ANAESTHESIA FOR

LAPAROSCOPIC SURGERY
Moderator: Dr. Madhu
Presentor: Dr. Megha
 Laparoscopy……..
• Defn: Visualization of abdominal cavity
through an endoscope.
 Historical Aspects
• First Laparoscopic tubal surgery:1962
• First Lap Cholecystectomy:by
Phillipe Mouret,in late1980s.
 Benefits of lap
– Reduce post op pain & analgesic requirement,
– Post op PULMONARY DYSFUNCTION
• Less severe
• Quick recovery
• Diaphragmatic fn significantly impaired
• Older,Obese,smoker,COPD: Slower recovery than
healthy but better than laparotomy.
• Less impaired in lap gynae than upper abdominal
Reduced stress response to surgery & better
maintenance of homeostasis
 reduction of acute phase reaction
 tissue damage(Dec CRP & IL-6)
 Dec metabolic response e.g. hyperglycemia, leukocytosis
 Thus,nitrogen balance & immune fn. better preserved.
Endocrine resp: similar, reduced by preop α2-agonists.
peritoneal stretching,
hemodynamic disturbances,
ventilatory changes induced by pneumoperitoneum
visceral nociception,
– Dec surgical trauma
• prolonged exposure & manipulation of
intestines avoided
• decreased need for peritoneal incision &
trauma.
-less postoperative ileus and fasting,
-less duration of IV infusion,
 – reduced recovery time & hospital stay ,early return to
work
– better cosmetic appearance,
– Less post op wound infectn
Overall, reduced morbidity, mortality & health care
cost.
 Complications of lap
– pathophysiologic changes,
– longer duration,
– unsuspected visceral injury(bowel,CBD,urinary tract),
– Vascular compli,evaluating blood loss
– Burns
– Conversion to open
• Learning curve: more experience----less compli
Features Laparotomy Laparoscopy

Intraoperative Factors    

Depression from pneumoperitoneum >

Hemodynamic factors Stimulation by surgical stress
stimulation by surgery

Ventilatory changes + ++

  Elevation of diaphragm + ++

  Increased intrathoracic pressure 0 ++

  Absorption of carbon dioxide 0 ++

  Controlled mechanical ventilation (min ventilation) + ++

  Patient position + ++

Anesthetic requirement = =

Endocrine response (cortisol,catecholamines) ++ ++

Surgical trauma ++ +

Postoperative Factors    

Pain (analgesic requirement) ++ +

Pulmonary dysfunction ++ +

Metabolic response and acute phase reaction ++ +

Postoperative fatigue ++ +

Recovery ++ +

Fasting ++ +

Nausea, vomiting + ++

Hospital stay ++ +

Mortality + (+)

Morbidity + (+)
 Establishing Pneumoperitoneum

• Decompress bladder & stomach(avoid inj)

• Small incision above or in umbilicus
• Verres needle insertion
– Under manual control
– 30deg dwnward angle towards pelvis
– Tip pointing below aortic bifurcation(avoid
arterial puncture)
 Establishing Pneumoperitoneum
Cntd….
• Correct Placement of verres:
1. Drop test:drops of saline placed at hub,drawn
inside d/t subatmospheric IAP
2. Aspiration:ensures it is not intravasc or in bowel
3. Pressure measurement:0 to -5mm Hg
 Establishing Pneumoperitoneum
Cntd….
• Large (11mm) cannula over trocar via
umbilical incision
– modern safety mech
– Mini lap tech
• Automatic insufflator @6-10L/min to maintain
3-5 L vol

