Anesthesia

in
Laparoscpi
c Surgery
DARMA WIRAWAN SOEREDI,
M.D.
DEPARTMENT OF ANESTHESIA
MANILA ADVENTIST MEDICAL
CENTER

Objectives
To discuss, briefly, the basic principles of
laparoscopic surgeries.
To discuss the physiological consequences of
laparoscopic surgeries.
To discuss the complications (management) of
laparoscopic surgeries.
To discuss the anesthetic management of
laparoscopic surgery.

Introduction
Laparoscopy (or peritoneoscopy) is a minimally
invasive procedure allowing endoscopic access to the
peritoneal cavity after insufflation of a gas (CO2) to
create space between the anterior abdominal wall and
the viscera
The space is necessary for the safe manipulation of
instruments and organs
Laparoscopic surgery can also be extraperitoneal.
It can also be gasless with abdominal wall retraction

Common Laparoscopic Surgery

Cholecystectomy
Vagotomy
Appendectomy
Colectomy
Inguinal hernia repair
Adrenalectomy
Nephrectomy
Prostatectomy
Pancreatectomy
Bariatric surgery
Nissen fundoplication
Para-esophageal hernia repair
Splenectomy
Liver resection
Cystectomy with ileal conduit

Common Laparoscopic Surgery (Cont.)

Ectopic pregnancy
Ovarian cystectomy
Reversal of ovarian torsion
Salpingo-oophorectomy
Hysterectomy
Myomectomy
Sacrocolpopexy
Lymphadenectomy
Lymphadenectomy, staging
Ablation of endometriosis

Advantages
the cosmetic results (small, nonmuscle-splitting
incisions)
decreased blood loss
less postoperative pain and ileus, shorter hospitalization
and convalescence, and ultimately lower cost
Postoperative respiratory muscle function returns to
normal more quickly than in open surgery
Wound complications such as infection and dehiscence
are less frequent, and host defense mechanisms may be
greater in laparoscopic than in open surgery.

Disadvantages
the long learning curve for the surgeon (most
complications occur during the first 10 laparoscopies)
the narrowed two-dimensional visual field on video
the need for general anesthesia, and the often longer
duration
Higher cost
Change in haemodinamic and respiratory due to intra
abdominal insufflation and hypercarbia

alter of
patient's physiology
The increase in intraabdominal pressure and volume
(pneumoperitoneum).
Extremes of patient positioning
Carbon dioxide and hypercarbia

Contraindications
patients with coagulopathy
diaphragmatic hernia
severe cardiovascular or pulmonary
disease (including bullae)
increased intracranial pressure or
space-occupying masses
impending renal shutdown
a history of extensive surgery or
adhesions

sickle cell disease

Peritonitis
a large intraabdominal mass,
tumor of the abdominal wall
hypovolemic shock
Patients with shunts (e.g.,
ventriculoperitoneal)

Gas of Choice for Laparoscopy

Carbon dioxide (CO2)
Nitrous oxide
Oxygen
Helium, air and nitrogen
Argon

Why???

Gas of Choice for Laparoscopy (Cont.)

Disadvantages of CO2
Not inert
Has local and systemic effects
Causes direct peritoneal irritation and pain during
laparoscopy under local anesthesia
Can remain in gaseous form intraperitoneally after
laparoscopy
Hypercarbia and respiratory acidosis occur when the
buffering capacity of blood is temporarily exceeded

Gas of Choice for Laparoscopy (Cont.)

Effects of CO2 on cardiovascular system
At the cellular level, hypercarbia is a direct depressor of
myocardial contractility and rate of contraction, and it is also
a direct stimulant of myocardial irritability and arrhythmicity.
These effects may be enhanced by the reduced pH caused by
hypercarbia
Local effect on isolated or denervated blood vessels is a
diminished responsiveness to catecholamines and
vasodilation especially on the venous side
MUWAHAHAH
causes AHAHA
profound

Hypercarbia
systemic changes secondary to
stimulation of the central nervous system and
Noo
sympathoadrenal system
Systemi
c Effects

Local
Effects

oo

Physiologic Changes
Cardiovascular Changes associated
with IAP

increase in systemic vascular resistance, mean arterial

pressure, and cardiac filling pressures

more severe in patients with preexisting cardiac disease

significant changes occur at pressures greater than 12 15 mmHg

increased plasma renin activity (PRA) due to increased

intra-abdominal pressure (IAP) and the local
compression of renal vessels

Hypertension, tachycardia leading to increased

myocardial oxygen demand

Physiologic Changes (Cont.)

Cardiovascular Changes associated with Patient
Positioning

Head up Position

Blood pooling -> Venous stasis

Thrombo-embolism
venous return
cardiac output
Blood Pressure

Head down Position:

Increases CVP
Increases cardiac output
Increases cerebral circulation
Increased ICP
Increased intra-ocular pressure

Physiologic Changes (Cont.)

Cardiac Arrhythmias during
Laparoscopy
common during insufflation and during desufflation
With the use of Halothane
Hypercarbia, hypoxia and gas embolism
Sudden stretching of peritoneum causes vagal
stimulation

Physiologic Changes (Cont.)

Respiratory System Changes associated with IAP
Exaggerated in obese patients, ASA classII and III patients & in those with
respiratory dysfunction
Intra-abdominal distension leads to a decrease in pulmonary dynamic
compliance

increased IAP displaces the diaphragm upward

functional residual capacity and total lung compliance decreases

early closure of smaller airways, basal atelectasis

increased peak airway pressures

increase in minute ventilation required to maintain normocarbia

Increase in intra pulmonary shunting

Physiologic Changes (Cont.)

