Jean L.

Joris

68
Key Points

Anesthesia for Laparoscopic Surgery

1. CO2 pneumoperitoneum results in ventilatory and respiratory changes. Pneumoperitoneum decreases thoracopulmonary compliance. Paco2 increases (15% to 25%) due to CO2 absorption from the peritoneal cavity. Capnography reliably reflects this increase, which plateaus after 20 to 30 minutes. 2. In compromised patients, cardiorespiratory disturbances aggravate the increase in Paco2 and enlarge the gradient between Paco2 and Petco2. 3. Any increase in Petco2 larger than 25% or occurring later than 30 minutes after the beginning of peritoneal CO2 insufflation should suggest CO2 subcutaneous emphysema, the most frequent respiratory complication during laparoscopy. 4. Peritoneal insufflation induces alterations of hemodynamics, characterized by decreases of cardiac output, elevations of arterial pressure, and increases of systemic and pulmonary vascular resistances. Hemodynamic changes are accentuated in high-risk cardiac patients. 5. The pathophysiologic hemodynamic changes can be attenuated or prevented by optimizing preload before pneumoperitoneum and by vasodilating agents, α2adrenergic receptors agonists, high doses of opioids, and β-blocking agents.

6. Similar pathophysiologic changes occur during pregnancy and in children. Laparoscopy can be safely managed in pregnant women before the 23rd week of pregnancy provided that hypercarbia is prevented. The open laparoscopy approach should be considered to avoid damaging the uterus. 7. Gasless laparoscopy may be helpful to reduce pathophysiologic changes induced by CO2 pneumoperitoneum but unfortunately increases technical difficulty. 8. Laparoscopy results in multiple postoperative benefits, allowing for quicker recovery and shorter hospital stay. These advantages explain the increasing success of laparoscopy, which is proposed for many surgical procedures. 9. Although no anesthetic technique has proved to be clinically superior to any other, general anesthesia with controlled ventilation seems to be the safest technique for operative laparoscopy. 10. Improved knowledge of the intraoperative repercussions of laparoscopy permits safe management of patients with more and more severe cardiorespiratory disease, who may subsequently benefit from the multiple postoperative advantages offered by this technique.

Surgical procedures have been improved to reduce trauma to the patient, morbidity, mortality, and hospital stay, with consequent reductions in health care costs. The provision of better equipment and facilities, along with increased knowledge and understanding of anatomy and pathology, has allowed the development of endos­ copy for diagnostic and operative procedures. Starting in the early 1970s, various pathologic gynecologic conditions were diagnosed and treated using laparoscopy. This endoscopic approach was extended to cholecystectomy in the late 1980s. Since the intro­ duction of the first laparoscopic cholecystectomy procedures,1 laparoscopy has expanded impressively both in scope and volume. It quickly became apparent that laparoscopy results in multiple

benefits compared with open procedures2,3 and was characterized by better maintenance of homeostasis. Overenthusiasm ensued, which explains the effort to use the laparoscopic approach for gastrointestinal (e.g., colonic, gastric, splenic, hepatic surgery), gynecologic (e.g., hysterectomy), urologic (e.g., nephrectomy, prostatectomy), and vascular (e.g., aortic) procedures. The pneumoperitoneum and the patient positions required for laparoscopy induce pathophysiologic changes that complicate anesthetic management. An understanding of the pathophysio­ logic consequences of increased intra­abdominal pressure (IAP) is important for the anesthesiologist who must ideally prevent or, when prevention is not possible, adequately respond to these
2185

and gas embolism. pain. Data are given as the mean ± SEM.32 7.22 These findings have been documented in patients with chronic obstructive pulmonary disease (COPD)23 and in children with cyanotic congenital heart disease. such as CO2 subcutaneous emphysema.. patient posi­ Ventilatory and Respiratory Changes During Laparoscopy Intraperitoneal insufflation of carbon dioxide (CO2).20 Paco2 and Δa­ETCO2 increase more in ASA class II and III patients than in ASA class I patients (Fig. the increase of Paco2 may be multifactorial: absorption of CO2 from the peritoneal cavity.19.48 * * * * * * * * 7. and in otherwise healthy patients with acute cardiopulmonary disturbances. Many animal and human studies of the consequences of laparoscopy have been published since the early 1970s. impairment of pulmonary ventilation and perfusion by mechanical factors such as abdominal distention.34 7.21.05 compared with time 0.30 PaCO2 ( pH ( .8.16 Although mean gradients (Δa­ETCO2) between Paco2 and the end­tidal carbon dioxide tension (Petco2) do not change significantly during peritoneal insufflation of CO2.12.15.25 During CO2 pneumoperitoneum. minute ventilation was kept constant at 100 mL/kg/min with a respiratory rate of 12 breaths/min during the study. The increase in Paco2 depends on the IAP. Increase in the Partial Pressure of Arterial Carbon Dioxide During uneventful CO2 pneumoperitoneum.13 )(mm Hg) 50 48 46 44 42 40 38 36 34 32 30 28 0 5 10 20 15 25 30 Min after insufflation 35 40 45 7.24 These data therefore highlight the lack of correlation between Paco2 and Petco2 in sick patients.9 Reduction in functional residual capacity10 and development of atelectasis due to elevation of the diaphragm11 and changes in the distribu­ tion of pulmonary ventilation and perfusion from increased airway pressure can be expected. we have focused on the human literature published after 1990 using low IAP (<15 mm Hg) and modern anesthesia techniques.46 7. The post­ operative period is considered next. P < .*. The pathophysiologic changes and the complications of laparoscopy are reviewed first.50 7. individual patient data regularly show variations of this difference during pneumoperitoneum. the cur­ rently routine technique to create pneumoperitoneum for laparos­ copy. with examination of the ben­ efits of laparoscopy and certain specific postoperative problems (e.11 However. Paco2 remains unchanged but minute ventilation sig­ nificantly increases. particularly those with impaired CO2 excretion capacity. 68­ 2). 68­1).V 2186 Adult Subspecialty Management changes and who must evaluate and prepare the patient preopera­ tively in light of these disturbances.g.17 During laparoscopy with local anesthesia. For 13 American Society of Anesthesiologists (ASA) class I and II patients. Consequently. Because much higher IAPs (>20 mm Hg) were previously used and because of potential species differences. Practical consequences for the anesthetic management of laparoscopy are presented. Paco2.38 7. results in ventilatory and respiratory changes and can cause four principal respiratory complications: CO2 subcutaneous emphysema. pneumothorax.4 Ventilatory Changes Pneumoperitoneum decreases thoracopulmonary compliance by 30% to 50% in healthy5­7 and obese patients. endobronchial intubation. Postoperative intra­abdominal CO2 retention results in increased respiratory rate and Petco2 of patients breathing spontaneously after laparoscopic cholecystec­ tomy as compared with open cholecystectomy. nausea). even in the absence of abnormal Petco2.16 Any significant increase in Paco2 after this period requires a search for a cause independent of or related to CO2 insufflation. the partial pressure of arterial carbon dioxide (Paco2) progressively increases to reach a plateau 15 to 30 minutes after the beginning of CO2 insufflation in patients under controlled mechanical ventilation during gyne­ cologic laparoscopy in the Trendelenburg position14 or during laparoscopic cholecystectomy in the head­up position (Fig.18 Capnography and pulse oximetry provide reliable monitor­ ing of Paco2 and arterial oxygen saturation in healthy patients and in the absence of acute intraoperative disturbances (see Figure 68­1).40 7. ) and PETCO2 ( * * 7. increasing IAP to 14 mm Hg with the patient in a 10­ to 20­degree head­up or head­down position does not significantly modify either physio­ logic dead space or shunt in patients without cardiovascular problems.42 ) Figure 68-1 Ventilatory changes (pH. Intraabdominal pressure was 14 mm Hg.36 7. and Petco2) during CO2 pneumoperitoneum for laparoscopic cholecystectomy.15.44 7. hypercapnia can develop.