** cannula must be intraperitoneal

 Properties of insufflation Gas

• Minimal peritoneal absorption

• Min physiological eff
• Rapid excretion of any absorbed gas
• Inability to support
combustion(electrocautery-safe)
• High blood solubility(dec risk of gas
embolism)
• Inexpensive
 WHY CO2 ?
• Colourless
• Not support combustion
• Highly soluble
• Inexpensive
• Residual CO2 cleared rapidly(min postop
discomfort)
*air & O2 support combustion, thus not used.
 Inert Gases
 eg helium, argon
 avoids inc in PaCO2 from absorption,hyperventilation
is not required.
 ventilatory consequences of the increased IAP
persist.
 hemodynamic changes
 d/t pneumo-as with CO2.
 accentuates dec in C.O
 attenuates increase in B.P.
 low blood solubility- serious CV sequelae in the event of gas
embolism.
 Argon- eff on hepatic blood flow.
 IAP
• Not higher than 15mm Hg
• High pressures:
– Circulatory & respi embarrassment
– Higher risk of CO2 embolism, subcutaneous
emphysema
Physiological changes
during lap
 Ventilatory Changes
• ↓thoracopulmonary compliance (30-50%) in healthy, obese
• ↓FRC & atelectasis due to diaphragm elevation
• increased airway pressure(50%)(80% inc in Pplat): Changes in
distribution of pulm ventillation & perfusion
• No change in physiologic dead space or shunt in healthy pat.
when intra abdominal pressure(IAP) upto 14mmHg and 10-200 tilt
 Ventilatory Changes Cntd…
• Mean gradient(Δa-ETCO2) between PaCO2 and
PETCO2 ↑more in ASA II/III than in ASA I
– Eg.COPD, congenital heart disease
• Lack of correlation between PaCO2 and PETCO2
in sick patients
– Impaired CO2 excretion capacity
• ABG recommended when hypercarbia suspected
 Ventillatory ch Cntd….
Increase in PaCO2
• PaCO2 plateau 15-30mins
• PaCO2 depends on IAP(15-30%)
• Local anesthesia – PaCO2 unchanged, ↑minute
ventilation(60%)
• GA with spontaneous ventillation: compensatory
hyperventilation insufficient due to respiratory
depresssion and decreased compliance ∴
↑PaCO2
 Ventillatory ch Cntd….
Causes of increased PaCO2 during
laparoscopy
Absorption of CO2 from peritoneal cavity(main cause, esply in
healthy pt.) depends on:
 diffusibility,
 absorption area
 perfusion of the walls of that cavity.
Thus,absorption of large quantities of CO2 into the blood is
expected
but
 capacity of body to store CO2
 impaired local perfusion d/t inc IAP.
(During deflation,transient increases in PaCO2 and CO2
elimination)   
 Other causes:
1. V/Q mismatch
 Increased physiologic dead space, ↓alveolar ventilation
 Abdominal distention
 Position (eg. Steep tilt)
 Controlled mechanical ventilation
 Reduced cardiac output
 Accentuated in sick patients
2. Increased metabolism(eg.insufficient anesthesia)
3. Depression of ventilation(eg.spontaneous breathing)
4. Accidental events :CO2 emphysema, Capnothorax, CO2 embolism,
selective bronchial intubation
To maintain physiologic PaCO2: inc alveolar venti 10-25%(except in
special circumstances)
 Respiratory complications

• CO2 pneumoperitoneum
– CO2 subcutaneous emphysema
– Pneumothorax
– Endobronchial intubation
– Gas embolism
 CO2 Subcutaneous Emphysema

 Incidence:0.4-2%
 Extraperitoneal insufflation
 Eg. Inguinal hernia, renal surgery, pelvic lymphadenectomy
 WHEN TO SUSPECT????
 PaCO2 and PETCO2 increase after plateaued
 Prevention of hypercapnia by aadjustment of ventillation,
almost impossible.
 CO2 Subcutaneous Emphysema Cntd….
 WHAT TO DO???
 Interrupt lap( allow CO2 elimination), resumed after
hypercapnia corrected using lower insufflation pressure
 Resolves after desufflation
 Does not contraindicate tracheal extubation
 Pt mechanically ventillated till CO2 correction,
particularly in COPD (to avoid excess inc in WOB).
 Pneumothorax Pneumomediastinum
Pneumopericardium
CAUSES:
 Embryonic remnants potential channels, Rt
peritoneopleural ducts
 Diaphragmatic defects, aortic and esophageal hiatus
 pleural tears
 Lung bullae
 Capnothorax
↓compliance, ↑airway pressure
 CO2 elimination, PaCO2 & PetCO2 inc.(PetCO2
dec in pneumo sec to alveolar rupture coz of dec
in C.O)
 Caution: tension pneumothorax
 Capnothorax Management(no lung trauma)