Respiratory System Changes associated with Patient
Positioning
Head-down position

Endo-bronchial intubation

Promotes atelectasis

Decreases Functional Residual Capacity (FRC)

Decreases Total Lung Capacity (TLC)

Decreases pulmonary compliance

Head-Up position: favorable for respiration

Laparoscopic Surgery Complications

Due to trochar injury
Positioning and compression effect
Cardiovascular complications
Respiratory complications
Thermal injuries
Gas embolism

Laparoscopic Surgery Complications

(Cont.)
Factors that increase risk of respiratory complications
The laparoscopic procedure itself.
Age
Smoking/chronic obstructive pulmonary disease (COPD).
Obesity
Overhydration

Laparoscopic Surgery Complications

(Cont.)
Pneumothorax and Pneumomediastinum

Patent pleuro-peritoneal channels

Pleural injuries
Ruptured emphysematous bullae
Sudden hypoxia, rise in peak airway pressure,
hypercarbia, haemodynamic alterations
Abnormal movement of the hemidiaphragm on
laparoscopic view should raise a suspicion of
pneumothorax

Laparoscopic Surgery Complications

(Cont.)
Management of Pneumothorax

Recommended Guidelines
Stop N2O
Adjust ventilator settings to correct hypoxemia
If due to pleuro peritoneal channel route apply PEEP
Reduce intra-abdominal pressure
Communicate with surgeon
Avoid thoracocentesis unless necessary
Avoid PEEP if there is rupture of emphysematous bulla;
thoracocentesis is mandatory

Laparoscopic Surgery Complications

(Cont.)
Gas Embolism
During laparoscopy, insufflation of a large amount of CO directly into
a blood vessel can occur initially after blind Veress needle insertion
2

Should be suspected if the abdominal cavity does not distend equally

in all four quadrants despite insufflation of several liters of CO .
2

Hypotension, hypoxia, cyanosis, or cardiac arrest can occur

The most sensitive means to detect gas emboli are the precordial and
Transesophageal Doppler and transesophageal echocardiography
Aspiration of foamy blood from a central venous catheter is diagnostic
and treatment

Anesthetic Goals

Accommodate surgical requirements and allow for

physiological changes during surgery.
Monitoring devices available for the early detection of
complications.
Recovery from anesthesia should be rapid with minimal
residual effects.
The possibility of the procedures being converted to
open laparotomy to be considered

Anesthesia Management

Pre-operative assessment

The cardiac and pulmonary status of all patients should

be carefully assessed
Pre-medication

Anxiolytics
antiemetic
H2 receptor blockers
Prokinetic drugs
Preemptive analgesia with NSAIDs
Atropine to prevent vagally mediated bradyarrhythmias

Anesthesia Management (Cont.)

1. Routine Patient Monitoring Include

Continuous ECG
Intermittent NIBP
Pulse oximetry (SpO2)
Capnography (EtCO2)
Temperature
Intraabdominal pressure

2. Optional Monitoring Include

Pulmonary airway pressure
Oesophageal stethoscope
Precordial doppler
Transoesophageal echocardiography

Anesthesia Management (Cont.)

Anesthesia Techniques
General Anesthesia
Spinal / Epidural Anesthesia
Local Anesthesia

Anesthesia Management (Cont.)

Conduct of Anesthesia
Goals:

IAP: 12 15 mmHg (dont allow to rise >20 mmHg)

Airway pressure <40 cmH2O (20 30)
EtCO2 ~ 35 mmHg
Maintain BP and HR.

Give attention to

Prevent Acid Aspiration

ET tube displacement
Rhythm changes esp. at the time of gas insufflation
PONV prophylaxis

Anesthesia Management (Cont.)

GA-ET with Controlled Ventilation
Induction: Injection opiod; then inj of induction agent; make sure able to
ventilate -> muscle relaxant (Succinylcholine / rocuronium / atracurium /
cisatracurium / vecuronium) + Inj Dexamethasone 4 mg iv for PONV
prophylaxis
Intubation: appropriate size cuffed ET tube (LMA not recommended). NG
or OG tube insertion and aspiration of stomach content (air)
Maintenance: either anesthetic gas or TIVA can be used + O2 + Muscle
relaxant.
Fluid 4cc/kg/hour - depending on the situations
Ventilation: O2 + IPPV or CPPV (spontaneous ventilation not
recommended) adjusted to eliminate CO2
End: Give antiemetic injection
Reversal agent

Anesthesia Management (Cont.)

Extubation
Watch out for facial edema
Delay extubation if the patient has edema, venous
congestion, and duskiness of the head and neck.
Sometimes the tongue becomes edematous. If unsure,
check the eyes for conjunctival and lid edema, and keep
the patient in head-up position until the conjunctivae no
longer seem raised or watery
Watch for subcutaneous emphysema
Inspect oropharynx
Avoid extubation on light plane anesthesia

Anesthesia Management (Cont.)

Postoperative management
Post-Operative Pain
At post op site
Referred pain on shoulder

Post Operative Nausea and Vomiting

Anesthesia Management (Cont.)

Postoperative management (Pain)
Preoperative or intraoperative administration of a nonopioid analgesic (e.g. NSAID, Paracetamol)
Local anesthetic infiltration at trocar insertion sites (e.g.
bupivacaine 0.25%, lidocaine 0.5%)
Rescue medication with small doses of an opioid (e.g.
morphine)
Treat postoperative shivering.

Anesthesia Management (Cont.)

Postoperative management (PONV)
Incidence as high as 42%.
Inj Dexamethasone 4 mg iv at the time of induction.
Inj Ondansetron 4 mg iv at the end of surgery.
Third anti-emetic for rescue therapy.
Adequate pain control also help the PONV

Thank You