PROSEDUR BEDAH MINIMAL

INVASIF
Pengampu : dr. Anisa Fadhila, Sp.An
Oleh : Semester 5 / 2023
 OUTLINE

LAPAROSCOPY / LAPAROSCOPIC
THORACOSCOPY GAS

GAS INSUFFLATION
BENEFIT AND LOSS
EFFECT
LAPAROSCOPY
• Over a century ago, laparoscopy was first introduced as a therapeutic
alternative to laparotomy
• Since then, the field of laparoscopic surgery has evolved and grown
tremendously
• In fact, laparoscopy is now the gold standard approach for cholecystectomy
and bariatric surgery
• The creation of protocolized, fast-track programs that maximize the benefits
of minimally invasive surgery has improved surgical utcomes and reduced
health-care costs

Rodriguez,
Rodriguez, G Joseph, SE 2017, G Joseph,
‘Anesthesia SE 2017. ‘Anesthesia
for Laparoscopic forSurgeries’
and Robotic Laparoscopic
in PGand Robotic
Barash, Surgeries’
BF Cullen, RK in PG Barash,
Stoelting, MK BF Cullen,etRKal,
Cahalan,
Clinical Anesthesia, 8th edn,Stoelting, MK Cahalan,
Wolters Kluwer, et al, Clinical
Philadelphia, Anesthesia. 8th edn. Philadelphia, Pennsylvania: Wolters Kluwer, pp. 3144.
pp. 3142-3182.
THORACOSCOPY
• Thoracoscopy (medical thoracoscopy) involves the insertion of an endoscope
into the thoracic cavity and pleural space.
• It is used for the diagnosis of pleural disease, effusions, and infectious disease
(especially in immunosuppressed patients and those with acquired
immunodeficiency syndrome) and for staging procedures, chemical pleurodesis,
and lung biopsy.
• A small incision is made in the lateral chest wall, and with the insertion of the
instrument, fluid and biopsy specimens are easily obtained.
• This procedure may be performed using local, regional, or general anesthesia;
the choice depending on the expected duration and the physical status of the
patient.
Eisenkraft,
Eisenkraft,James
JamesB,B,Edmond
EdmondCohen,
Cohen,Steven
StevenM.M.Neustein.
Neustein.(2017).
(2017).‘Anesthesia
‘AnesthesiaforforThoracic
ThoracicSurgery’
Surgery’ininPGPGBarash,
Barash,BFBFCullen,
Cullen,RKRKStoelting,
Stoelting,MK
MK
Cahalan,
Cahalan,etetal,al,Clinical
ClinicalAnesthesia,
Anesthesia.8th
8thedn,
edn.Wolters
Philadelphia,
Kluwer,Pennsylvania:
Philadelphia, Wolters
pp. 2551Kluwer,
- 2673.pp. 2628.
THORACOSCOPY
• Video-Assisted Thoracoscopic Surgery (VATS) is now used for most
lung resections.
• Most procedures are performed through several small incisions in the
chest wall, with the patient in the lateral decubitus position.
• Anesthetic management is similar to that for open procedures, except
that one lung ventilation is required (as opposed to being desirable)
for nearly all procedures.
• As previously mentioned, “tubeless” VATS are increasingly performed.