14. et al: Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. particularly in COPD patients. the absorption area. does not counterindicate tracheal extubation at the end of surgery. and volume­controlled mechanical ventilation. In these circumstances. the continued rise of Paco2 without a corresponding increase in VCO2 results from an increase in respiratory dead space. Indeed.14 Any increase in Petco2 occurring after Petco2 has plateaued should suggest this complication. 68­3). VCO2 .28 or laparoscopic cholecystectomy in the head­up position.37 unilateral and bilateral pneumothoraces.17 During deflation. fundoplication for hiatal hernia). Pneumomediastinum. direct measurement of CO2 elimination ( VCO2 ) using a metabolic monitor combined with investigation of gas exchange showed a 20% to 30% increase of VCO2 without significant changes in phy­ siologic dead space in healthy patients undergoing pelvic lapar­ oscopy (IAP of 12 to 14 mm Hg) in the head­down position14. but not nitrous oxide (N2O) or helium. ventilatory changes also significantly contribute to increasing Paco2. PaCO2 (mm Hg) Figure 68-2 Ventilatory changes as a function of patient physical status. as reflected by a wid­ ening of the Δa­ETCO2 gradient.32 Lister and colleagues17 investigated the relationship between VCO2 and intraperitoneal CO2 insufflation pressure in pigs.13 It is wise to maintain Paco2 within a physiologic range by adjusting the mechanical ventilation. laparoscopy must be temporarily interrupted to allow CO2 elimination and can be resumed after correction of hypercapnia using a lower insufflation pressure.14. Pneumothoraces may also develop secondary to pleural tears during laparoscopic surgical procedures at the level of the gastroesophageal junction (e. even cervical. Because CO2 diffusibility is high.18. the pneumo­ thorax associated with fundoplication is more frequently in the left side of the chest. In healthy patients. absorp­ tion of CO2 from the abdominal cavity represents the main (or the only) mechanism responsible for increased Paco2.17 If controlled ventilation is not . correction of increased Paco2 can be easily achieved by a 10% to 25% increase in alveolar ventilation. alveolar ventila­ tion will decrease and Paco2 will rise. Defects in the diaphragm or weak points in the aortic and esophageal hiatus may allow gas passage into the thorax. Paco2. CO2 subcutaneous emphy­ sema readily resolves once insufflation has ceased. CO2 that accumulated in col­ lapsed peritoneal capillary vessels reaches the systemic circula­ tion. ASA I (n = 20). (Data from Wittgen CM.13 but in patients with cardiorespiratory problems. For an IAP up to 10 mm Hg. In this case.) tion. group 2 (blue circles). Mismatched ventila­ tion and pulmonary perfusion can result from the position of the patient and from the increased airway pressures associated with abdominal distention. to avoid an excessive increase in the work of breathing. Although opening of peritoneo­ pleural ducts is associated with mainly right­sided pneumo­ thoraces (in the same way that ascites or peritoneal dialysis may be associated with right­sided pleural effusions40). CO2 pressure determines the extent of the emphysema and the magnitude of CO2 absorption. such as when CO2 subcutaneous emphysema occurs (see later). was used as the insufflating gas suggests that the main mechanism of the increased Paco2 during CO2 pneumo­ peritoneum is absorption of CO2 rather than the mechanical ven­ tilatory repercussions of increased IAP. and pelvic lym­ phadenectomy (Fig.Anesthesia for Laparoscopic Surgery 2187 39 37 PETCO2(mm Hg) 35 33 31 29 27 25 Before 25 30 35 40 45 50 ASA I ASA II–III During 68 adjusted in response to the increased dead space. leading to transient increases in Paco2 and VCO2 . absorption of large quantities of CO2 into the blood and the subsequent marked increases in Paco2 would be expected to occur.36 We recommend keeping the patient mechanically ventilated until hypercapnia is corrected. and the perfusion of the walls of that cavity.39 Embryonic rem­ nants constitute potential channels of communication between the peritoneal cavity and the pleural and pericardial sacs. Except in special circum­ stances. Pneumopericardium Movement of gas during the creation of a pneumoperitoneum can produce pneumomediastinum. Patients were grouped according to ASA classification: group 1 (green circles).27 Accordingly. Arch Surg 126:997. Fitzgerald SD. the opening of the peritoneum overlying the diaphragmatic hiatus allows passage of CO2 under pressure through the mediastinum to the cervicocephalic region.38 and pneumopericardium.g. 1991. ASA II-III (n = 10). The observa­ tion of an increase in Paco2 when CO2. increased VCO2 accounts for the increased Paco2.21 Pao2 values and intrapulmonary shunt do not significantly change during laparoscopy. renal surgery. and Petco2 increase. which can open when intraperitoneal pressure increases.29 The time courses of the increase in VCO2 and Paco2 are similar.26. Section V Adult Subspecialty Management Respiratory Complications CO2 Subcutaneous Emphysema CO2 subcutaneous emphysema can develop as a complication of accidental extraperitoneal insufflation33 but can also be consid­ ered as an unavoidable side effect of certain laparoscopic surgical procedures that require intentional extraperitoneal insufflation..31 Respiratory changes during the laparoscopic procedure may contribute to increasing CO2 tension. At higher IAPs. The increase in VCO2 may be such that prevention of hypercapnia by adjustment of ventilation becomes almost impossible.34. The limited rise of Paco2 actually observed can be explained by the capacity of the body to store CO230 and by impaired local perfusion due to increased IAP. Pneumothorax. Andrus CH.12.35 During laparoscopic fundoplica­ tion for hiatal hernia repair. CO2 sub­ cutaneous emphysema. The Paco2 and Petco2 were measured before and during CO2 insufflation. The absorption of a gas from the peritoneal cavity depends on its dif­ fusibility. such as inguinal hernia repair.