1. Stop N2O administraion

2. 100% FiO2:Adjust ventilator settings to correct
hypoxemia
3. Apply PEEP
4. Desufflate:Reduce IAP as much as possible
5. Maintain close communication with surgeon
6. Avoid thoracocentesis unless necessary,
spontaneous resolution after exsufflation
• Pneumothorax from ruptured bullae
– No PEEP
– Thoracocentesis is required
 Endobronchial Intubation

• Cephalad displacement of diaphragm

• Can occur in head up or down position
• ↓SpO2
• ↑plateau airway pressure
 Gas Embolism

 Rare but most feared complication

CO2 better than others…..
 CO2 more soluble than air, O2, N2O
 Bicarbonate buffering, binding with Hb, plasma
proteins, rapid elimination
 Lethal dose= 5x of air
 Gas Embolism Cntd….
 Etio:
 High insufflating pr(>15)
 Open venous channels following dissection or trauma
 During application of constant pr pneumoperitoneum
 Verres needle penetrating blood vessel
 Gas Embolism Cntd….
Pathophysiology:
 Size and rate(rapid--- gaslock)
 Patent foramen ovale – emboli to coronary,
brain
 V/Q mismatch : physiologic dead space, hypoxia
 Gas Embolism Cntd….
• Early clues:
– Falling BP
– Desaturation
– etCO2- dec
– Millwheel murmur
– Cyanosis
 Gas Embolism Cntd….

• Diag: detection of gas emboli in rt heart or physiologic

changes.
• <0.5ml/kg of air
– Changes in doppler sounds
– ↑mean Pulm Art Pr
• 2ml/kg of air
– Tachycardia, arrhythmias, hypotension,
↑CVP,mill wheel murmur, cyanosis, Rt heart
strain
 Gas Embolism Cntd….
• Pulm edema: early sign
• ↓PETCO2
– ↓cardiac output
– ↑physiologic dead space
– Initial increase in CO2 excretion
• Aspiration of foamy blood from central
venous line.
 Treatment of CO2 embolism

 Stop& release pneumoperitoneum

 Steep head down and left lateral decubitus (durant) position
 100% O2
 Hyperventilation
 Central venous line – aspirate gas
 Foamy blood
 External cardiac massage – break gas into small bubbles
 Cardiopulm bypass
 Hyperbaric O2 t/t: if cerebral gas embolism
 Ac hypotension,hypoxemia & CV
collapse
 D/D:
1.Reflex inc in vagal tone
2.IVC compression
3.Hemorrhage
4.Pneumothorax
5.Venous gas embolism
6.Hypercarbia
7.Rapid CO2 exsufflation
 Risk of aspiration
• higher risk
• But:
• inc IAP l/t changes in LES.
• Head down posn
No increased risk
 Hemodynamic effects
• Causes:
– Pneumoperitoneum
– Position
– Anaesthesia
– Hypercapnia
– Reflex changes in vagal tone & arryth
 Hemodynamic changes d/t
pneumoperitoneum
• Initial inc in venous return(IAP <10)
• Dec venous return
confirmed by:
• TEE(LVEDV)
• Low ANP,despite inc in pulm capi occlusion pr
Attenuated by:
• Fluid loading
• Head down before insufflation
• Preventing pooling with
– intermittent sequential pneumatic compression device or
– wrapping legs with elastic bandages.
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
• Hemodynamic perturbations occur mainly at
the beginning of peritoneal insufflation.
• Fall in C.O- 10-30% f/b inc d/t surgical stress.
• EF- no change
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
• SVR-
– inc d/t mech & neurohumoral factors(esply
vasopressin)
– Affected by pt position
• Head dwn:attenuates
• Head up:aggravates
– Correction:
• Vasodilating anaesthetic agents eg iso
• Direct vasodilators:NTG, Nicardipine
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
• thus,arterial pressure inc but C.O falls.
• Use of α2-adrenergic agonists such as clonidine or
dexmedetomidine and β-blocking agents reduces
hemodynamic changes and anesthetic requirements.
• Use of high doses of remifentanil almost completely
prevents the hemodynamic changes
• Minor changes in heart transplant pt with good
veentri fn
• Well tolerated by morbid obese
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
• Lower limb venous stasis
– Inc IAP & head up pos
– Literature : laparoscopy no ↑in DVT
• Renal eff:
– ↓urine output and GFR, inc renal vasc resis
• +/- splanchnic & hep blood flow
• IOP- no eff
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
• Neurologic eff:
– Inc cerebral blood flow
– Inc ICT
– Dec CPP
o Also d/t
– hypercapnia,
– Head low
– Inc SVR
 Hemodynamic changes d/t
pneumoperitoneum Cntd….
 Arrhythmias
 ↑Vagal tone (sudden peritoneum stretch, electrocoagulation of
fallopian tubes) → bradycardia, arrhythmias, asystole
 Vagal stimulation when low level anesthesia, or pt on B-
blockers.
t/t: stop insufflation
Atropine
Deepen aneasthesia after recovery of H.R
Other causes:
 Sympathetic stimulation d/t hypercapnia & volatile agents
 Gas embolus
 Positioning effects

