory pressure (PEEP) and the high peak airway
pressures that may be required during pneumoperitoneum, especially with Trendelenburg
positioning.

SGAs are commonly used for airway management for anesthesia and can be used with positive
pressure ventilation. The use of SGAs for laparoscopy is controversial. These devices do not fully
protect against aspiration of stomach contents and are ordinarily used with lower peak
inspiratory pressures. However, there are a number of studies and case reports describing the
safe use of second-generation SGAs for laparoscopic procedures [45-48]. Second-generation
SGAs allow the use of higher airway pressure without leak and have esophageal vents to
minimize the chance of aspiration. (See "Supraglottic devices (including laryngeal mask airways)
for airway management for anesthesia in adults", section on 'Choice of supraglottic airway'.)

Positioning — Laparoscopy is often performed in extreme head-up (ie, reverse Trendelenburg)

(eg, for cholecystectomy or gastric surgery) or head-down (ie, Trendelenburg) (eg, pelvic
surgery) positions to allow the intraabdominal organs to fall away from the surgical field. In
addition, any of the positions used for open procedures may be required (ie, lithotomy, lateral
decubitus, operating room [OR] table flexion or rotation). The arms are often tucked at the
patient's sides for laparoscopic and robotic surgery. As for all longer surgical procedures, a goal
for positioning and padding is the prevention of injuries to peripheral nerves and bony
prominences. Pressure points should be padded, as should the plastic connectors on IV tubing
and monitoring devices. (See 'Complications related to positioning' below.)

Positioning devices are often used to avoid having the patient slide on the operating table with
steep Trendelenburg or reverse Trendelenburg positioning. A foot support attached to the end
of the operating table may be used for laparoscopic cholecystectomy and other procedures that
require reverse Trendelenburg positioning.
Nonslip padding and cross-body taping are options for preventing the patient from sliding on
the operating table during steep Trendelenburg positioning. We use nonslip padding with
cross-body taping (ie, tape attached to the operating table from over the shoulder to near the
opposite hip). Shoulder supports have been associated with brachial plexus injury; if they are
used, they should be placed laterally, at the acromioclavicular joint, to avoid direct nerve
compression (see "Patient positioning for surgery and anesthesia in adults", section on 'Nerve
injuries associated with the Trendelenburg position'). We test for sliding with maximal
Trendelenburg positioning prior to surgical prep and drape and confirm that taping does not
restrict chest excursion or affect ventilation.

For robotic surgery, once the robotic device is docked with the arms connected to the
instruments, the position of the operating table must not be changed. With instruments in
fixed position, patient movement can result in injury to the abdominal wall and intraabdominal
structures.

Maintenance of anesthesia

Use of nitrous oxide — As for open abdominal procedures, various inhalation and IV
anesthetics can be used for maintenance of general anesthesia for laparoscopy [41]. (See
"Maintenance of general anesthesia: Overview".)

The use of nitrous oxide (N2O) for maintenance during laparoscopy is controversial. In our view,
the balance of the literature on the use of N2O along with prophylaxis for postoperative nausea
and vomiting (PONV) for laparoscopy supports its use when clinically indicated. For longer
procedures, if the surgeon reports difficulty with exposure related to bowel distention, N2O may
be discontinued.

Concerns regarding the use of N2O for laparoscopy include an increase in PONV and bowel
distention.

● PONV – Although N2O is associated with a modestly higher incidence of PONV than other
inhalation anesthetic agents, this can be mitigated by antiemetic prophylactic measures
[49,50]. (See "Postoperative nausea and vomiting", section on 'Anesthetic factors'.)

● Bowel distention – N2O diffuses into air-containing closed spaces over time and can lead
to bowel distention, which can theoretically impair surgical exposure and dissection. Based
on small studies, N2O does not appear to affect operating conditions during relatively
short procedures [41]. A surgeon-blinded study of operating conditions during
laparoscopic cholecystectomy lasting an average of 75 minutes with and without N2O
found no difference in technical difficulty with N2O administration [51]. Similarly, a
 surgeon-blinded study of the effects of N2O during 50 laparoscopic gastric bypass
surgeries found no noticeable bowel distention during 90 minutes of anesthesia [52]. In
both of these studies, the surgeons correctly determined that N2O was being used less
than half of the time.

Bowel distention with laparoscopy may be a more significant concern during longer
procedures since diffusion of N2O into gas-filled spaces increases over time. In a surgeon-
blinded study of approximately 350 patients who underwent colon surgery lasting 3 to 3.5
hours, surgeons were asked to rate intraoperative bowel distention at the end of surgery
[53]. Moderate or severe bowel distention occurred more than twice as often when N2O
was administered compared with air (23 percent versus 9 percent), but there was no
reported bowel distention in the majority of cases in both groups.