Tessler MJ. When a pneumothorax is caused by highly diffusible gas such as N2O or CO2 without associated pulmonary trauma.30 Rapid elimination also increases the margin of safety in case of intravenous injection of CO2. Early events. Petco2. the Petco2 decreases because of decreased cardiac output. obstruction to venous return with a fall in cardiac output or even circulatory collapse can result. This complication develops principally during the induc­ tion of pneumoperitoneum. the rapid insufflation of gas under high pressure probably causes a “gas lock” in the vena cava and right atrium.42 When capnothorax develops during laparoscopy.41 In con­ trast. ECG. The pathophysiology of gas embolism is also determined by the size of the bubbles and the rate of intravenous entry of the gas.41 In effect.52. however.57 Ventilation­perfusion ( V Q) mismatching develops with increases in physiologic dead space and hypoxemia. Capnothorax (CO2 causing a pneumothorax) reduces thoracopulmonary compliance and increases airway pressures.54 Paradoxical embolism.53 During laparoscopy. Endobronchial Intubation Cephalad displacement of the diaphragm during pneumoperito­ neum results in cephalad movement of the carina in children43 and adults.44. or it may occur as a consequence of gas insufflation into an abdominal organ. When a pneumothorax occurs secondary to alveolar rupture. Paco2.48 particularly in patients with pre­ vious abdominal surgery.47. occur­ ring with 0. electrocardiographic. the absorption surface of CO2 is increased and the absorption from the pleural cavity is greater than from the peritoneal cavity. or N2O.55 Volume preload diminishes the risk of gas embolism56 and of paradoxical embo­ lism. All these characteristics explain the rapid reversal of the clinical signs of CO2 embolism with treatment.50. It should be noted that cervical and upper thoracic subcutaneous emphysema can develop without the presence of a pneumothorax. treatment with positive end­expiratory pres­ sure (PEEP) is an alternative to chest tube placement. PEEP must not be applied and thoracocentesis is mandatory.) These complications are potentially serious and may lead to respiratory and hemodynamic disturbances.5 mL/kg of air or less. spon­ taneous resolution of the pneumothorax occurs within 30 to 60 minutes without thoracocentesis. the lethal dose of embolized CO2 is approximately five times greater than that of air.51 CO2 is used most frequently for laparoscopy because it is more soluble in blood than either air. gas embolism is the most feared and dangerous complication of laparoscopy.50. Acute right ven­ tricular hypertension may open the foramen ovale. Gas Embolism Although rare. if the pneumothorax is secondary to rupture of preexisting bullae. VCO2 . may occur without patent foramen ovale. 1996. Hemodynamic changes and oxygen desaturation should suggest the presence of a tension pneumothorax. Intravascular injection of gas may follow direct needle or trocar placement into a vessel.49 Gas embolism may also occur later during surgery. Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominal surgery. end-tidal carbon dioxide tension. (Data from Wahba RW. The diagnosis of gas embolism depends on the detection of gas emboli in the right side of the heart or on recognition of the physiologic changes from embolization. allowing para­ doxical gas embolization. Paw. Can J Anaesth 43:77. 68­3). When the size of the embolus .46 This complication results in a decrease in the oxygen saturation as measured by pulse oximetry (Spo2) associated with an increase in plateau airway pressure (see Fig. The low incidence of gas embolism during laparoscopy precludes the routine use of invasive or expensive monitors to detect emboliza­ tion of small quantities of gas. include changes in Doppler sounds and increased mean pulmonary artery pressure.44 potentially leading to an endobronchial intubation.V 2188 Adult Subspecialty Management Capnography Increased PETCO2 Decreased PETCO2 No Yes Yes Yes Yes Pulse oximetry Desaturation No change Desaturation Desaturation Desaturation Airway pressure Clinicial examination a) Reduced air entry b) Hyperresonance c) Swelling and crepitus Presumptive diagnosis Increased Paw No change Increased Paw Increased Paw No change Yes No No No No Yes Yes Yes Possibly Yes Yes Possibly Murmur Hypotension ECG changes Endobronchial Subcutaneous Capnothorax intubation emphysema Pneumothorax Massive CO2 embolism Figure 68-3 Diagnosis of respiratory complications during laparoscopy. airway pressure. Cases of endobronchial intubation associated with laparoscopy are reported during procedures in the head­down position45 and in the head­up position. The laparoscopist may observe abnormal motion of one hemidiaphragm when a tension pneumothorax has occurred. oxygen. and Petco2 also increase. Consequently.

patient position.80 and an increase in venous resistance.73­75 Normal intraoperative values of venous oxygen saturation (SvO2 ) and lactate concentrations suggest that changes in cardiac output occurring during pneu­ moperitoneum are well tolerated by healthy patients. Cardiopul­ monary bypass has been used successfully to treat massive CO2 embolism. This increase in afterload is not a reflex sympathetic response to the decreased cardiac output.73. which parallels the decrease in cardiac output. A decrease in venous return is observed after a transient increase in venous return at low IAPs (<10 mm Hg). However.73. Hemodynamic Repercussions of Pneumoperitoneum in Healthy Patients Peritoneal insufflation to IAPs higher than 10 mm Hg induces significant alterations of hemodynamics. most studies have shown a fall of cardiac output (10% to 30%) during perito­ neal insufflation whether the patient was placed in the head­ down68. Routine preoperative insertion of a central venous line. cardiac arrhythmias. millwheel murmur).82 Right atrial pressure and pulmonary artery occlu­ sion pressure can no longer be considered reliable indices of cardiac filling pressures during pneumoperitoneum. however. increased central venous pressure.77. cyanosis.72 and transesopha­ geal echocardiography. which has been absorbed into the blood. which decrease shortly after the beginning of the perito­ neal insufflation. may be fatal. Discontinuing N2O will allow ventilation with 100% O2 to correct hypoxemia and reduce the size of the gas embolus and its consequences.67 steepness of patient tilt. The amount of gas that advances through the right side of the heart to the pulmonary circulation is less if the patient is in this position because the buoyant foam is displaced laterally and caudally away from the right ventricular outflow tract.66 These discrepancies might be caused by differences in rates of CO2 insufflation.63 Cardiac output has also been reported to be increased64 or unchanged during pneumoperitoneum. The decrease in Petco2 may be preceded by an initial increase secondary to pulmonary excretion of the CO2. however. tachycardia.69 or head­up position. hypotension. However.54 Although pulse oximetry is helpful in recognizing hypoxemia.82 Section V Adult Subspecialty Management Hemodynamic Problems During Laparoscopy Hemodynamic changes observed during laparoscopy result from the combined effects of pneumoperitoneum. time intervals between insufflation and collection of data.77.79 pooling of blood in the legs. Treatment of CO2 embolism consists of immediate cessa­ tion of insufflation and release of the pneumoperitoneum. In addition to these pathophysiologic changes.78 The decline in venous return.85 or by wrapping the legs with elastic bandages. a central venous or pul­ monary artery catheter may be introduced for aspiration of the gas. resulting in rapid absorption from the bloodstream. The fact that atrial natriuretic peptide concentrations remain low despite increased pulmonary capillary occlusion pressure during pneu­ moperitoneum further suggests that abdominal insufflation interferes with venous return. anesthesia. rise during peritoneal insufflation. Heart rates remain unchanged or increased only slightly.70.71 thoracic electrical bioimpedance.74 However.77. The mechanism of the decrease of cardiac output is multi­ factorial (Fig.53 Hyperventilation increases CO2 excretion and is made necessary by the increase in the physiologic dead space. External cardiac massage may be helpful in fragmenting CO2 emboli into small bubbles. probably as a result of surgical stress.71 The paradoxical increase of these pressures can be explained by the increased intrathoracic pressure associated with pneumoperi­ toneum.78 Increased IAP results in caval compression. all studies describe an increase in systemic vascular resistance during the existence of the pneumoperitoneum. Cardiopulmonary resuscitation must be initiated if necessary.69. alteration in heart tones (i.54 Risk of Aspiration of Gastric Contents Patients undergoing laparoscopy might be considered to be at risk for acid aspiration syndrome (see also Chapter 50). however. accounts for the rapid reversal of the clinical signs of CO2 embolism with treatment.83 The reduction in venous return and cardiac output can be attenuated by increasing circulating volume before the pneumoperitoneum is produced (Fig. and electrocardiog­ raphic changes of right­sided heart strain can develop.70.71 These adverse hemodynamic effects of pneumoperitoneum have been confirmed by studies using pulmonary artery catheterization. Con­ sequently.48 CO2 embolism. the increased IAP results in changes of the lower esophageal sphincter that allow maintenance of the pressure gradient across the gastroesophageal junction and that may therefore reduce the risk of regurgitation. reflex increases of vagal tone and arrhythmias can also develop. and elevation of systemic and pulmonary vascular resistances.70 esophageal echo­Doppler. and anesthetic techniques. increased arte­ rial pressures.74 Cardiac filling pressures. If these simple measures are not effective. 68­4).71. The high solubility of CO2 in blood. techniques used to assess hemodynamics.60 Furthermore.59. 68­5). and hypercapnia from the absorbed CO2..62 These disturbances are characterized by decreases in cardiac output.50 Hyperbaric oxygen treatment should be strongly considered if cerebral gas embolism is suspected.69.81. does not appear justified for these procedures.84 Increased filling pressures can be achieved by fluid loading or tilting the patient to a slight head­down position before peritoneal insufflation. does not appear to decrease significantly when IAP increases to 15 mm Hg.70. by preventing the pooling of blood with intermittent sequential pneumatic compression device. subsequently increase. capnometry and capnog­ raphy are more valuable in providing early diagnosis of gas embo­ lism and determining the extent of the embolism. the head­down position should help to prevent any regurgitated fluid from entering the airway.Anesthesia for Laparoscopic Surgery 2189 68 increases (2 mL/kg of air).61.86 The ejection fraction of the left ventricle. . The patient is placed in steep head­down and left lateral decubitus (Durant) position.58 Pulmonary edema can also be an early sign of gas embolism.68.53 Aspiration of gas or foamy blood from a central venous line establishes the diagnosis. Petco2 decreases in the case of embolism owing to the fall in cardiac output and the enlargement of the physiologic dead space.e.63 is confirmed by a reduction in left ventricular end­diastolic volume measured using transesophageal echocardiography.76 Cardiac outputs. The decrease in cardiac output is proportional to the increase in IAP. IAP.65.71 Hemodynamic perturbations occur mainly at the beginning of peritoneal insufflation. assessed by echocardiography. all these changes are rarely consistently positive. Δa­ETCO2 increases.