Butterworth, John F, David C Mackey, John D Wasnick 2022, Anesthesia for Thorasic Surgery in Morgan & Mikhail’s Clinical Anesthesiology,
7th edn, Mc Graw Hill, New York, pp. 888 - 932
 Ochroch,EE.Andrew,
Ochroch, Andrew,Stuart
StuartJ J. Weiss.
Weiss 2017,2017. ‘Thoracic
‘Thoracic Anesstesia’
Anesstesia’ in David
in David E. Longnecker,
E Longnecker, Sean
Sean C. Mackey,
C Mackey, MarkMark F. Newman,
F Newman, et al,et al,
Anesthesiology.3rd
Anesthesiology, 3rdedn,
edn.Mc
New YorkHill
Graw : Mc Graw HillNew
Education, Education, pp.888
York, pp. 910- 939
 Ochroch,E.E.Andrew,
Ochroch, Andrew,Stuart
StuartJ.J.Weiss.
Weiss 2017.
2017, ‘Thoracic
‘Thoracic Anesstesia’
Anesstesia’ in
in David
David E.
E. Longnecker,
Longnecker, Sean
Sean C.
C Mackey,
Mackey, Mark
Mark F
F.Newman,
Newman,et
etal,
al,
Anesthesiology, 3rd edn, Mc Graw Hill Education, New York, pp.
Anesthesiology. 3rd edn. New York : Mc Graw Hill Education, pp. 910 888 - 939
Surgical Approach
• Laparoscopic surgery is a minimally invasive surgical technique where
specialized tubes are inserted for surgical access
• Small skin incisions are made, approximately 1 cm in length, to
facilitate insertion of rigid tubes, called trocars.
• Trocars are sharp, multiport, one-way conduits used to insufflate gas
and to guide various specialized surgical instruments.
• Intraperitoneal viewing is conducted using a video-capable telescopic
camera, called a laparoscope
• Exposure of the intraperitoneal space can be achieved either by
intraperitoneal pressurization, called pneumoperitoneum, or by
external abdominal wall retraction.
Rodriguez,
Rodriguez,GGJoseph,
Joseph,SE
SE2017.
2017.‘Anesthesia
‘Anesthesiafor
forLaparoscopic
Laparoscopicand
andRobotic
RoboticSurgeries’
Surgeries’ininPG
PGBarash,
Barash,BF
BFCullen,
Cullen,RK
RKStoelting,
MK Cahalan, et al, Clinical Anesthesia. 8th edn. Philadelphia, Pennsylvania: Wolters Kluwer,
Stoelting, MK Cahalan, et al, Clinical Anesthesia. 8th edn. Wolters Kluwer, Philadelphia, pp. 3142-3182. pp. 3144.
Physiologic Impact of Laparoscopy
• Laparoscopic surgery induces complex physiologic changes that
impact multiple organ systems.

• Direct mechanical stress placed on the patient, as well as

neuroendocrine stimulation during laparoscopy are the primary
forces responsible for much of the physiologic derangement
observed

• Physiologic changes during minimally invasive surgery are well

tolerated in healthy patients, minimizing complications and
optimizing conditions for a successful surgical result, require an
understanding of the interplay between physiology and laparoscopic
surgery. Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK
Stoelting, MK Cahalan, et al, Clinical Anesthesia. 8th edn. Wolters Kluwer, Philadelphia, pp. 3142-3182.
Physiologic Impact of Laparoscopy

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK
Stoelting, MK Cahalan, et al, Clinical Anesthesia. 8th edn. Wolters Kluwer, Philadelphia, pp. 3142-3182.
Physiologic Impact :
Cardiovascular System
• In patients, the cumulative effect is an increase in mean arterial pressure
(MAP), myocardial oxygen demand, and systemic vascular resistance
(SVR).
• Carbon dioxide gas is highly soluble and, during insufflation, rapidly
moves from the peritoneal cavity into the circulation. Prolonged
surgeries and high insufflation pressures can lead to increased CO2 gas
absorption.
• Systemic CO2 gas then exerts both direct and indirect effects on the
cardiovascular system via adrenergic pathways.
• Mild hypercarbia (PaCO2 of 45 to 50 mmHg) alters hemodynamics very
little, whereas severe hypercarbia (PaCO2 55 to 70 mmHg) and acidosis
can lead to myocardial depression, dysrhythmias from catecholamine-
induced myocardial sensitization, and peripheral vasodilation.
Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting,
MK Cahalan, et al, Clinical Anesthesia. 8th edn. Wolters Kluwer, Philadeplhia, pp. 3142-3182.
• The peritoneum and abdominal viscera are highly innervated by
autonomic nerve fibers.
• Stimulation of these autonomic pathways during
pneumoperitoneum, typically results in :
• sympathetic nervous system activation,
• catecholamine release,
• activation of the renin–angiotensin system,
• and release of the neurohypophysial hormone vasopressin
• This potent endogenous hormone can cause intense
vasoconstriction, an increase in MAP, and increases in left
ventricular afterload
Rodriguez, G Joseph, SE 2017, ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia, 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
• Mechanical stretch on the peritoneum and abdominal viscera can
result in parasympathetic stimulation through the vagus nerve, but
sympathetic tone usually predominates.
• Intravascular volume status is an important modifier of the
mechanical effects of pneumoperitoneum
• In instances where low right atrial pressures reflect low cardiac filling
volumes, an increase IAP can result in compression of the inferior vena cava
(IVC), causing a decrease in venous return and cardiac filling.