Neuromuscular blockade — Neuromuscular blocking agents (NMBAs) are administered

during abdominal surgery to facilitate endotracheal intubation and to improve surgical
conditions. The literature regarding the need for and optimal level of neuromuscular blockade
during laparoscopic procedures is inconclusive. Some studies have shown improved surgical
exposure in this setting with deep block (ie, train-of-four twitch count of zero but post-tetanic
count of 1 to 2) compared with moderate block (ie, train-of-four twitch count of ≥1) [54-58],
while others have shown no benefit from deeper block [59,60]. A 2018 meta-analysis of
randomized controlled trials that compared deep with moderate neuromuscular blockade
during laparoscopy found insufficient evidence to support the use of deep neuromuscular
blockade [61]. A 2019 randomized trial of 35 patients who underwent laparoscopic robotic
surgery in the Trendelenburg position found that respiratory mechanics, regional aeration and
ventilation, and hemodynamics were similar in patients who received deep versus moderate
neuromuscular blockade [62].

We administer NMBAs as required by the clinical situation, aiming for the least degree of block
necessary for the clinical situation. The need for neuromuscular blockade may depend on the
surgical procedure, positioning, and the patient's body habitus. As examples, exposure during
laparoscopic cholecystectomy in a lean patient may be adequate with minimal neuromuscular
block, while laparoscopic deep-pelvic surgery may require relatively deep block to optimize
surgical conditions.

During robotic procedures, deep neuromuscular block should be maintained as long as the
robotic device is docked with intraabdominal instruments attached. In this setting, any degree
of unexpected patient movement can result in injury.
 Mechanical ventilation — The dynamic changes in pulmonary function during laparoscopy
require intraoperative adjustment of mechanical ventilation. (See 'Pulmonary changes' above.)

Our strategy for ventilation — We follow a lung-protective intraoperative ventilatory

strategy using pressure controlled ventilation with volume guarantee. If this mode of ventilation
is unavailable, we use volume-controlled ventilation. We start with a fraction of inspired oxygen
(FiO2) of 0.5, tidal volume of 6 to 8 mL/kg ideal body weight, and with PEEP of 5 to 10 cm H2O, at
a respiratory rate of 8 breaths/minute. We adjust these settings to maintain ETCO2 at
approximately 40 mmHg and oxygen saturation (SaO2) >90 percent. Such a strategy may reduce
postoperative pulmonary complications and improve oxygenation during laparoscopy [63-66].

For patients who develop the following conditions, we modify ventilation as follows:

● For peak pressures over 50 cm H2O, we set the I:E ratio at 1:1.

● For hypoxia (ie, SaO2 <90 percent), we auscultate breath sounds bilaterally to rule out
endobronchial intubation and bronchospasm. We increase the FiO2 and perform a
recruitment maneuver (maintain peak airway pressures at 30 cm H2O for 20 to 30 seconds
if arterial BPs [ABPs] permit); if oxygenation improves, we increase PEEP values and
perform periodic recruitment maneuvers (eg, every 30 minutes). (See 'Pulmonary
complications' below.)

● If hypoxemia and/or high peak airway pressures persist for patients in Trendelenburg
position, we reduce the degree of tilt and/or reduce the insufflation pressure (eg, from 15
to 12 mmHg or less).

● We prefer to increase the respiratory rate, rather than the tidal volume, to increase minute
ventilation and compensate for CO2 absorption. We accept mild hypercapnia (ie, end-tidal
CO2 [ETCO2] approximately 40 mmHg) if necessary to maintain peak airway pressures
under 50 cm H2O in order to avoid barotrauma. In addition, mild hypercarbia can improve
tissue oxygenation by increasing cardiac output (CO) and vasodilation, and a shift to the
right of the oxyhemoglobin dissociation curve [41,67,68].

For hypercarbia (ie, ETCO2 >50 mmHg) despite hyperventilation, we examine for signs of
subcutaneous emphysema. (See 'Subcutaneous emphysema' below.)

● If hypercarbia and/or hypoxia persist, we discuss further reduction in insufflation pressure

or conversion to open surgery.

Modes of ventilation — Various modes of ventilation have been used in an attempt to

reduce peak inspiratory pressure during laparoscopy.
 ● While pressure support ventilation may reduce the chance of high inspiratory pressure
compared with volume control, changes in intraabdominal pressure (IAP) during surgery
can result in varied minute ventilation with pressure control settings. Pressure control with
volume guarantee, where available, can be used to limit peak airway pressure while
maintaining constant ventilation [69]. (See "Mechanical ventilation during anesthesia in
adults", section on 'Pressure control with volume guarantee'.)

● During laparoscopic robotic surgery the driving pressures are distributed more to the
chest wall and less to the lungs [62]. Therefore, in may be necessary to accept higher peak
airway and driving pressures in order to prevent lung collapse and maintain adequate
ventilation.

● Alveolar recruitment in conjunction with high PEEP (15 cm H2O) applied before the onset
of pneumoperitoneum may prevent the alveolar collapse induced by pneumoperitoneum,
though this approach has not been shown to improve postoperative lung function [70].
Higher PEEP levels may be more appropriate in high risk patients in whom impaired
pulmonary mechanics is more likely to cause injury [71].