• Dep on: pos & steepness of tilt.

Head down :
• CVS-↑CVP and cardiac output
– Affect patients with coronary artery disease esply
poor ventri fn l/t inc myocardial O2 demand
– Elevation intraocular venous pressure(worsen acute
glaucoma)
 Positioning effects Cntd…
– Dec transmural pr in pelvic viscera, reduc bld loss
but,
– Increase risk of gas embolism
RESPI
– Atelectasis
– Decreased FRC, total lung volume, compliance
– Endobronchial intubation
– More in obese, elderly, debilitated
 Positioning effects Cntd…

NERVE INJURY
– Avoid Overextension of arm.
– Shoulder braces not impinge on the brachial
plexus.
– Lower extremity neuropathies (e.g., peroneal
neuropathy, meralgia paresthetica, femoral
neuropathy) have been reported after
laparoscopy.
 Positioning effects Cntd…

• Head up
– ↓venous return →↓cardiac output and BP
– Favorable for respi
– Securely strap- prevent slipping
 Positioning effects Cntd…

• Lithotomy
– More venous stasis(with knees flexed)
CAUTION:
– legs freely supported, not tight
– no pressure on popliteal fossa
– Protect Common peroneal nerve
– If prolonged- lower extremity compartment
syndrome.
 Hemodynamic changes d/t
hypercapnia

• Sympathetic N.S stimulation l/t inc in

HR,BP,myocardial contractility & arrythmias.
• Sensitizes myocardium to Cch
 Laparoscopy during Pregnancy
• Common non obs surgeries during preg:
– Adnexal surgery
– Appendicectomy
– Cholecystectomy
• Risk of miscarriage, premature labour, fetal
acidosis,damage to gravid uterus
• Adv:
– Less expo of fetus to potentially toxic agents
– Smaller incision- less pain & analgesics
– Rapid recovery & mobilization
 Laparoscopy during Pregnancy Cntd….
• Maternal normocapnia: fetal placental perfusion pressure, blood
flow, pH unaffected
• Capno guides ventillation(controlled hyperventillation as maternal
respi alkalosis cs dec uteroplacental perfusion)
• Similar hemodynamic changes
 Laparoscopy during Pregnancy Cntd….
 Recommendations:
 2nd trimester <23 wk, minimize preterm labor, adequate working
room,organogenesis complete
 Debatable use of tocolytics to arrest preterm labor-isoxsuprine or terbutaline
 Pneumatic compression stocking
 RSI with aspiration prophylaxis
 Position with uterine displacement
 Orogastric tube
 Limit IAP to 12-15mmHg
 Open laparoscopy to avoid damaging uterus
 Fetal monitoring with transvaginal ultrasonography
 Ensure adequate maternal oxygenation
 Mechanical ventilation to maintain physiologic maternal alkalosis