pneumoperitoneum was induced with patients in a 10-degree head-up position. . the increases in afterload produced by the presence of a pneumoperitoneum can be deleterious to patients with cardiac disease. yellow bars).90 The return of hemodynamic parameters to baseline values is gradual.76.81 Mechanical stimulation of peritoneal recep­ tors also results in increased vasopressin release. only the time course of vaso­ pressin release parallels that of the increase in systemic vascular resistance. taking several minutes.76 Although the normal heart tolerates increases in afterload under physiologic conditions. n = 10.87 The increase in systemic vascular resistance is affected by patient position.91.82 or direct vasodilating drugs.65. such as nitroglycerin88 or nicardipine.83.71.83 The increase in systemic vascular resistance can be corrected by the administration of vasodilating anesthetic agents.92 Increases in plasma vasopressin concentrations correlate with changes in intrathoracic pressure and transmural right atrial pressure.70.93 systemic vas­ Systemic vascular resistance Control Volume loaded 3000 2500 2000 1500 1000 (L/min/m2) 3 2 1 Post induct 5 min 15 min 30 min Pneumoperitoneum (dynes•sec•cm-5) 500 Post induct 15 min 5 min 30 min Pneumoperitoneum Figure 68-5 Changes in the cardiac index and systemic vascular resistance during laparoscopy in two groups of patients. catechol …) Venous return Inotropism?? Systemic vascular resistance Cardiac output Arterial pressure Figure 68-4 Schematic representation of the different mechanisms leading to decreased cardiac output during pneumoperitoneum for laparoscopy. the renin­angiotensin system. the head­up position aggravates it.69. and especially vasopressin are all released during the pres­ ence of the pneumoperitoneum and may contribute to increasing the afterload.70. The Trendelenburg position attenuates this increase.68.82. Systemic vascular resistance was reported to be increased in studies where no decrease in cardiac output was found. Group 2 (volume loaded.73.89 Cardiac index 4 The increase in systemic vascular resistance is thought to be mediated by mechanical and neurohumoral factors.V 2190 Adult Subspecialty Management Intra-abdominal pressure Pooling of blood in the legs Caval compression Venous resistance Intrathoracic pressure Stimulation of peritoneal receptor? Vasc. blue bars) patients received 500 mL of lactated Ringer’s solution before anesthesia induction and were insufflated in the supine position. organs Release of neurohumoral factor(s) (vasopressin. n = 10.71.92 However. such as isoflu­ rane. For group 1 (controls. Data are presented as the mean ± SEM.87 Catecholamines. suggesting the involvement of neuro­ humoral factor(s).81. resistance of intraabd.

101­103 The effect of CO2 pneumoperitoneum on renal function has also been investigated. Cardiac irregularities occur most often early. Although cases of thromboem­ bolism have been reported in the literature.87.80. SvO2 decreased in 50% of patients despite preoperative hemodynamic optimization using a pulmonary artery catheter. and glomerular filtration rate decrease to less than 50% of base­ line values during laparoscopic cholecystectomy and are signifi­ cantly lower than those during open cholecystectomy.88. during insuf­ flation.87. Dhoste and associ­ ates129 did not observe impaired hemodynamics in elderly ASA class III patients.94 However. their actual incidence does not seem to be increased by laparoscopy. others have not observed any significant changes.88. atropine administration. These events are easily and quickly reversible. arrhythmias may also reflect intol­ erance of these hemodynamic disturbances in patients with Hemodynamic Repercussions of Pneumoperitoneum in High-Risk Cardiac Patients The demonstration of significant hemodynamic changes during pneumoperitoneum raises the question of tolerance of these changes in cardiac patients (see Chapters 35 and 60).89. The hemodynamic consequences of pneumoperitoneum are minor in heart transplant recipients who have good ventricular function. the pattern of change in mean arterial pressure. independently of changes in Paco2.108­110 However. Arrhythmias do not correlate with the level of the Paco2 and may develop early during insufflation.66 Effect of Pneumoperitoneum on Regional Hemodynamics Increased IAP and the head­up position result in lower limb venous stasis. whether increasing IAP to 14 mm Hg is sufficient to stimulate these recep­ tors is unknown.134 Section V Adult Subspecialty Management Cardiac Arrhythmias During Laparoscopy Arrhythmias during laparoscopy have several causes. observed a reduction in splanchnic blood flow during air pneumoperitoneum but not during CO2 pneumoperitoneum. Intravenous nitroglycerin. and deepening of anesthesia after recovery of the heart rate. The increased Paco2 may not be the cause of the arrhythmias occur­ ring during laparoscopy.120 Intraocular pressure is not affected by pneumoperitoneum in women with no preexisting eye disease. Increased afterload is a major contributor to the altered hemodynamics seen during pneumoperitoneum in cardiac patients.121 In an animal model of glaucoma. pneumoperitoneum combined with the head­down position does not induce harmful changes in intracranial dynamics. even during prolonged proce­ dures. Reflex increases of vagal tone may result from sudden stretching of the peritoneum and during electrocoagulation of the fallopian tubes. The investigators suggest preoperative preload augmentation to offset the hemodynamic effect of pneumoperi­ toneum.62.112 comparing CO2 pneumoperitoneum and air pneumoperitoneum in pigs.128 Because normalization of hemodynamic variables does not occur for at least 1 hour post­ operatively in certain patients.104 Urine output significantly increases after deflation.99 Femoral vein blood flow decreases progres­ sively with increasing IAP. renal plasma flow.8. Controversy exists regarding the effect of the CO2 pneu­ moperitoneum on splanchnic and hepatic blood flow. pneumoperitoneum only slightly increases intraocular pressure.130.122 with mild to severe cardiac disease.Anesthesia for Laparoscopic Surgery 2191 68 cular resistance. cardiac output.104­106 Urine output. but they used low IAP (10 mm Hg) and slow insufflation rates (1 L/min). Vagal stimulation is accentuated if the level of anesthesia is too superficial or if the patient is taking β­blocking drugs.132 Several studies suggest that hemodynamic changes during pneumoperitoneum are well tolerated by morbidly obese patients.125 congestive heart failure can develop in the early postoperative period. Nicardipine acts selectively on arterial resistance vessels and does not compromise venous return.85. or dobutamine has been used to manage the hemodynamic changes induced by increased IAP in selected patients with heart disease. The increase in systemic vascular resistance also explains why the arterial pressure increases but the cardiac output falls. Use of high doses of remifentanil almost completely prevents the hemodynamic changes. A signifi­ cant reduction was reported in animals107 and humans. In patients . nicardipine. They suggest that the direct splanchnic vasodilating effect of CO2 may counteract the mechan­ ical effect of increased IAP. when high Paco2 is not present. and no adaptation to the reduced femoral venous outflow occurs.111­114 Blobner and coworkers. in pigs with preoperative induced intracranial hyperten­ sion or normal intracranial pressure118.117 Intracranial pressure nevertheless rises during CO2 pneumoperitoneum. In a initial study including ASA class III or IV patients. cardiac arrhythmias.95 or dexmedetomidine96.115. For this reason. and asystole can develop.90 Use of α2­adrenergic agonists such as clonidine71. and systemic vascular resistance is qualitatively similar to that in healthy patients. The administration of nicardipine may be more appropriate than that of nitroglycerin.124 Patients who experienced the most severe hemodynamic changes with inadequate oxygen delivery were patients with low preoperative cardiac outputs and central venous pressures and high mean arterial pressures and systemic vascular resistances—a profile suggesting depleted intra­ vascular volume.131 Laparoscopic adrenalectomy in patients with pheochromocytoma can be successfully managed using a continuous infusion of nicardipine.116 When normocarbia is maintained.127 This drug is beneficial in case of congestive heart failure. these changes appear to be more marked. Cerebral blood flow velocity increases during CO2 pneu­ moperitoneum in response to the increased Paco2.123­126 Quan­ titatively.119 and in children with ventriculoperitoneal shunts. when pathophysiologic hemodynamic changes are the most intense. Treatment consists of interruption of insufflation.133. and arterial pressure.97 and of β­blocking agents98 significantly reduces hemodynamic changes and anesthetic requirements.135 Bradycardia.126 Nitro­ glycerin was chosen to correct the reduction in cardiac output associated with increased pulmonary capillary occlusion pres­ sures and systemic vascular resistance.100 These changes may predispose to the development of thromboembolic complications. Right atrial and pulmonary capillary occlusion pressures are not reliable indices of cardiac filling pressure during pneumoperito­ neum.