● Increasing the inspiratory to expiratory (I:E) ratio may be beneficial in steep Trendelenburg
position during laparoscopy. A study of ventilatory strategy in 80 patients who underwent
robotic laparoscopy found that an I:E ratio of 1:1 reduced peak inspiratory pressure
compared with a ratio of 1:2 without a change in CO, though there was no difference in
oxygenation [72].

● One study found that the respiratory effects of increased intraabdominal pressures may
be counterbalanced with targeted PEEP; however, a preferable approach may be to lower
abdominal pressures [73].

● In some patients with obesity complete airway closure (ie, lack of communication between
proximal airways and alveoli due to airway collapse), can occur with induction of
anesthesia, and alveolar opening pressure may increase to very high levels with institution
of pneumoperitoneum and Trendelenburg positioning [74]. This suggests that pressure-
controlled modes may not be appropriate for many patients with obesity, as the increased
airway opening pressures may prevent ventilation unless very high peak pressures are
used.

Fluid management — Perioperative fluid therapy is one of the major factors known to
influence postoperative outcomes after abdominal surgery. Avoidance of fluid excess improves
outcome after major gastrointestinal surgery by reducing bowel edema and interstitial fluid
accumulation. Intraoperative fluid therapy is discussed in greater depth separately. (See
"Intraoperative fluid management".) We administer balanced crystalloid solution 3 to 5 mL/kg/h
as baseline supplemented with additional fluids based on blood loss.

In patients undergoing robotic surgery in prolonged steep head-down position, excessive fluid
administration may result in facial, pharyngeal, and laryngeal edema. Traditional indicators
used to guide fluid therapy (eg, heart rate [HR], ABP, central venous pressures [CVPs], and urine
output) are unreliable. Dynamic indicators such as stroke volume (SV) or systolic pressure
variation may also be unreliable, and use of invasive or noninvasive monitors for goal-directed
therapy in laparoscopic procedures remains controversial. The cardiopulmonary changes
resulting from intraabdominal CO2 insufflation interfere with interpretation of the dynamic
variables (eg, SV variation, pulse pressure variation, systolic pressure variation). We use these
monitors or place arterial lines selectively in patients with significant cardiopulmonary disease.
(See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume
responsiveness'.)

Nausea and vomiting prophylaxis — Laparoscopy has been identified as a risk factor for
PONV, though the literature on this issue is conflicting [75]. Although risk-based approaches for
antiemetic therapy have been proposed, the compliance with these strategies is poor [76].
Therefore, routine prophylactic multimodal antiemetic therapy should be utilized in all patients
undergoing laparoscopic/robotic surgery. The number of antiemetic medications can be based
on the patient's level of risk [76]. Our approach to antiemetic prophylaxis in this setting is as
follows:

● All patients – We administer dexamethasone (4 to 8 mg IV after induction) and 5-HT3

antagonists (eg, ondansetron 4 mg at the end of surgical procedure).

● High-risk patients – For patients at very high risk of PONV (eg, female patients, history of
motion sickness, history of previous PONV, high opioid requirements for pain relief), we
administer additional antiemetic therapy with preoperative transdermal scopolamine (1.5
mg transdermal patch). In addition, we use total IV anesthesia (TIVA) with propofol.

● Rescue therapy – For rescue therapy in the immediate postoperative period, we

administer low-dose promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV).

The management of PONV is discussed in more detail separately. (See "Postoperative nausea
and vomiting".)

Postoperative pain management — The origins of pain after laparoscopic and robotic
surgical procedures may be both somatic (ie, from port-site incisions) and visceral (ie, from
peritoneal stretch and manipulation of abdominal tissues). The degree of pain after
laparoscopic and robotic surgery is usually low to moderate [77,78] and is less than the
corresponding open procedure, but the degree of pain depends on the specific surgery. (See
"Approach to the management of acute pain in adults".)

We follow a procedure-specific, multimodal approach to the management of postoperative

pain, starting prior to and continuing in the OR [77-80]. We aim to minimize perioperative
administration of opioids [81]. Pain after laparoscopy can often be managed effectively with
acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase2 (COX2)-
specific inhibitors, and dexamethasone [80,82-86]. We routinely infiltrate the incisions with local
anesthetic (LA) at the time of wound closure [87]. In the postoperative period, if necessary, low-
to moderate-intensity pain may be treated with weak opioids (eg, tramadol), and moderate- to
high-intensity pain may be treated with strong opioids (eg, hydrocodone and oxycodone) [80].

For hybrid or laparoscopy-assisted surgical procedures with longer incisions, fascial plane
blocks (eg, transversus abdominis plane blocks) may be beneficial [88] (see "Transversus
abdominis plane (TAP) blocks procedure guide"). Alternatively, surgical site infiltration has also
been shown to provide good pain relief [87].

The author does not use neuraxial analgesia (ie, continuous epidural analgesia or intrathecal
opioids) for postoperative pain after laparoscopic surgery, while others may use these
techniques in selected patients [80].