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
• Patient positioning can further modify the effects of IAP. Steep
Trendelenburg positioning during pneumoperitoneum may augment
venous return and cardiac filling
• In contrast, reverse Trendelenburg position during
pneumoperitoneum can result in an increase in SVR and minor
reductions in CI that are soon reversed
• Initiating insufflation while supine and maintaining IAP within the
recommended range (12 to 15 mmHg) can minimize any reduction
in preload

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn. Wolters Kluwer, Philadelphia, pp. 3142-3182.
Physiologic Impact :
Respiratory System
• Laparoscopic abdominal surgery exerts changes on the pulmonary
system by :
• mechanically displacing thoracic structures,
• altering lung mechanics (i.e., volumes, compliance, resistance)
• and disrupting gas exchange through ventilation–perfusion mismatch

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
• An early effect of insufflation on the pulmonary system is the
displacement of the diaphragm into the thorax, which can be
further aggravated by Trendelenburg positioning  This shifts the
carina cephalad, increasing the risk of endobronchial intubation.
• Elevated IAP and diaphragmatic displacement also lead to
compression of the lung bases, atelectasis, ventilation–perfusion
mismatch, and hypoxemia.
• The change in pulmonary compliance can be observed as an
increase in peak inspiratory pressure (PIP) during positive pressure
ventilation  Ventilator adjustments may be needed to minimize
peak airway pressure, while maintaining acceptable minute
ventilation. Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
• Hypercarbia routinely develops in all patients from the absorption of
intraperitoneal CO2 into the circulatory system
• The concentration gradient that develops preferentially drives CO2
from the pulmonary capillaries into the alveolar network, where it is
removed during exhalation and measured by capnography as end-
tidal CO2 (EtCO2.)
• In lieu of CO2 absorption, calculated CO2 elimination during
intraperitoneal and extraperitoneal laparoscopy could increase
rapidly then reach a steady state within 30 minutes, regardless of
surgery duration.

Rodriguez, G Joseph, SE 2017. ‘Anesthesia

Barash, for Laparoscopic
P.G., Cullen, and Robotic
B.F. and Stoelting, Surgeries’
R.K. (2017) in PG
‘Chapter Barash, BF Cullen,
44 Anesthesia RK Stoelting,
for Laparoscopic andMK Cahalan,
Robotic et al, in
Surgeries’,
Clinical Anesthesia. 8th edn Wolters Kluwer, Philadelphia, pp. 3142-3182.
Clinical anesthesia. 8th edn. Philadelphia, Pennsylvania: Wolters Kluwer, pp. 3142–3182.
• Hypoxia during laparoscopy is usually due to a transient ventilation–
perfusion mismatch that is commonly attributed to pulmonary
shunting
• Physiologic changes induced during pneumoperitoneum and
extreme positioning can reduce the number of ventilated alveolar
units being perfused.

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
Physiologic Impact :
Regional Perfusion Effects
• In healthy patients undergoing laparoscopy the splanchnic, renal,
cerebral, and ocular organ systems undergo physiologic changes
that are transient and f limited clinical significance

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
Laparoscopy Gas
• Conventional laparoscopy uses carbon dioxide (CO2) for
intraperitoneal (e.g., bariatric and cholecystectomy surgery) and
extraperitoneal insufflation (e.g., adrenal and inguinal hernia repair
surgery)
• CO2 → highly soluble in blood, rapid pulmonary removal,
nonflammable, nonoxidizing, and safe to use during electrocautery,
thus set a desirable safety profile

