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th i ffor
Laparoscopic Surgery
Ricky S. Harika
History and Benefits
¾ 1910 – Hans Christian Jacobaeus (Sweden)
performed first laparoscopic procedure on a
¾ Benefits
z Smaller incision

z Reduced post-
post-op pain
z Decreased
ec eased post
post--op ileus
z Earlier ambulation and shorter hospital stay
Insufflation with Carbon Dioxide
¾ Insufflation of the abdominal cavityy with CO2 via
a small infra/supra-umbilical trocar
z 12-15mm Hg, tolerable in healthy patients

z Possible vascular injuries from trocar

z Foley catheter and NG tube may be placed to

d risk
i k off ttrauma with
ith ttrocar iinsertion
z CO2 is readily absorbed, non-combustible and

Why Not Nitrous Oxide?
¾ Concerns due to its ability to diffuse into the bowel
l di tto di
leading distention
t ti and d expand d iin closed
l d spaces, which
hi h
may interfere with surgical field
z Nitrous oxide can leave blood and enter air filled cavity 34x more
rapidly then nitrogen can leave the cavity to enter blood
¾ Combustible
¾ Egar & Saidman (1965) – noted an increase of >200% in
the intestinal lumen after 4 hours of breathing nitrous
¾ Taylor, et. al (1992) – no difference in surgical conditions
during lap chole lasting 80-
80-90 minutes with/without NO2.
Bowel distention did not increase with time.
¾ Tramer, et. al (1996) - emetic effect of NO2 is not
Hemodynamic Effects

¾ D
d on th
the iinteraction
t ti of:
z patient’s pre
pre--existing cardiopulmonary status
z anesthetic
th ti technique
t h i
z intra--abdominal pressure
z carbon
b dioxide
di id absorption
b ti
z patient position
z duration of surgery
¾ ↑ in MAP, SVR and variable/↓ CO
z ↑ SVR secondary
d tto PaCO2
P CO2 iincrease d
due tto carbon
b didioxide
absorption from the peritoneal cavity.
• Hypercarbia Æ initial reduction of HR (~28% @ 15mm Hg)
and contractilityy ÆSympathetic/catecholamine
y p
release/vasopressin Æ mild increase in HR and BP
• ↓ CO due to ↓ pre-load (VC compression), ↓ LV-EDV and ↑
z Prevent by giving adequate fluids to keep CO increased

• ↑ myocardial wall tension Æ ↑ myocardial oxygen demand

¾ ↑ Cardiac filling pressures

• Compression of abdominal organs due to increased
abdominal pressures and increased sympathetic response
• Increased intra-thoracic pressures

• Esmolol (B-blocker), or Fentanyl (opioid) to ↓ HR and BP

¾ CO2 insufflation into peritoneal cavity Æ ↑ PaCO2 Æ ↑ minute
ventilation (TV, RR)
¾ Mullet, et al. (1993)
z CO2 absorptionp reached a p plateau within 10min after starting
intra--peritoneal insufflation but increased slowly throughout
extra--peritoneal insufflation
z During g only
y intra-
intra-pperitoneal insufflation PaCO2 rises and
plateaus at 15-15-30min
• If CO2 continues to rise – search for other etiology including
subcutaneous emphysemap y
¾ Important to monitor ET- ET-CO2 and may need ABG for patient’s with
pulmonary disease
¾ ↑ PVR secondary to ↑ intraintra--thoracic pressure
¾ ↑ Intra-Abdominal pressures
• P
h th the di
h upwardd lleading
di tto ↑
intrathoracic pressure, ↑ airway pressure
• ↓ FRC and TLC
• May need to use PEEP for alveolar recruitment
prevent alveolar collapse, increase oxygenation,
improve lung compliance
• Embryonic channels may open Æ
pneumomediastinum, pneumoperdicardium, PTX
z Diffusion of gas from mediastinum to extra-
peritoneal may lead to subcutaneous emphysema
off face/neck
f / k
z Capnography will show increase in end-tidal CO2
after plateau, and crepitus over abdominal wall
z Tx
T – stopt surgery and d deflate,
d fl t correctt increased
i d
CO2 levels
Regional Circulatory Changes
z Renal
• ↓ GFR (up to 50%) and ↓ renal plasma flow Æ ↓ urine
z GI
• Compression Æ ↓ bowel circulation Æ decreased
gastric pH
z Brain
• ↑ CO2 Æ ↑ cerebral blood flow Æ ↑ ICP
Position of the Patient
z Supine
p – reduces CV changes
z Reverse Trendelenburg (head up)
z moves abdominal organs away from operative site and
will help
p respiration
z May ↓ venous return and CO, thus fluid replacement
z ↑ femoral venous p pressure Æ risk of DVT or PE
z Trendenelburg (head down)
z ↑ venous return, CVP and CO
z ↓ lung
l compliance
li and
d atelectasis
t l t i off b
bases off llung Æ
V/Q mismatch
Anesthetic Management
¾ General Anesthesia with tracheal intubation and muscle
z Because ventilatory function may be compromised

d tto pneumoperitoneum
due it and
d patient
ti t positions
z Controlled ventilation necessary to prevent

z Muscle paralysis to avoid further increase in intra-
thoracic pressure
z Large
Large--bore peripheral IV – especially if arms are to be
tucked during case
z Orogastric tube to aspirate gas from stomach before

trocars placed
Post--Op Care
¾ Pain control – opiods, NSAIDs
¾ Unrecognized intra-
intra-abdominal visceral and/or
vascular injury
j y
z Progressive hypotension, increased abdominal size,
decreased Hct
¾ Increased N/V
z Zofran, Reglan, Decadron, Scopolamine patch
¾ PE due to venous stasis
z Risk of 0.016% vs. open surgery 0.8%
Works Cited
¾ Dunn, P. (2007). Clinical anesthesia procedures of the
M h it l. Philadelphia:
tt generall hospital.
h Phil d l hi LiLippincott
i tt
Williams & Wilkins.
¾ Egar, E., Saidman, I. (1965). Hazards of nitrous oxide
th i iin b
bowell obstruction
b t ti and d pneumothorax.
Anesthesiology,, 26, 61-
Anesthesiology 61-66.
¾ Joshi, G. (2002) Anesthesia for laparoscopic surgery.
Anesthesia,, 49,
Canadian Journal of Anesthesia 49 45
¾ Kaba, A. & Joris, J. (2001) Anesthesia for laparoscopic
surgery. Current Anesthesia and Critical Care,
Care, 12(3),
159 165 Retrieved August 22 22, 2009 from
¾ Mullet, C., Viale J., Sagnard, P., et al. (1993). Pulmonary
CO2 elimination
li i ti d during
i surgical
i l procedures
d using
i iintra-
t -
or extraperitoneal CO2 insufflation. Anesthesia &
Analgesia, 76, 622
¾ St lti
Stoelting, R
R., & Mill
Miller, R
R. (2007)
(2007). Basics th i .
B i off anesthesia.
Philadelphia: Churchill Livingstone
¾ Taylor, E., Feinstein, R., White, P., & Soper, N. (1992).
Anesthesia for laparoscopic cholecystectomy: is nitrous
oxide contraindicated? Anesthesiology
Anesthesiology,, 76, 541-
¾ Tramer, M., Moore, A., & McQuay, H. (1996). Omitting
nitrous oxide in general anesthesia: meta
meta--analysis of
interoperative awareness and postoperative emesis in
randomized controlled trials. British Journal of
Anesthesiology, 76, 186-