Neuraxial analgesia is usually unnecessary and not beneficial. Epidural analgesia may delay
ambulation and increase the length of stay [80,89]. A review of registry data from an enhanced
recovery after surgery (ERAS) protocol for colon surgery found that while the laparoscopic
approach reduced the hospital length of stay (odds ratio [OR] 0.83), the addition of epidural
analgesia to laparoscopy modestly increased the length of stay (OR 1.1) [90]. Similarly, a
database review of approximately 192,000 laparoscopic colorectal procedures reported an
increase in mean length of stay in patients who had epidural analgesia (six days versus five
days, mean difference 0.6 days, 95% CI 0.27-0.93 days) [91].

Intraperitoneal instillation of LAs (eg, bupivacaine and ropivacaine) may reduce the intensity of
postlaparoscopic pain [92], but the concentration and dose of the LA, as well as optimal timing
of administration, remain unknown, and routine use has not been recommended [77,79].
Management of postoperative pain is discussed in more depth separately. (See "Approach to
the management of acute pain in adults".)

INTRAOPERATIVE COMPLICATIONS
Complications during laparoscopy include those related to the physiologic effects of the
laparoscopic approach (eg, hemodynamic compromise, respiratory decompensation), surgical
maneuvers (eg, access-related injury; vascular, solid-organ, or bowel injury; carbon dioxide
[CO2] spread to subcutaneous and intrathoracic spaces; gas embolism), and patient positioning
[78,93-98]. The impact of intraoperative complications on the anesthetic management of
patients is discussed in the following sections. Further details regarding the complications of
laparoscopic surgery are discussed separately. (See "Complications of laparoscopic surgery".)

Hemodynamic complications — Hypotension, hypertension, and arrhythmias can occur

during laparoscopy as a result of the physiologic effects of the technique ( table 3). (See
'Cardiovascular changes' above.)

● During insufflation – Surgical injury during abdominal access (eg, gas embolism, vascular
or solid organ injury with hemorrhage) can cause rapid cardiovascular decompensation.
Initial abdominal insufflation is a time for hypervigilance with regard to blood pressure
(BP), heart rate (HR), peak inspiratory pressures, end tidal CO2 (ETCO2), and oxygen
saturation. Changes in vital signs should be immediately discussed with the surgeon to
allow reevaluation of the position of the needle or port and possible release of the
pneumoperitoneum.

Treatment of hemodynamic dysfunction includes confirmation that intraabdominal

pressure (IAP) is within acceptable limits; exclusion of treatable causes; and supportive
therapy including reduction in anesthetics, fluid administration, and pharmacologic
interventions. If supportive therapy is ineffective, deflation of the abdomen may be
necessary. After cardiopulmonary stabilization, cautious, slow re-insufflation may then be
attempted using lower IAP. However, with persistent signs of significant cardiopulmonary
impairment, it may be necessary to convert to an open procedure.

● During surgery – During surgery, hemodynamic instability can occur for a variety of
reasons and may be more likely in patients with cardiac comorbidities. (See
'Cardiovascular changes' above.)

• Hemorrhage – Hemorrhage may be less obvious during laparoscopic procedures

because of the limited and focused surgical field. Unexplained hypotension should be
discussed with the surgeon.

• Hyperventilation – When ventilation is increased to compensate for CO2 absorption,

venous return to the heart may be compromised and result in hypotension, especially
with the use of positive end-expiratory pressure (PEEP). Fluid administration and/or
change in ventilatory settings may improve BP. (See 'Mechanical ventilation' above.)
 • Positioning – Head-up positioning can cause venous pooling and reduced venous
return to the heart. Vasopressor administration (eg, phenylephrine) and/or fluid
administration may be required.

Pulmonary complications — Pulmonary complications during laparoscopy, including

hypercarbia and hypoxemia, can relate to the physiologic effects of the technique (eg, altered
respiratory mechanics, CO2 absorption, ventilation perfusion mismatch) or surgical injury (eg,
diaphragm or lung injury) ( table 4 and table 5).

● Hypercarbia – It may be necessary to increase ventilation during laparoscopy to

compensate for CO2 absorption. When hypercarbia or an increase in ETCO2 occurs despite
increase in ventilation, causes for increased absorption or decreased elimination of CO2
should be considered, including both those that may occur during any anesthetic and
those specific to laparoscopy ( table 4).

When severe hypercarbia occurs during laparoscopy, the patient should be examined for
signs of subcutaneous emphysema (ie, crepitus over the abdomen, chest, clavicles and
neck). (See 'Subcutaneous emphysema' below.)

When high ETCO2 persists despite aggressive hyperventilation (eg, peak airway pressures
>50 cm H2O), reduced insufflation pressure or conversion to open surgery may be
required.

● Hypoxia – Oxygen desaturation can occur during laparoscopy as a result of the

physiologic changes of the technique, surgical positioning, or for reasons that hypoxia can
occur during any anesthetic ( table 5).

The chest should be auscultated for the quality and presence of bilateral breath sounds to
rule out bronchospasm and endobronchial intubation. Initial treatment includes an
increase in inspired oxygen concentration. Unless the patient is hypotensive, a recruitment
maneuver should be performed (ie, manual breath with plateau pressure 30 cm H2O, held
for 20 to 30 seconds duration, if BP permits), and PEEP should be optimized. If refractory
hypoxemia occurs, the pneumoperitoneum should be released.

