Anaesthesia for Laparoscopy

Aims

• to underline the principles of anaesthesia

for laparoscopic surgery
• to point out the dangers of peritoneal
insufflation of CO2 and look at alternatives
• to examine claims that laparoscopic
procedures are less stressful than open
procedures
 Objectives

• to increase awareness of the risks and

benefits of laparoscopic surgery from the
anaesthetist’s (and patient’s) point of view
• to stimulate further interest and research in
newer techniques which may reduce the
risks
 Introduction

• Gynaecological laparoscopy
• Dangers of peritoneal insufflation of CO2
“Though laparoscopy offers advantages to both patients and
surgeon it involves considerable alteration in respiratory
and cardiovascular homeostasis and should not be
regarded as yet another minor investigation”
Hodgson, McClelland and Newton 1970
 Anaesthetic techniques

• The role of endotracheal intubation

• The role of mechanical ventilation
• The role of muscle paralysis
• The role of nitrous oxide
 Anaesthetic techniques
• Capnography
– CO2 absorption through peritoneum, venous channels,
retroperitoneal and subcutaneous tissues
• Invasive monitoring
• Insufflating gas
– air, nitrous oxide, carbon dioxide
• Helium
– Haemodynamic stability (Fleming et al., Junghans et al.
1997)
– Inhibition of tumour growth (Neuhauss et al. 1999)
 Pathophysiological effects

Haemodynamic
• head up versus head down position
• bradycardia
• blood loss
• visceral traction
• gas embolus: early versus late
 Pathophysiological effects

Respiratory: Hypercapnoea
• Head down, spontaneous respiration
• CO2 absorption
• Compromised diaphragm function with
raised IAP
• Pneumothorax
 Pathophysiological effects
CO2 pneumoperitoneum (Safran and Orlando AJS 1994)

• Hypertension, tachycardia leading to increased myocardial oxygen demand

• Increased noradrenaline levels leads to increased SVR (and decreased Q)
• Hypercarbia and acidosis
• Decrease in urine output and increased plasma renin activity (PRA)
– due to increased intra-abdominal pressure (IAP) and the local compression of renal
vessels
• Intra-abdominal distension leads to a decrease in pulmonary dynamic
compliance .
• Low compliance, together with an increased minute volume of ventilation, is
accompanied by high peak airway pressures .
• head-up positioning and fluid deficit accounts for many of the
adverse effects in haemodynamics during laparoscopic
cholecystectomy (Hirvonen et al 2000).
 Pathophysiological effects
Gasless/abdominal wall lift techniques

• abdominal wall lift permits the

conduct of laparoscopic
procedures at an intra-abdominal
pressure of only 6-8 mm Hg
• benefits patients with pre-
existing cardiac disease and
chronic bronchitis, especially for
liver surgery (Banting et al.
1993).
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

• .. gasless technique provided inferior exposure and the

operation took longer, … value in high-risk patients with
cardiorespiratory disease? (Vezakis et al. 1999, Johnson and
Sibert 1997)
• .. using thoracic epidural: no clinically important
differences in cardiovascular and systemic response
were observed between patients undergoing CO2 or
gasless laparoscopy for colonic disease (Schulze et al. 1999).
• .. compromised surgical exposure and thus increased
technical difficulty. Patients realised no benefits from its
use in terms of postoperative discomfort or return to
activity (Goldberg and Maurer 1997)
• .. gasless laparoscopic cholecystectomy resulted in
more uneventful and faster immediate and late
postoperative recovery than conventional carbon
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

Conclusion
• Most studies have shown decreased surgical
access and increased conversion rates
• Cardiorespiratory benefits are limited in
most studies
• Side effects are similar overall
• Need a meta-analysis/more studies
 Studies of laparoscopic vs open procedures

• endocrine and metabolic changes during

acute emergency abdominal surgery
performed using either laparoscopy or
laparotomy in children. Prolactin,
cortisol, interleukin-6, glucose, insulin,
lactic acid and epinephrine levels .. No
differences were elicited (Bozkurt et al.
2000)
• stress responses after sigmoid
colectomy, in patients undergoing lap.
assisted colectomy, are comparable with
open operation (Fukushima et al. 1996)
• LC produces significant increases in
stress hormone levels … “not
 Studies of laparoscopic vs open procedures

• significant lower values of

intraoperatively and postoperatively
measured epinephrine, norepinephrine,
interleukin-1 beta, and interleukin-6 in
patients with laparoscopic vs open
cholecystectomy (Glaser et al. 1995)
• neuroendocrine stress response and
inflammatory response following
laparoscopic cholecystectomy were
significantly reduced compared with
those after open cholecystectomy
(Karayiannakis et al. 1997)
Studies of laparoscopic vs open procedures

Conclusion

More studies and larger patient groups are

needed to be certain that laparoscopic
procedures produce less stress response
than open procedures … especially if the
duration of the operation is longer
 Conclusion

• Laparoscopic procedures are not minimally

invasive physiologically
• The benefits of gasless techniques are yet to
be established