Rodriguez,
Rodriguez, G Joseph, G Joseph,
SE 2017. SE 2017.
‘Anesthesia ‘Anesthesia for
for Laparoscopic andLaparoscopic and Robotic
Robotic Surgeries’ in PG Surgeries’
Barash, BFinCullen,
PG Barash, BF Cullen,
RK Stoelting, MKRK Stoelting,
Cahalan, MK
et al,
Cahalan,
Clinical Anesthesia. et al,
8th edn, ClinicalKluwer,
Wolters Anesthesia. 8th edn.pp.
Philadelphia, Philadelphia,
3142-3182.Pennsylvania: Wolters Kluwer, pp. 3145.
Gas Insuflation Effect
• Intraperitoneal insufflation is
generally established by creating a
small subumbilical incision, through
which a stainless steel, spring-
loaded, blunt needle, called a Veress
needle, is inserted
• Maximal preset intra-abdominal
pressures (IAP) above 15 mmHg
should be avoided as to minimize
CO2-related complications and Rai, Mandavi et al. 2015, Comparison between Different Entry Techniques in Performing
Pneumoperitoneum in Laparoscopic Gynecological Surgery, viewed 13 August 2023
significant cardiopulmonary
instability.
• The Veress needle is replaced with a
trocar for laparoscope insertion
Rodriguez, G Joseph, SE 2017.Rodriguez,
‘AnesthesiaG for
Joseph, SE 2017.
Laparoscopic ‘Anesthesia
and for Laparoscopic
Robotic Surgeries’ and BF
in PG Barash, Robotic
Cullen,Surgeries’ in PG
RK Stoelting, MKBarash, BFetCullen,
Cahalan, al,
Stoelting, MK Cahalan, et al, Clinical Anesthesia. 8th edn. Philadelphia, Pennsylvania: Wolters Kluwer, pp. 3145.
RK
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
Allowable Intrabadominal Pressure
• Most surgeons currently limit the IAP in neonates and young infants
to 6 to 8 mm Hg and in children to 10 to 12 mm Hg

Hansen Tom G, Steen W Henneberg, Jerrold Lerman 2019, ‘General Abdominal and Urology Surgery’ in Coté Charles J, Jerrold Lerman, Brian J
Anderson, in Coté and Lerman’s A Practice of Anesthesia for Infants and Children. Elsevier, 6 th edn, Elsevies, Philadelphia, pp. 2955-3052
Gas Insuflation Effect (VATS)
• In some cases, carbon dioxide is insufflated into the pleural cavity to
facilitate visualization.
• Insufflation pressures should be maintained as low as possible and the
CO2 inflow rate kept less than 2 L/min.
• Higher pressures can cause mediastinal shift, hemodynamic
compromise, increases in airway pressure, and increases in end-tidal
CO2.
• Hemodynamic compromise presents a picture similar to that because of
tension pneumothorax.
• Significant hemodynamic changes can be produced when pressures as
little as 5 mmHg are used to insufflate CO2 into the chest cavity.
Rodriguez,
Rodriguez, G Joseph, SE 2017. G Joseph,
‘Anesthesia SE 2017. ‘Anesthesia
for Laparoscopic for Surgeries’
and Robotic Laparoscopic and
in PG Robotic
Barash, BFSurgeries’
Cullen, RKinStoelting,
PG Barash,MKBFCahalan,
Cullen, RK
et al,
Stoelting,
Clinical Anesthesia. 8th edn. Wolters MK Cahalan,
Kluwer et al, Clinical
Philadelphia, Anesthesia. 8th edn. Philadelphia, Pennsylvania: Wolters Kluwer, pp. 3145.
pp. 3142-3182.
Benefit of Laparoscopic Surgery

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
Disadvantages of Laparoscopy Surgery

Rodriguez, G Joseph, SE 2017. ‘Anesthesia for Laparoscopic and Robotic Surgeries’ in PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al,
Clinical Anesthesia. 8th edn, Wolters Kluwer, Philadelphia, pp. 3142-3182.
REFFERENCE
• PG Barash, BF Cullen, RK Stoelting, MK Cahalan, et al 2017,Clinical
Anesthesia, 8th edn. Wolters Kluwer, Philadelphia, Pennsylvania.
• David E. Longnecker, Sean C. Mackey, Mark F. Newman, et al 2017,
Anesthesiology, 3rd edn, Mc Graw Hill Education, New York.
• Butterworth, John F, David C.Mackey, John D. Wasnick 2022, Morgan
& Mikhail’s Clinical Anesthesiology, 7th edn, Mc Graw Hill New York.
• Coté Charles J, Jerrold Lerman, Brian J Anderson 2019, Coté and
Lerman’s A Practice of Anesthesia for Infants and Children, 6th edn,
Elsevier, Philadelphia.
TERIMA KASIH