Anesthesia for Laparoscopic

Surgery
Dr. Kelvin Louies P. Tuazon
2nd yr Resident
 OBJECTIVES
• To know the advantages and disadvantages of
laparoscopic surgery
• To understand the physiologic effects of
laparoscopic surgery
• To know the advantages and disadvantages of
other gases for gas insufflation
• To discuss the anesthetic management
• To know the possible complications of
laparoscopic surgery
 LAPAROSCOPY
– Aka peritoneoscopy
– Minimally invasive procedure allowing endoscopic
access to the peritoneal cavity after insufflation of
gas to create space between the anterior
abdominal wall and the viscera
• Advantages
– Cosmetic results of small, non muscle splitting
incisions
– Dec blood loss
– Less post operative pain and ileus
– Shorter hospitalization
– Lower cost
– Postoperative respiratory muscle function returns
to normal more quickly
• Disadvantages
– Long learning curve for surgeon
• Most complications occur during 1st 10 laparoscopies
– Narrowed two dimensional visual field on video in
conventional laparoscopy
– Need for general anesthesia
– Longer operative duration
 PHYSIOLOGIC EFFECTS
• Hemodynamic effects
– Increased SVR and MAP
• Hypercarbia
• Neuroendocrine response
– Increased catecholamines, vasopressin, cortisol)
• Mechanical factors
– Compression of aorta
– Inc/NC in cardiac filling volumes
• Compression of intra abdominal organs (liver and spleen)
– Inc/NC in cardiac index
• Inc afterload, decreased venous return and cardiac filling
– Cardiac dysrhytmias (brady or tachy)
• Peritoneal stretch, hypercarbia, hypoxia, capnothorax,
pulmonary embolism
– Induction of pneumoperitoneum in SUPINE
position and limiting IAP to 12-15mmHg minimize
the alterations in cardiovascular function
– Hemodynamic changes are similar to those
observed in the obese and non –obese
• Reason not clear
• Regional Circulatory Changes
– Inc cerebral perfusion and intracranial pressure
• Caution in patient with brain tumor or VP shunt
– Dec splanchnic blood flow
• Variable in bowel perfusion, mechanical
pneumoperitoneum compression balanced by
hypercarbic vasodilation
– Dec hepatic blood flow
• Beneficial during cryoablation of liver metastasis
• Reduced renal perfusion and urine output (reduced
during pneumoperitoneum/recovery following
deflation)
– Dec femoral vein flow
• Inc potential for DVT and pulmonary embolism
• Renal function
– UO reduced
• Dec renal blood flow
• Compression of renal parenchyma
• Neuroendocrine
– Factors that influence UO
• Pre- existing renal compromise
• Longer insufflaiton times
• High IAP
– Inatraoperative oliguria reversible within 2 hrs
postop
– IAP <15mmHg safe even in patients with renal
disease
• Pulmonary changes
– Diaphragm elevated
– Dec lung volumes (FRC)
• Inc ventilation perfusion mismatch
• Inc alveolar arterial oxygen gradient
– Dec lung compliance and inc resistance
• Inc pleural pressures
• Inc airway pressure
– Uneven gas distribution
– Cephalad displacement of carina
• Endobronchial intubation
3 Major forces that uniquely alter patient’s
physiology during laparoscopy:
1. pneumoperitoneum
2. CO2
3. positioning (steep trendelenburg)
 Question
• What is the gas of choice for laparoscopy?