 gasless lap using epidural anaesthsia

 Laparoscopy in children
• Respi: same changes
PetCO2 s/t overestimates PaCO2
• CVS: same
• Oliguria/ anuria: reversible after desufflation
 Contraindications of lap
Relative CI
– Raised ICT(tumor,hydrocephalus,head trauma)
– VP or PJ shunts( if no unidirectional valve)
– Hypovolemia
– CHF
– Severe cardiopulm disease
– coagulopathy
 Anesthesia for laparoscopy
Preop evaluation:
History & baseline investigations
• h/o GE reflux- preop PPI
• DVT prophylaxis- heparin or LMWH
• Special consideration for pt with:
– History or ECG s/o heart disease
– Renal failure
– Respi disease
 Premedication
• Depends on:
– Dur of lap
– Outpatient setting(quick recovery)
• Preop NSAIDS(dec post op pain & opiate
requirements)
• Preop clonidine & dexmedetomidine(dec intra
op stress resp& improve hemody stability)
 Positioning
• Empty bladder before lap
• Prevent nerve injury
– Padding
– Shoulder braces placed overlying coracoid process
• Tilt
– not exceed 15-20 degrees
– Slow & progressive, avoid sudden hemody & respi
changes
 Monitoring
• BP, HR,ECG,etCO2,pulse oxy,Paw
• IAP
• Cardiac disease:
– ABG
– TEE(if severe)
• Pregnant:
– Fetal monitoring
 Anesthesia for laparoscopy

• GA with ET & controlled venti : safest technique

compared to local, regional
• But now LMA-P &supreme: equally safe as ET if
correct position
• Choice of anaesthetic: similar pt outcome with all
– Avoid Halo
– Propofol: fewer postop s/e
 Anesthesia for laparoscopy Cntd….
• Mask venti : stomach aspirated before trocar
place(avoid gastric perf)
• Check ET placement after positioning
• Maintain PetCO2- 35mmHg
• Increase RR rather than tidal volume in COPD,
spontaneous pneumothorax, bullous emphysema
(to avoid inc in alveolar inflation & reduce risk
of pneumothorax)
 Anesthesia for laparoscopy Cntd….

• To reduce hemody repercussions esply in

cardiac pt, infusion of:
– Vasodilators egNicardipine
– a2 agonists
– Remifentanyl
• IAP: as low as possible
– Not more than 20
– Ensure deep plane of anaesthesia
 Anesthesia for laparoscopy Cntd….

• Liberal periop IV fluids

– Dec hemody changes
– Dec PONV
– Better postop recovery
• Atropine: must
 Recovery & post op monitoring
• Post op: hemodynamic changes(eg.↑SVR)
outlasts the release of pneumoperitoneum
• Increased O2 demand after laparoscopy(O2 must
even for healthy pt)
• Higher RR and PETCO2 higher after laparoscopy
• Prevention & t/t of nausea, vomiting & pain
 Pt with heart disease

• Hemodynamic chnges: similar but more

marked.
• Hypovolemic Pts are at higher risk i.e:
– Low pre op CO,CVP
– High MAP,SVR
 Pt with heart disease Cntd….
• Preoperative Evaluation: Echo
If LVEF< 30%:
– Intraoperative monitoring
•  Intra-arterial line
• Continous pressure monitoring
•  Pulmonary artery catheter?   
• Transesophageal echocardiography   
• Continuous ST-segment analysis?
• Gasless laparoscopy?  
• Laparotomy?
 Pt with heart disease Cntd….
• Intraoperative Management
– Hemodynamic optimization before
pneumoperitoneum (preload augmentation)
– Slow insufflation
– Low intra-abdominal pressure
– CVP,PCOP not reliable
– Patient tilt after insufflation
– Anesthesia: remifentanil,vasodilating anesthetics
– Vasodilators (nicardipine, nitroglycerin),
 Pt with heart disease Cntd….
– cardiotonic agents eg dobu to improve
ventricular fn
– Diuretic+/- at end of surgery
– Experienced surgeon
• Postoperative Care
– chances of CHF in early post op period
– Slow recovery from anesthesia (benefit of clonidine)
 Pt with Renal failure:

– care to optimise hemodynamics intrap

– Avoid nephrotoxic drugs
 pt with respi disease
 laparoscopy preferable to laparotomy:
 reduced postop respi dysfunction,counterbalances the risk
of pneumothorax during pneumoperitoneum and the risk
of inadequate gas exchange from    mismatching.
 Preop optimization:
Bronchodilator
t/t of super added infection
Chest physiotherapy
 Intraop:
Adequate expi time(to prevent auto-peep)
Paw high-limit hyperventillation, accept modest hypercapnia
etCO2 not correct estimate, gradient inc
 Role of LMA-p
 fewer cases of sore throat
 alternative to endotracheal intubation
 Effective protectn of airway from aspiration if
properly positioned
 allows controlled ventillation
 accurate PETCO2.
 Lma-p Cntd….
• LMA-P guarantees seal upto Paw 30cm H2O
• Thus,GA +spont breathing+ no intubation,
safe in:
– Short procedures
– Low IAP
– Small deg tilt
 Role of N2O
• Concerns:
– Bowel distension during surgery
– Inc PONV
• No conclusive evidence
 Local Anaesthesia for lap
• Benefits
– Quick recovery
– Dec PONV
– Early diag of complications
– Few hemody changes
 Local Anaesthesia for lap Cntd….
• Disadv:
– Pt anxiety,
– Pain & discomfort during organ manipulation
• Thus, IV sedation
• Pneumoperotoneum +sedation l/t
Hypoventillation & arterial desaturation
 Regional Anaesthesia for lap
• CSE with head-down position: for
gynecologic laparoscopy w/o major
impairment of ventilation.
• Lap cholecystectomy:using epidural
anesthesia in COPD patients.
 Regional Anaesthesia for lap Cntd….
• Benefits:
– As for LA
– Reduced metabolic response
– Reduces the need for sedatives and narcotics
– better muscle relaxation
– can be proposed for laparoscopic procedures
other than sterilization.
 Regional Anaesthesia for lap Cntd….
• Disadv:
– As for LA
– Shoulder-tip pain from diaphragmatic irritation
– discomfort from abdominal distention
– Necessary Extensive sensory block (T4-L5) l/t
discomfort.
 Regional Anaesthesia for lap Cntd….
• Epidural opiates or clonidine, or both, may
help to provide adequate analgesia.
• Hemodynamic effects of pneumoperitoneum
not studied.
• Adequate relief of pain and discomfort in
case of gasless laparoscopy, thus avoiding
most of the s/e of CO2 pneumoperitoneum.
 Post op pain:
 Causes:
 Incisional pain(less)
 Visceral pain
 Shoulder tip pain
 Residual CO2 (careful evacuation)
 t/t: multimodal
 Suction to remove any blood, insufflted gas, instillation of normal saline to dilute
pain mediators
 Infilteration:controversial
 Mesosalpinx block(lap sterilization)
 Local spraying of rt diaphragmatic crus
 Preop NSAIDS
 COX-2 inh
 Opioids
 Dexa
 PONV
Incidence: 40-75%
• Opioids- inc
• Dec with:
– Propofol
– Gastric aspiration
– Periop liberal IVF
– Droperidol,ondansetron
– Transdermal scopolamine(out pt)
 Alternatives to
pneumoperitoneum
• Gasless lap
• Hand assissted lap
 GASLESS LAP
• Abdominal wall lift
• Benefits:
– Avoids hemody & respi ch d/t inc IAP
– Compli d/t CO2 insufflation
– Port site mets reduced
• Disadv:
– Compromised surgical exposure
– Technical difficulty
**severe cardiac & pulm disease
**combi of abdo lift & low pressure CO2
pneumo(5mmHg)--- improved surgical condi
 latest aspects
• 3 D images
• Flexible laparoscopes
• Robotic surgery
Thank you