visceral nociception. The legs must be freely supported and not tightly strapped.80.121 Although the intravascular pressure increases in the upper torso. Overextension of the arm must be avoided. reduced postoperative fatigue.141 and anesthetic requirements3 are similar after both procedures. which reflect the extent of tissue damage. and ventilatory changes induced by pneumoperitoneum may contribute to the stress response of laparoscopy.32 . hypergly­ cemia. Nerve Injury Nerve compression is a potential complication during the head­ down position. or contribute to.139. the greater the fall in cardiac output.32 Because pneumoperitoneum further increases blood pooling in the legs. Although parietal afference.g.g. whereas laparoscopy allows for a reduction of surgical trauma. can result in lower extremity compartment syndrome.. reducing blood loss but increasing the risk of gas embolism. These positions may be responsible for.3. Prolonged lithotomy position. the total lung volume. particularly with poor ventricular function.147­149 The duration of postoperative ileus is less shortened when compared with laparot­ omy than previously reported..V 2192 Adult Subspecialty Management known or latent cardiac disease. nitrogen balance and immune function might be better preserved.30. the endocrine response to laparoscopic and open cholecystectomy does not differ significantly. The patient is often placed in the lithotomy position. particularly in case of low intracranial compliance. Gas embolism can also result in cardiac arrhythmias.151­153 Surprisingly. leukocytosis) is also reduced after laparoscopy.56 With the head­up position.154.82 This decrease in cardiac output compounds the hemodynamic changes induced by pneumoperitoneum. Consequently. and debilitated patients. the laparoscopic approach allows for a reduction of the acute phase reaction seen after open cholecystectomy. are significantly lower after laparoscopy as compared with laparotomy. In contrast to laparotomy. Problems Related to Patient Position Patient positioning (see Chapter 36) depends on the site of surgery.137. Plasma concentrations of C­reactive protein and interleukin­6.140 and a heightened feeling of well­being are commonly reported and reflect better maintenance of homeostasis.139 Cardiovascular Effects In normotensive subjects. femoral neu­ ropathy) have been reported after laparoscopy.155 urinary concentra­ tions of cortisol and catecholamine metabolites. the head­down position decreases transmural pressures in the pelvic viscera. Pain and discomfort from peritoneal stretch­ ing.69. and hospital stay are significantly reduced after laparoscopy. meralgia paresthetica. and pressure on the popliteal space must be prevented.139.138 The common peroneal nerve is particularly vulnerable and must be protected when the patient is placed in the lithotomy position. Stress Response In patients undergoing cholecystectomy. Venous stasis in the legs occurs during the head­up posi­ tion and may be aggravated by the lithotomy position with knees flexed. Although these different reflexes may be impaired during general anesthesia. Shoul­ der braces should be used with great caution and must not impinge on the brachial plexus. and the pulmonary compli­ ance.3.32 The head­up position is usually considered to be more favorable to respiration.3. The steepness of the tilt also affects the magnitude of these changes. elderly. whereas head­down tilt is used for pelvic and lower abdominal surgery.76 However. improved and more rapid recovery.99 any additional factor contributing to cir­ culatory dysfunction should be avoided. Lower extremity neuropathies (e.136 and result in elevation of the intraocular venous pressure (which can worsen acute glaucoma). As a con­ sequence.150 The economic implications of these factors are self­evident and beneficial. postoperative ileus and fasting. a decrease in cardiac output and mean arterial pressure results from the reduction in venous return. hemodynamic disturbances.141. which is markedly reduced by laparoscopy.32 The Trendelenburg position may also affect the cerebral circula­ tion. plasma concentra­ tions of cortisol and catecholamines. the head­down position results in an increase in central venous pressure and cardiac output.76. appears to be an important stimulus for postoperative hyperglycemia. leading to potentially deleterious increased myocardial oxygen demand.154 Several hypotheses can be invoked to explain these observations. In healthy patients no major changes are seen. Combined general and epidural anesthesia for laparoscopic cholecystectomy does not result in a decreased stress response compared with general anesthesia alone. peroneal neuropathy.2.3. These changes are more marked in obese.141­143 The metabolic response (e. the head­up position is preferred for upper abdominal surgery. duration of intravenous infusion. Postoperative Benefits and Consequences of Laparoscopy Implicit in the decision to use the laparoscopic approach is the assumption that the intraoperative consequences of pneumoperi­ toneum described in the previous sections are counterbalanced by multiple postoperative benefits.69. The baroreceptor reflex response to increased hydrostatic pressure consists of systemic vasodilation and bradycardia.32. the development of pathophysiologic changes or injury during laparoscopy. such as required for some operative laparos­ copies.139. The steeper the tilt. the hemodynamic changes induced by this position during laparos­ copy remain insignificant.144­147 Laparoscopy avoids prolonged exposure and manipulation of the intestines and decreases the need for perito­ neal incision and trauma. which is less Respiratory Changes The head­down position facilitates the development of atelectasis. Steep head­down tilt results in decreases in the functional resid­ ual capacity. central blood volume and pressure changes are greater in patients with coronary artery disease.