– A. CO2
– B. N2O
– C. O2
– D. Argon
 Carbon Dioxide
• Insufflating gas of choice
• Nonflammable
• Does not support combustion
• Readily diffuses across membranes
• Rapidly removed in the lungs
• Highly soluble
• Risk of embolization is small
• Forms to Carbonic Acid when in contact with moist
peritoneum peritoneal irritation and pain
 Other Gases
• N20
– Does not cause pain intra- abdominally
– Does not supress combustion
• O2
– Flammable
• No hemodynamic or acid base sequale but can cause
gas emboli
– Helium
– Air
– nitrogen
 Anesthetic Management
• GETA
– Anesthetic technique of choice
– Trendelenburg position may cause respiratory
compromise and dyspnea in the awake or in
spontaneously breathing patient
– Muscle relaxation
• Most important reason
– Insertion of nasogastric or orogastric tube
• Decompress stomach, minimize risk of aspiration or
perforation
• LMA
– For brief laparoscopic procedures in healthy
patients
– Not recommended
– Does not protect against aspiration

• Local anesthesia
– C02 may cause pain intraop, referred to shoulder
– N20 may be used as insufflating gas for very brief
diagnostic laparoscopy without cautery
– May cause nausea sec to rapid peritoneal
distention
• Regional anesthesia
– May be combined with general anesthesia
– Sympathetic denervation resulting from high regional
anesthesia will result in hypotension and dec cardiac output
rather than the hypertension and inc CO usually seen with
general anesthesa
– Requires high level of sensory block dyspnea in
trendelenburg position
– Hyperventilation in response to hypercarbia too
much movement in surgical field
– Spontaneous ventilation may be inadequate to
compensate for hypercarbia
• Ultrashort acting opiod (remifentanil) or
sympatholytic drugs (esmolol and nicrdipine)
– Treatment for pneumoperitoneum induced
hypertension
• Glucagon
– Antagonize opiod induced spasm of sphincter of
oddi
• Mechanical ventilation
– MV needs to be incraesed by 20%-30%
• Achieved by inc RR while maintaing constant TV
– Pressure controlled ventilation with low TV (6-
8ml/kg IBW and PEEP of 5-10 cm H2o
– Avoid hyperventilation
• Metabolic alkalosispost op hypoventilation
• Nausea and vomiting prevention
– Dexamethasone 4-8mg after induction of
anesthesia
– 5HT3 antagonist at end of surgery
• Ondansetron 4mg
– Aggressive hydration (20-40ml/kg)
– Minimal opiod use
– Aggressive pain control
– Scopolamine patch prior surgery
• Pain prevention
– Origin of pain is predominantly visceral rather than
parietal (from incision site)
– Non opiod analgesic if possible
– NSAID or COX2 inhibitor combined with acetaminophen
• Combination is superior to either drug alone
– Opiods
– Glucocorticoids
• Dexamethasone
– Surgical wound infiltration
– TAP block (transversus abdominis plain)
• Administration of anesthesia bet layers of internal oblique
and transversus abdominis muscle
 Intraoperative complications
• Subcutaneous emphysema
– Inadvertent extraperitoneal insufflation in
subcutaneous, preperitoneal or retroperitoneal
tissue or from extension of extraperitoneal
insufflation
– Predictors:
• > 200 minutes of operative time
• Use of 6 or more surgical ports
– Readily resolves after cessation of insufflation
• Capnothorax
– Most common in procedures near the diaphragm
(fundoplication and adrenorenal procedures)
– Tracking of insufflated CO2 around aortic, caval and
esophageal hiatuses of diaphragm into the mediastinum
with subsequent rupture into the pleural space
– Passage of gas through congenital defects
– Signs:
• Reduced air entry
• Inequality of chest expansion
• Subcutaenous emphysema
• Increased airway pressure
• Hemodynamic changes
– Management:
• Stop surgery, deflate pneumoperitoneum
• Supportive tx, hyperventilation, PEEP
• Chest UTZ or Xray- if time permits
• Minimal compromise: conservative management for
observation
• Moderate to severe: intercostal cannula or temporary
drain
• After stabilazation, may resume procedure with lower
IAP (10mm Hg)
• Gas embolism
– Inadvertent intravenous placement of Veress
needle or passage of CO2 into the abdominal wall
and peritoneal vessels during insufflation
– Most fatal
– Diagnosis:
• Tachycardia
• Arrhythmia
• Hypotension
• cyanosis
 Question
• What maneuver is used for the management
of gas embolism?
– A. Durant’s
– B. Westbrook’s
– C. Harden’s
– D. Lavar’s
– E. Tuazon’s
– Management:
• Immediate cessation of insufflation
• Deflate the abdomen
• Head down and LLDP (Durant’s Position/maneuver)
– To allow gas to rise to the apex of the RV to prevent entry
from pulmonary artery
• 100% oxygen
 Reference
• Barash 7th edition
• Yao and Artusio 8th edition
Thank you