Carbon dioxide insufflation

Subcutaneous emphysema — Subcutaneous emphysema can occur during laparoscopy

when CO2 is insufflated into subcutaneous tissues. This can occur during intraperitoneal
insufflation with an improperly placed Veress needle or trocar, during extraperitoneal
laparoscopy (eg, renal surgery), or during upper abdominal laparoscopy (eg, Nissen
fundoplication) [23,99]. In rare cases, gas can track into the thorax and mediastinum, thereby
resulting in capnothorax, capnomediastinum, and capnopericardium ( table 6) [100]. (See
'Capnothorax' below.)

The following have been identified as risk factors for subcutaneous emphysema during
laparoscopy [101]:

● Surgery lasting longer than 200 minutes

● The use of six or more surgical ports
● Patient age >65
● Nissen fundoplication surgery

Multiple studies have found that subcutaneous emphysema is associated with increased
absorption of CO2 [21-23]. When hypercarbia occurs despite hyperventilation, the patient
should be examined for signs of subcutaneous gas over the abdomen, chest, and neck. If
crepitus or swelling is found, the surgeon should be notified; readjustment of ports, reduction
of insufflation pressure, or conversion to open surgery may be required.

In most cases, subcutaneous emphysema resolves after the abdomen is deflated, and no
specific intervention is required. When crepitus or swelling occurs in the head, neck, or upper
chest, the potential for airway compromise after extubation is increased, especially for patients
who may be edematous after prolonged procedures in Trendelenburg position. In most cases,
subcutaneous CO2 is superficial and does not compromise the airway lumen. When external
swelling is severe, options include the following:

● Laryngoscopy to assess airway edema while the patient is anesthetized.

● Extubation over a tube changer. (See "Management of the difficult airway for general
anesthesia in adults", section on 'Extubation'.)
● Delayed extubation for several hours, with the patient positioned head-up, to allow
resorption of CO2.

Absorption of CO2 from subcutaneous emphysema may continue for up to several hours after
surgery [102]. Healthy patients are able to increase ventilation to eliminate CO2, but those with
chronic lung disease or with opioid-induced respiratory depression can remain hypercarbic and
acidotic early in the postoperative period. Somnolence, hypertension, and tachycardia may
occur.

For symptomatic patients with subcutaneous emphysema of the head and neck region, a
postoperative chest radiograph should be performed to rule out capnothorax. Patients with
significant subcutaneous emphysema should be observed in the post-anesthesia care unit
(PACU) for several hours, until swelling begins to subside and vital signs are normal.

Capnothorax — Capnothorax, although rare, can be potentially life-threatening [94,103].

Causes of capnothorax are presented in a table ( table 6). Capnothorax should be suspected
in the setting of an unexplained increase in airway pressure, hypoxemia, and hypercapnia,
especially during Nissen fundoplication. Other signs suggestive of capnothorax include
subcutaneous emphysema of the head and neck, inequality in chest expansion, reduced air
entry, and a bulging diaphragm (visualized by directing the videoscope towards the diaphragm)
[104]. If necessary, a chest radiograph or transthoracic ultrasound can confirm the diagnosis of
capno- or pneumothorax [105].

In this setting, treatment depends on the patient's hemodynamic and respiratory status and the
stage of the surgery. If stable, reduction of insufflation pressure, hyperventilation, and increase
in PEEP may be sufficient; CO2 is resorbed quickly after even large capnothorax. In one reported
case of near total capnothorax during Nissen fundoplication, the gas resorbed within one hour
postoperatively, with no specific treatment [104].

However, hemodynamic compromise can occur, requiring placement of an intrathoracic needle

or a chest tube for decompression and to allow completion of surgery [106-109]. If tension
capnothorax persists despite these measures, conversion to open surgery may be required.

Capnomediastinum and capnopericardium — Capnomediastinum and capnopericardium,

although rare, can be associated with significant hemodynamic compromise. Risk factors for
these complications are similar to the risk factors for capnothorax. The diagnosis is made by
chest radiograph (ie, air is visible in the mediastinum or pericardium). Management depends on
the degree of hemodynamic compromise. In most patients, deflation of the
pneumoperitoneum and close observation is adequate, while others might require supportive
therapy along with hyperventilation.

Gas embolism — Venous gas embolism is extremely common during laparoscopy, though
clinically significant emboli are rare. Studies using transesophageal echocardiography (TEE)
during laparoscopic surgery have reported an incidence of subclinical gas embolism between
17 and 100 percent [110-113].

In this setting, gas embolism can occur via two mechanisms. Rarely, direct venous injection of
CO2 with the Veress needle can result in rapid, high-volume CO2 embolism at the time of
abdominal insufflation. Alternatively, CO2 entrainment is possible if a vein is severed or
disrupted during surgery, allowing the gas under pressure access to the circulation.
Signs of gas embolism include unexplained hypotension, abrupt reduction of ETCO2,
hypoxemia, and arrhythmias. The electrocardiogram (ECG) may show right heart strain with a
widened QRS complex. Paradoxical embolism through a patent foramen ovale (PFO) or atrial
septal defect (ASD) can occur, with cerebral or coronary ischemia.