3. after laparotomy.141.g.3.229.156­160 Never­ theless. whereas the increase in arterial pressure is attenuated. Laparoscopy allows a significant reduction in postoperative pain and analgesic consumption (see Chapter 87).206.154 Greater reductions in expiratory volumes and slower recovery of pulmonary function after laparo­ scopy are reported in older patients. is appealing for patients with severe cardiac or pulmonary disease.154.27.219.223.221­223 Also. gasless laparoscopy compromises surgical exposure and increases technical difficulty.g. Postoperative Nausea and Vomiting Laparoscopy is frequently associated with minor postoperative sequelae that can persist more than 48 hours and that can signifi­ Laparoscopy During Pregnancy and in Children The most common nonobstetric surgical procedures during preg­ nancy are adnexal surgery. biliary colic [cholecystectomy].141.226 Pulmonary Dysfunction Upper abdominal surgery results in postoperative changes in pulmonary function (see also Chapter 93).166­170 Benefits of intraperitoneal local anesthetic are greater after gynecologic laparoscopy..233.164. pelvic spasm [tubal ligation]).199 Gasless Laparoscopy Another alternative is gasless laparoscopy.204­206 propofol anesthesia can markedly reduce the high incidence of these side effects.. one of the main complaints is postoperative nausea and vomiting (PONV) (40% to 75% of patients).166.232 Port­site metastases after laparoscopic surgery for cancer are reduced after gasless laparoscopy. and cholecystectomy. whereas after laparoscopic cholecystectomy.173 Preoperative administration of nonsteroidal anti­inflammatory drugs (NSAIDs) and of cyclooxygenase­2 inhibitors decreases pain.. and patients with COPD198 than in healthy patients. patients complain more of parietal pain (e.201 Perioperative liberal intravenous fluid therapy can contribute to decreasing these symptoms and to improve postoperative recovery. and different treatments have been proposed to provide pain relief.234 Combining abdominal wall lifting with low pressure CO2 pneumoperitoneum (5 mm Hg) may improve surgical conditions.172. Postoperative pulmonary function of these patients.165 Local anesthetic infiltration (e.188­190 cantly delay discharge of outpatients.164.208. pain intensity may be significant.156. therefore. hyper­ ventilation is not required. argon) instead of CO2 avoids the increase in Paco2 from absorption.159.139 The intraoperative stress response. port­site infil­ tration) for postoperative pain relief after laparoscopic chole­ cystectomy produces contradictory results.159. However. can be reduced by preoperative administration of α2­agonists.Anesthesia for Laparoscopic Surgery 2193 68 affected by laparoscopy.224 Unfortunately.g. This technique avoids the hemodynamic and respiratory repercussions of increased IAP and the consequences of the use of CO2.96. is improved after laparoscopy as compared with laparotomy. the use of these gases accen­ tuates the decrease in cardiac output.194­196 Thoracic epidural analgesia does not improve lung function after laparo­ scopic cholecystectomy.187 Multimodal analgesia is now recommended to prevent and treat post­laparoscopy pain. and shoulder­tip pain resulting from diaphrag­ matic irritation.191­193 Nevertheless.g.225.200 In addition to post­ operative pain of various types.108.211­215 Transdermal scopolamine reduces nausea and vomiting after outpatient laparoscopy. Respiratory dysfunc­ tion is less severe and recovery is quicker after laparo­ scopy.206.183­186 Dexamethasone is also effective in reducing postoperative pain.90. The peritoneal cavity is expanded using abdominal wall lift obtained with a fan retrac­ tor. as does opiate con­ sumption after gynecologic laparoscopy174­177 and laparoscopic cholecystectomy.216­218 Section V Adult Subspecialty Management Alternatives to CO2 Pneumoperitoneum New approaches have been investigated to reduce pathophysio­ logic consequences of CO2 pneumoperitoneum.161­163 The nature of pain varies depending on the surgical technique. intraperitoneal.97 Postoperative Pain Surgical trauma contributes to pain and pulmonary dysfunction. However.90. Inert Gases Insufflation of inert gas (e.233. patients report also visceral pain (e.71.201­203 Whereas perioperative opioids increase the inci­ dence of PONV.154.198 Postoperative pulmonary function is less impaired after gyneco­ logic laparoscopy than after upper abdominal laparoscopic surgery. abdominal wall). however.157. helium.206.171 Mesosalpinx block decreases postoperative pain and analgesic consumption after laparoscopic sterilization.197 obese patients.220 Consequently. appendectomy.162. the low blood solubility of the inert gases raises the issue of safety in the event of gas embolism. diaphragmatic function remains significantly impaired after laparoscopy.210 Intraoperative administration of droperidol and a 5­hydroxytryptamine type 3 antagonist appears to be helpful in the prevention and treatment of these side effects.209 Intraoperative drainage of gastric contents also reduces PONV. may contribute more to adrenocortical stimulation. . others have failed to demonstrate any significant effect of preoperative NSAID on pain after laparo­ scopic sterilization more severe than after diagnostic gynecologic laparoscopy.166 Residual CO2 pneumoperitoneum contributes to postoperative pain.27. however..227­231 Renal and splanchnic perfusion is not altered.207 The effect of N2O on the incidence of nausea is still controversial.198 smokers. the ventilatory conse­ quences of the increased IAP persist. The hemodynamic changes produced by pneumoperitoneum using inert gas are similar to those observed with CO2.178­182 However.163 Pain after laparoscopy is multifactorial.160.234 This technique. Careful evacuation of residual CO2 after desufflation was shown to be effective.

The number of serious complications requiring laparotomy was 2 to 10 per 1000 cases.. He or she must be ready to respond promptly and adequately to these mishaps and to help the surgeon diagnose a complication. the most frequent indication for laparoscopy in children.251 The profile of CO2 absorption and the magnitude of CO2 absorption compared with metabolic VCO2 are similar in infants and children to those recorded in adults. fetal placental perfusion pressure and blood flow. Unrecognized gastrointestinal tract injury and subhepatic abscess formation can lead to potentially lethal septic complica­ tions. reversible after desufflation.000 cases. Pneumoperi­ toneum is undesirable in patients with increased intracranial pressure (e. whereas open cholecystectomy had a more frequent rate of minor general com­ plications.242 Capnography is adequate to guide ventilation during laparoscopy in pregnant patients. ideally before the 23rd week of pregnancy.269 Although large vessel injury (e.272 The rate of postoperative infections (e. . aorta. CO2 pneumoperitoneum induces significant fetal acidosis.246 Laparoscopy is frequently performed in infants and chil­ dren (see Chapter 82). large surveys are availa­ ble. 4. Anesthesia for Laparoscopy Preoperative Evaluation of the Patient and Premedication Without regard to surgical contraindications. it is important to consider the risks and benefits of laparos­ copy. complications occur more frequently during the creation of pneumoperitoneum and the introduction of trocars. and significant hemorrhage in 2 to 9 per 1000 cases.245. probably because of the increased complex­ ity of the laparoscopies performed over the past few years.252 The hemodynamic changes observed in children are similar to those reported in adults.V 2194 Adult Subspecialty Management and they are amenable to laparoscopic surgery (see Chapter 69). respiratory) seems to be significantly lower after laparoscopy than after laparotomy. knowledge of the incidence of complications is more imprecise and is frequently based on retrospective studies. hydrocephalus. all the reports in the literature of laparoscopy carried out between 4 and 32 weeks of estimated gestational age have resulted in uncomplicated pregnancies.268 Conversion to laparotomy was necessary in approximately 1% of patients.270.241 Provided maternal Paco2 is maintained at normal levels. common bile duct injury in 2 to 6 per 1000 cases. but their prophylactic use is debatable.152.152. head trauma) and hypovo­ lemia. Bowel perforation occurred in about 2 per 1000 cases.264­268 The overall mortality rate is 0.244 The following recommendations are for safe laparoscopy in preg­ nant patients236: 1.258 Controversy concerning the benefits (improved analgesia and postoperative recovery) of laparoscopy for appendectomy. Tocolytics are beneficial to arrest preterm labor. and blood gas tensions are unaffected by insufflation or desufflation. Fetal monitoring may be performed using transvaginal ultrasonography.. the complication rate was slightly higher in the most recent surveys. Knowledge of the pathophysiologic changes induced by laparoscopy in children is necessary to adapt their monitoring and anesthetic technique. A learning curve was demonstrated for laparoscopic cholecystectomy. but Petco2 may sometimes overestimate Paco2. and some still require characterization (see Chapter 34). surgical site. Intestinal injuries accounted for 30% to 50% of these and remained undiagnosed during laparoscopy in one half of the cases.259­261 The experience of gynecologic laparoscopists extends over a relatively long time and. leading to delayed diagnosis.248­250 Paco2 and Petco2 increase during pneumoperitoneum. However.253­257 Pneumoperitoneum results in oliguria or anuria in children.235 Laparoscopy during pregnancy raises several concerns. Laparoscopic cholecystectomy was accompanied by a greater frequency of minor operative complications.g. 3. retroperitoneal hematoma can develop insidiously and result in significant blood loss without major intraperitoneal effusion. as a result.273 Although all these events are surgery related. Some of these complications might be prevented by open laparoscopy. experience was associated with decreased oper­ ative times and rates of minor or moderate complications. Open laparoscopy should be used for abdominal access to avoid damaging the uterus. Gasless laparoscopy is an alternative to avoid the potential side effects of CO2 pneumoperitoneum and can sometimes be managed using epidural anesthesia.271 Injuries provoked by the Veress needle are usually less severe than those by trocars and may even remain undiag­ nosed. tumor.243 Hemodynamic changes induced by pneu­ moperitoneum are similar in pregnant and nonpregnant women. inferior vena cava. Mechanical ventilation must be adjusted to maintain a physiologic maternal alkalosis. Fetal heart rate and arterial pressure increase. absolute contrain­ dications to laparoscopy and pneumoperitoneum are rare. The operation should occur during the second trimester. Although the death rate decreased. the anesthesiologist must be aware of the complications and timing of their occurrence. During gynecologic laparoscopy. Although the benefits of the laparoscopic approach are well documented.g. Laparoscopy can be performed safely in patients with ven­ tricular peritoneal shunt and peritoneojugular shunt that are Complications of Laparoscopy With the development of more sophisticated endoscopic opera­ tions. Vascular complica­ tions also accounted for 30% to 50%. but these changes are minimal. pH. to minimize the risk of preterm labor and to maintain adequate intra­ abdominal working room. 5..247 CO2 pneumoperi­ toneum induces the same changes in respiratory mechanics to those reported in adults.262. whereas during gastrointestinal surgery they are more closely related to the surgical procedure itself.263 Mortality rates have varied from 1 per 10. persists. Burns were responsible for 15% to 20% of the reported complications. This can be avoided by alternative entry sites for the Veress needle and trocars. Abdomi­ nal surgery increases the risk of miscarriage or premature labor.236­240 Another concern is the risk of damaging the gravid uterus. iliac vessels) caused emergency situations. 2.000 to 1 per 100.1 to 1 per 1000 cases. Large surveys of complications after laparoscopic cholecys­ tectomy are available.g.

Induction and release of the pneumoperitoneum must be smooth and progres­ sive. cardiac function should be evaluated in light of the hemodynamic changes induced by pneu­ moperitoneum and patient position. the Δa­ETCO2 may vary from patient to patient and during the course of laparoscopy in the same patient. Although this level of monitoring is valuable for detection of cardiac arrhythmias. particularly for supramesocolic laparos­ copy. local. Preoperative clonidine and dexmedetomidine decrease the intraoperative stress response and improve hemodynamic stability. Mask ventilation before intubation can inflate the stomach with gas. Because of venous stasis in the legs during laparoscopy. Because Δa­ETCO2 may increase more in patients with cardiac and pulmonary diseases. Patients with severe congestive heart failure and terminal valvular insufficiency are more prone to develop cardiac complications than patients with ischemic cardiac disease during laparoscopy. and pulse oximetry must be continuously monitored. vasodilating anesthetic and drugs (nicardipine.132 α2­adrenergic . The bladder should be emptied before pelvic laparoscopy or prolonged procedures. In case of glaucoma. con­ trolled ventilation must be adjusted to maintain Petco2 between 35 and 40 mm Hg.Anesthesia for Laparoscopic Surgery 2195 68 provided with unidirectional valve resistant to IAPs used during pneumoperitoneum. In our experience. capnometry. During pneumoperitoneum. patients with renal failure deserve special care to optimize hemodynamics during pneumoperitoneum. increased intrathoracic pressure complicates the interpretation of measured central venous and pulmonary artery pressures. cardiotonic agents Experienced surgeon Postoperative Care Slow recovery from anesthesia (benefit of clonidine) Anesthetic Techniques General. and pneumothorax. the effects on intraocu­ lar pressure do not seem to be clinically significant but deserve further confirmation. Infusion of vasodilating drugs. Tilting must be slow and progressive to avoid sudden hemodynamic and res­ piratory changes. Gasless laparoscopy may represent an alternative for these patients. it provides only indirect evidence of the hemodynamic changes induced by the pneumoperitoneum. electrocardiography. if needed. padding should protect from nerve com­ pression. Petco2 must be monitored carefully to avoid hypercapnia and to detect gas embolism. In patients with respiratory disease. this requires no more than a 15% to 25% increase of minute ventilation.71. CO2 subcutaneous emphysema. Although more invasive hemodynamic monitoring may be necessary in patients with cardiac diseases. Preoperative administration of NSAIDs may be helpful in reducing postoperative pain and opiate require­ ments. and shoulder braces. Trans­ esophageal echocardiography may be more helpful in patients with severe cardiac disease (see Table 68­1).95­97 Patient Positioning and Monitoring Patients must be positioned (see Chapter 36) with great care to prevent nerve injuries. Whether laparos­ copy is more dangerous than laparotomy in these patients has not yet been explored directly but deserves careful consideration. except when CO2 subcutaneous emphysema develops. However. During laparoscopy. Petco2 and Spo2 reliably reflect Paco2 and arterial oxygen saturation (Sao2). and the concomitant use of nephrotoxic drugs should be avoided. Patient tilt should be reduced as much as possible and should not exceed 15 to 20 degrees. gas embolism. Increase of respiratory rate rather than of tidal volume may be preferable in patients with COPD and in patients with a history of spontaneous pneu­ mothorax or bullous emphysema to avoid increased alveolar inflation and reduce the risk of pneumothorax. heart rate. and regional anesthesia have all been used success­ fully and safely for laparoscopy.122 In patients with heart disease. cannulation of a radial artery may be helpful to allow direct measurement of Paco2 from an arterial blood sample. should be placed overly­ ing the coracoid process. The position of the endotracheal tube must be checked after any change in patient position. General Anesthesia General anesthesia with endotracheal intubation and controlled ventilation is certainly the safest and most commonly used technique and therefore is recommended for inpatients and for long laparoscopic procedures. arterial blood pressure. For these patients. particularly in case of com­ promised ventricular function (Table 68­1). such as nicardipine. which must be aspirated before trocar placement to avoid gastric perforation. prophylaxis of deep vein thrombosis should be the same as for laparotomy. nitroglycerin). Because of the side effects of increased IAP on renal func­ tion. Section V Adult Subspecialty Management Table 68-1 Management of Patients with Cardiac Disease for Laparoscopy Preoperative Evaluation: Echocardiography If left ventricular ejection fraction < 30%: Intraoperative monitoring Intra-arterial line Pulmonary artery catheter? Transesophageal echocardiography Continuous ST-segment analysis? Gasless laparoscopy? Laparotomy? Intraoperative Management Slow insufflation Low intra-abdominal pressure Hemodynamic optimization before pneumoperitoneum (preload augmentation) Patient tilt after insufflation Anesthesia: remifentanil. This positive effect counterbalances the risk of pneumothorax during pneumoperitoneum and the risk of inadequate gas exchange from V Q mismatching. the postoperative benefits of laparoscopy must be balanced against the intraoperative risks when the choice of laparoscopy versus laparotomy is discussed. laparoscopy appears preferable to laparotomy because of reduced postoperative respi­ ratory dysfunction. Premedication should be adapted to the duration of the laparoscopy and to the necessity for quick recovery in the outpatient setting.89.