If gas embolism is suspected, the abdomen should be deflated to reduce CO2 entrainment, and
ventilation should be increased to reduce the size of CO2 bubbles, though hyperventilation may
worsen hypotension. Since gas embolism results from a vascular injury, hemorrhage is possible
when the intraabdominal pressure is reduced. Therefore, re-insufflation or open surgery may
be required to stop hemorrhage if hemodynamic instability persists.

Treatment is otherwise supportive, with fluid and vasopressor administration and, if necessary,
cardiopulmonary resuscitation. The left-lateral, head-down position may allow the gas bubble to
float to the apex of the right heart, away from the pulmonary artery.

Complications from surgical instrumentation — Complications of surgical instrumentation

can occur during abdominal access or during the surgical procedure. The complications of most
concern to the anesthesiologist include vascular and abdominal organ injury, both of which can
result in significant hemorrhage.

Up to half of serious surgical complications occur during placement of the Veress needle or an
access port [114]. Therefore, significant injury and major hemorrhage can occur even during
relatively low-risk procedures (eg, diagnostic laparoscopy, laparoscopic appendectomy). In this
setting, surgical access to a bleeding vessel or organ may take time; BP should be supported
with IV fluid and vasopressor administration, as necessary.

As with open surgical procedures, injury to intraabdominal structures can occur during
dissection. Bleeding may be less obvious during laparoscopy than it is during open procedures.
The view of the surgical field is limited, and blood can pool away from the surgical field when
patients are in head-up or head-down position. Signs of hypovolemia (ie, hypotension,
tachycardia) may suggest occult bleeding and should be brought to the surgeon's attention.

The incidence, risk factors, and technical aspects of surgical complications are discussed in
more detail separately. (See "Complications of laparoscopic surgery".)

Complications related to positioning — Prolonged steep Trendelenburg positioning can

cause conjunctival, nasal, and laryngopharyngeal edema and may result in increased upper
airway resistance [26] and, rarely, postextubation laryngospasm and airway obstruction.
Both minor (ie, corneal abrasion) and significant (ie, ischemic optic neuropathy) ocular injuries
have been reported after laparoscopy performed in steep Trendelenburg position.
Postoperative visual loss and ocular injury are discussed in more detail separately. (See
"Postoperative visual loss after anesthesia for nonocular surgery".)

As for other long surgical procedures, patients who undergo prolonged laparoscopy are at risk
for position-related nerve injury and even compartment syndrome [115,116]. Pressure points,
plastic tubing connectors, monitoring cables, and leg supports for lithotomy positioning should
all be padded. With steep Trendelenburg positioning, the arms should be positioned without
caudad pull on the shoulders in order to reduce the chance of brachial plexus stretch injury.

Shoulder braces may be used to prevent sliding during Trendelenburg positioning; their use has
been associated with brachial plexus injury in this setting, though the incidence is unknown
[117].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Enhanced recovery after
surgery".)

SUMMARY AND RECOMMENDATIONS

● Use of laparoscopic and robotic approaches – The laparoscopic approach has become
the standard of care for many surgical procedures. Abdominal robotic surgery is
performed laparoscopically; anesthetic concerns for conventional laparoscopy and robotic
surgery are similar. (See 'Surgical techniques' above.)

● Physiologic effects

• Laparoscopy requires insufflation of CO2 to create space for visualization and surgical
maneuvers. The associated increase in intraabdominal pressure (IAP), along with
absorption of CO2 and effects of surgical positioning, result in neuroendocrine and
mechanical changes that affect cardiopulmonary function. (See 'Physiologic effects of
laparoscopy' above.)

• Cardiopulmonary physiologic changes include the following:

 - Cardiovascular changes – Increased systemic vascular resistance (SVR), arterial
blood pressure (ABP), and cardiac filling pressures ( table 1). (See 'Cardiovascular
changes' above.)

- Pulmonary changes – Increased intrathoracic pressure, reduced functional

residual capacity (FRC), and increased airway pressures ( table 2). (See
'Pulmonary changes' above.)

● Choice of anesthetic technique – We perform general anesthesia with endotracheal

intubation for laparoscopy, though others have used regional anesthesia safely for short
laparoscopic procedures. (See 'Choice of anesthetic' above.)

● Anesthetic agents

• When indicated, we administer nitrous oxide (N2O) as part of a balanced general

anesthetic, along with prophylaxis for postoperative nausea and vomiting (PONV). (See
'Use of nitrous oxide' above.)

• For laparoscopy, we administer neuromuscular blocking agents (NMBAs) based on

clinical need, aiming for the least degree of block necessary for the clinical situation.
For robotic surgery, we maintain deep neuromuscular blockade (ie, one twitch with
train-of-four peripheral nerve stimulator) until the robotic device is undocked. (See
'Neuromuscular blockade' above.)

● Ventilation – We ventilate with a fraction of inspired oxygen (FiO2) of 0.5, a starting tidal
volume of 6 to 8 mL/kg ideal body weight, with positive end expiratory pressure (PEEP) of 5
to 10 cm H2O, at a respiratory rate of 8 breaths/minute, adjusted to maintain end tidal CO2
(ETCO2) at approximately 40 mmHg and oxygen saturation (SaO2) >90 percent. We use
pressure control ventilation with volume guarantee; if unavailable, we use volume control
ventilation. We modify ventilation during laparoscopy as follows:

• For peak pressures over 50 mmHg, we set the I:E ratio at 1:1. (See 'Mechanical
ventilation' above.)

• For hypoxia (ie, SaO2 <90 percent), we increase the FiO2, auscultate bilaterally for
breath sounds, and perform a recruitment maneuver (maintain peak airway pressures
at 30 cm H2O for 20 to 30 seconds if ABPs permit); if oxygenation improves, we increase
PEEP values and perform periodic recruitment maneuvers (eg, every 30 minutes). (See
'Pulmonary complications' above.)
 • If hypoxemia and/or high peak airway pressures persist, for patients in Trendelenburg
position, we reduce the degree of tilt and/or reduce the insufflation pressure (eg, from
15 to 12 mmHg).

• For hypercarbia (ie, ETCO2 >50 mmHg) despite hyperventilation, we examine for signs
of subcutaneous emphysema. (See 'Subcutaneous emphysema' above.)

• If hypercarbia and/or hypoxia persist, we discuss reduction in insufflation pressure

and/or degree of head down position or conversion to open surgery.

● Postoperative analgesia – Laparoscopic surgery results in less pain than the

corresponding open procedure. We use a multimodal approach to postoperative pain
control, including acetaminophen, nonsteroidal antiinflammatory drugs, and
local/regional analgesia, with the addition of opioid medication only as necessary. (See
'Postoperative pain management' above.)

● Prophylaxis for postoperative PONV – We suggest prophylaxis for PONV for all patients
who undergo laparoscopy (Grade 2C). We use the following approach (see 'Nausea and
vomiting prophylaxis' above):

• All patients – We administer dexamethasone (4 to 8 mg IV after induction) and 5-HT3

antagonists (eg, ondansetron 4 mg at the end of surgical procedure).

• High-risk patients – For patients at very high risk of PONV (eg, history of motion
sickness, history of previous PONV, high opioid requirements for pain relief), we also
use preoperative transdermal scopolamine (1.5 mg transdermal patch). In addition, we
use total intravenous anesthesia (TIVA) with propofol.

• Rescue therapy – For rescue therapy in the immediate postoperative period, we

administer low-dose promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV).

● Complications of laparoscopy

• Hemodynamic (eg, hypotension, hypertension, and arrhythmias) and pulmonary

complications (eg, hypoxia, hypercarbia) can occur as a result of the physiologic effects
of laparoscopy ( table 3 and table 4 and table 5). (See 'Hemodynamic
complications' above and 'Pulmonary complications' above.)

• Rare but significant complications can occur, including traumatic vascular and organ
injury, CO2 embolism, capnothorax, and capnomediastinum. Treatment is supportive
 and may require release of the pneumoperitoneum and conversion to open surgery
( table 4 and table 6) (See 'Carbon dioxide insufflation' above.)

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Topic 100120 Version 30.0
GRAPHICS

Operating room layout during robotic surgery

The most commonly used robotic system occupies a lot of operating room space. This
graphic shows one configuration, with the robotic cart positioned at the patient's head.
The cart may be placed at the patient's side (eg, for kidney surgery), and is often placed
between the patient's legs in the lithotomy position for gynecologic and urologic
surgery.
Reproduced with permission from: Horgan S, Sedrak MF. Robotic surgery. In: Fischer's Mastery of Surgery,
6th ed, Fischer JE, Jones DB, Pomposelli FB, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2012.
Copyright © 2012 Lippincott Williams & Wilkins (www.lww.com). Unauthorized reproduction of this material
is prohibited.

Graphic 104766 Version 4.0

Cardiovascular changes during laparoscopy

Parameters Change Causes

Systemic vascular resistance Increased Hypercarbia

and Neuroendocrine response
mean arterial pressure (ie, increased
catecholamines,
vasopressin, and cortisol)
Mechanical factors (ie, direct
compression of aorta)

Cardiac filling pressures Increased Increased intrathoracic

pressure secondary to
pneumoperitoneum
Increased sympathetic
output due to
neuroendocrine response
and hypercarbia

Cardiac filling volumes Variable; increased or no Interaction among:

change Increased intravascular
volume resulting from
compression of liver and
spleen
Reduced preload and
venous return
Positioning
Patient's preexisting status

Cardiac index Variable; decreased or no Interaction among:

change Increased afterload
Decreased venous return
Decreased cardiac filling
Increased intravascular
volume
Positioning
Patient's preexisting status

Cardiac rhythm Bradyarrhythmias Peritoneal stretch - vagal

Tachyarrhythmias Hypercarbia
Hypoxia
Capnothorax
Pulmonary embolism
Adapted from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical Anesthesia, 7th ed,
Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013.