epidural and local anesthesia share the same benefits and disad­ vantages. Although laparoscopy tends to be considered a minor surgical procedure. and discomfort during the manipulation of pelvic and abdominal organs. combined with the head­down position can be used for gynecologic laparoscopy without major impairment of ventila­ tion. this anesthetic approach requires precise and gentle surgical technique and may result in increased patient anxiety. In compromised patients.289 It allows controlled ventilation and accurate monitoring of Petco2.208 omission of N2O improves sur­ gical conditions for intestinal and colonic surgery.294. Intraopera­ tive cardiorespiratory changes occur during pneumoperitoneum. Local and Regional Anesthesia Local anesthesia offers several advantages: quicker recovery.303 Recovery and Postoperative Monitoring Hemodynamic monitoring should be continued in the PACU (see Chapter 85). particularly after outpatient laparoscopic procedures.298 Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia in COPD patients.302 The hemodynamic effects of pneu­ moperitoneum under epidural anesthesia have not been studied. decreased PONV. and 52). oxygen should be administered post­ operatively. The combined effect of pneumoperitoneum and sedation can lead to hypoventilation and arterial oxygen desaturation.87. cardiorespiratory disturbances aggravate this increase in Paco2. and shorter hospital stay. Increases in IAP can be avoided by ensuring a deep plane of anesthesia. including epidural and spinal tech­ niques.282 Liberal perioperative intravenous fluid therapy decreases hemodynamic changes from pneumoperitoneum77. or both. The actual con­ tribution of N2O to PONV is probably less than previously con­ sidered. Alternative insufflating gases (e.293 and is therefore recommended.291 General anesthesia in patients breathing spontaneously without intubation can be performed safely and avoids tracheal irritation as well as administration of muscle relaxant. even to healthy patients.3. The death rate during opera­ tive laparoscopy is 0. the laryngeal mask airway might improve the safety of anesthe­ sia283. Summary Laparoscopy results in multiple postoperative benefits including less trauma. Hemodynamic changes are accentuated in high­risk cardiac patients. results in fewer postoperative side effects.278­280 Propofol anesthesia for laparo­ scopic fertility procedures involving genetic material transfers. vomiting. Gasless laparoscopy may be more helpful but unfortu­ nately increases technical difficulty.g. the incidence of hem­ orrhagic complications and visceral injury is 2 to 5 per 1000 cases. produces better muscle relaxation. 51. These advantages are regularly emphasized and explain the increasing success of laparoscopy.304 Finally.V 2196 Adult Subspecialty Management receptor agonists.84 and PONV and improves postoperative recovery.286.18. The hyperdynamic state developing after laparoscopy could conceiv­ ably lead to a precarious hemodynamic situation in patients with cardiac disease. For these reasons. Whether profound muscle relaxation is necessary for laparoscopy is not clear. outlast the release of the pneumoperitoneum. which is now proposed for many surgical procedures. The laryngeal mask airway results in fewer cases of sore throat and may be proposed as an alternative to endotracheal intubation283­287 (also see Chapter 50) even if this device does not protect the airway from aspiration of gastric contents. Pao2 still decreases after laparoscopic cholecystec­ tomy. nevertheless. decreased thoracopulmonary compliance during pneumoperitoneum frequently results in airway pressures exceeding 20 cm H2O.302 Extensive sensory block (T4­L5) is necessary for surgical laparoscopy and may also lead to discomfort.1 to 1 per 1000 cases. Shoulder­tip pain from diaphragmatic irritation and discomfort from abdomi­ nal distention are incompletely alleviated using epidural anesthe­ sia alone. less pain. This anes­ thetic technique must be restricted to short procedures performed using low IAP and small degrees of tilt.71.297. kept as low as possible to reduce hemodynamic and respiratory changes. Hemodynamic changes induced by the pneumo­ peritoneum. quicker recov­ ery. Whereas no anesthetic technique has proved to be clinically supe­ rior to any other. Improved knowledge of the pathophysiologic hemodynamic changes in healthy patients allows for successful anesthetic management of cardiac patients. Paco2 increases because of CO2 absorption from the peritoneal cavity. The ProSeal laryngeal mask airway may be an alternative to guarantee an airway seal up to 30 cm H2O.281 IAP should be monitored. Regional anesthesia reduces the need for sedatives and narcotics. general anesthesia with controlled ventilation . pain..192 Increased oxygen demand is observed after laparoscopy.300 The metabolic response is reduced by regional anesthesia.275­277 Propofol. and fewer hemodynamic changes (see Chapters 30.274 The choice of anesthetic technique does not seem to play a major role in patient outcome. by optimizing preload before pneumoperitoneum and through judicious use of vasodilating agents.156.299.288. Regional anesthesia. Regional anesthesia can provide adequate relief of pain and dis­ comfort in case of gasless laparoscopy.95­97 and remifentanil66 reduces the hemody­ namic repercussions of pneumoperitoneum and may facilitate management of cardiac patients (see Table 68­1). He. may help to provide adequate analgesia. N2O) do not seem to reduce the hemodynamic changes. prevention and treatment of nausea. however. and more particularly the increased systemic vascu­ lar resistance.295 However. atropine should be available if necessary. thus avoiding most of the side effects of CO2 pneumoperitoneum.292 In these conditions. is associated with lower clinical and ongoing pregnancy rates compared with isoflurane. local anesthesia is routinely supplemented with intravenous sedation.301 Globally. The incidence of complica­ tions has now been reported in several large surveys and compares favorably with that of open surgery.206 Although N2O does not seem to be contraindicated for laparoscopic cholecystectomy.246.125 Despite the reduction in postoperative pulmonary dys­ function. and pain are important. However. The epi­ dural administration of opiates or clonidine. less pulmonary dysfunction.290. early diagnosis of complications. and can be proposed for laparoscopic procedures other than sterilization. and not allowed to exceed 20 mm Hg.296 Complex laparoscopic procedure must not be managed with local anesthesia. Ar.216­218 Because of the poten­ tial for reflex increases of vagal tone during laparoscopy.

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