Graphic 105517 Version 2.0

Pulmonary changes during laparoscopic and robotic surgery

Parameter Change Causes

Lung volume (ie, functional Decrease Elevation of diaphragm

residual capacity) Increased intraabdominal
pressure
Positioning

Lung compliance Decreased Elevation of diaphragm

Increased pleural pressure Increased intraabdominal
Increased airway pressure pressure

PCO2 Increased, depending on CO2 absorption

ventilation

PO2 Variable Interaction among:

Atelectasis
Hypoxic pulmonary
vasoconstriction
Preoperative pulmonary
status

Tracheal position Cephalad displacement, Increased intraabdominal

possible mainstem intubation pressure
Trendelenburg position

PO2: partial pressure of oxygen; PCO2: partial pressure of carbon dioxide; CO2: carbon dioxide.

Adapted from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical Anesthesia, 7th ed,
Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013.

Graphic 105522 Version 2.0

CO2 absorption during laparoscopy

Mean CO2 elimination versus time in patients with transperitoneal and retroperitoneal
laparoscopic approaches.

CO2: carbon dioxide; VCO2: mean CO2 elimination.

Reproduced from: Kadam PG, Marda M, Shah VR. Carbon Dioxide Absorption During Laparoscopic Donor
Nephrectomy: A Comparison Between Retroperitoneal and Transperitoneal Approaches. Transplant Proc 2008;
40:1119. Illustration used with the permission of Elsevier Inc. All rights reserved.

Graphic 105217 Version 2.0

Differential diagnosis of hemodynamic collapse during laparoscopy

Decreased cardiac preload:

Hemorrhage

Positional blood pooling

Gas embolism

Excessive intraabdominal pressure

Capnothorax

Cardiac tamponade due to capnomediastinum or capnopericardium

Decreased cardiac contractility:

Anesthetic medication effect

Myocardial ischemia or infarction

Acidosis due to hypercarbia

Decreased SVR:

Anesthetic overdose

Acidosis due to hypercarbia

Anaphylaxis

Sepsis

Bradycardia:

Vagal stimulation

SVR: systemic vascular resistance.

Adapted from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical Anesthesia, 7th ed,
Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013.

Graphic 105520 Version 2.0

Differential diagnosis of hypercarbia during laparoscopic and robotic
surgery

Increased CO2 absorption

CO2 insufflation (extraperitoneal insufflation > intraperitoneal insufflation)

Subcutaneous emphysema
CO2 embolism
Capnothorax, capnomediastinum, capnopericardium

Decreased CO2 removal (ie, hypoventilation, V/Q mismatch)

Endobronchial intubation
Atelectasis
Airway obstruction
Reduced cardiac output

Increased CO2 production

Obesity
Malignant hyperthermia
Fever
Thyrotoxicosis

CO2 rebreathing

Defective CO2 absorber

Malfunctioning breathing circuit valves

CO2: carbon dioxide; V/Q: ventilation/perfusion.

Adapted with permission from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical
Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright
© 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105521 Version 5.0

Causes of hypoxemia during laparoscopic and robotic surgery

Patient factors

Preexisting cardiopulmonary dysfunction

Morbid obesity

Intraoperative ventilation

Low FiO2
Hypoventilation

V/Q mismatch

Endobronchial intubation
Atelectasis
Capno (pneumo) thorax
Pulmonary embolism
Patient position (eg, lateral decubitus)

Reduced cardiac output

Inferior vena cava compression

Dysrhythmias
Myocardial depression (eg, anesthetic drug effects)
Hemorrhage

Anemia

Pre-existing anemia
Hemorrhage

FiO2: fraction of inspired oxygen; V/Q: ventilation/perfusion.

Adapted with permission from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical
Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright
© 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105518 Version 4.0

Causes of subcutaneous emphysema, capnothorax, and capnomediastinum
during laparoscopy and robotic surgery

Inadvertent peritoneal breach

Retroperitoneal insufflation
Misdirected Veress needle or peritoneal port (eg, damage to falciform ligament, subcutaneous
needle or port placement)
Specific to capnothorax and capnomediastinum:
Gas tracked through fascial planes from neck and thorax into the mediastinum and pleural
space
Dissection around the diaphragm (eg, during Nissen fundoplication, gastric bypass surgery)
Passage of gas through the pleuroperitoneal hiatus (ie, foramen of Bochdalek)
Passage of gas through congenital defects (ie, foramen of Morgagni)

Adapted with permission from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical
Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright
© 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105519 Version 4.0

Contributor Disclosures
Girish P Joshi, MB, BS, MD, FFARCSI Consultant/Advisory Boards: Baxter [anesthesia]. All of the relevant
financial relationships listed have been mitigated. Stephanie B Jones, MD No relevant financial
relationship(s) with ineligible companies to disclose. Marianna Crowley, MD No relevant financial
relationship(s) with ineligible companies to disclose.

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