Anaesthesia for laparoscopy

ANAESTHESIA FOR
LAPAROSCOPY
DR KIRAN RAJAGOPAL DA DNB.
ANAESTHESIOLOGIST

LAPAROSCOPY – OVERVIEW
 MINIMAL INVASIVE SURGICAL PROCEDURE WHICH ALLOWS 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 SAFE MANIPULATION OF INSTRUMENTS AND
ORGANS.
 Term coined by HANS CHRISTIAN JACOBAEUS in 1910.
 CO2 WAS USED by RICHARD ZOLLIKOFER IN 1924

WHY CARBON DIOXIDE ??
• NON COMBUSTIBLE
• MORE SOLUBLE IN BLOOD
WHICH INCREASES THE SAFETY
MARGIN AND DECREASES THE
CONSEQUENCES OF GAS EMBOLISM.
• RAPIDLY ELIMINATED BY
LUNGS
• INERT & NOT IRRITANT TO
TISSUES
DISADVANTAGES
HYPERCARBIA
ACIDOSIS
SYMPATHETIC STIMULATION
NEED FOR HYPERVENTILATION

OTHER GASES
• AIR
• OXYGEN
• ARGON
• HELIUM
IDEAL GAS FOR
PNEUMOPERITONEUM
LIMITED SYSTEMIC ABSORPTION
LIMITED SYSTEMIC EFFECTS IF
ABSORBED
RAPID EXCRETION
HIGH SOLUBILITY IN BLOOD
SHOULD NOT SUPPORT
COMBUSTION
COLOURLESS, INERT, NON-
EXPLOSIVE
READILY AVAILABLE,
NON EXPLOSIVE, NONTOXIC

 AIR WAS THE FIRST GAS TO BE USED
POORLY SOLUBLE IN BLOOD CAUSING EMBOLIC PHENOMENON.
 O2 DISCARDED BECAUSE OF BEING COMBUSTIBLE
 N2O ALSO SUPPORTED COMBUSTION , WHEN MIXED WITH THE
METHANE IN THE BOWELS.
 INERT GASES LIKE HELIUM, ARGON & XENON ARE
EXPENSIVE AND CAUSE GAS EMBOLISM.

GASLESS LAPAROSCOPY
 THE PERITONEAL CAVITY IS EXPANDED USING ABDOMINAL WALL LIFT
OBTAINED WITH A FAN RETRACTOR.
 AVOIDS THE HEMODYNAMIC AND RESPIRATORY REPERCUSSIONS OF
INCREASED IAP AND THE CONSEQUENCES OF THE USE OF CO2.
 RENAL AND SPLANCHNIC PERFUSION IS NOT ALTERED.
 APPEALING FOR PATIENTS WITH SEVERE CARDIAC OR PULMONARY DISEASE.
 HOWEVER, GASLESS LAPAROSCOPY COMPROMISES SURGICAL EXPOSURE AND
INCREASES TECHNICAL DIFFICULTY.

ADVANTAGES
• MINIMIZES SURGICAL INCISION AND STRESS RESPONSE
• DECREASES POSTOPERATIVE PAIN AND OPIOID REQUIREMENTS
• PRESERVES DIAPHRAGMATIC FUNCTION
• IMPROVES POSTOPERATIVE PULMONARY FUNCTION
• EARLIER RETURN OF BOWEL FUNCTION
• FEWER WOUND RELATED COMPLICATIONS
• EARLIER AMBULATION
• SHORTER HOSPITAL STAYS
• EARLY RETURN TO NORMAL ACTIVITIES AND WORK

DISADVANTAGES
 MORE EXPENSIVE
 MORE OPERATING TIME
 DIFFICULT IN COMPLICATED CASES
 POTENTIAL FOR MAJOR COMPLICATIONS IN INEXPERIANCED HAND

CONTRAINDICATIONS
EACH PATIENT EVALUATED ON A RISK BENEFIT BASIS
GENERAL CONTRAINDICATIONS
 RAISED ICP
 HYPOVOLEMIA
 RL SHUNTS
 PATENT FORAMEN OVALE

REDUCED WOUND
INFECTION
FASTER RECOVERY
REDUCED MORBIDITY
REDUCED PAIN
VISCERAL & VASCULAR DAMAGE
POSITIONAL COMPLICATION
A/C KIDNEY INJURY
CARDIO CEREBRAL INSUFFICIENCY
ATELECTASIS
GAS EMBOLISM
WELL LEG COMPARTMENT SYNDROME

LAPAROSCOPY – ANAESTHETIC
CONCERNS
 CO2 PNEUMO PERITONEUM
 PATIENT POSITIONING
 SURGICAL COMPLICATIONS
 DIFFICULTY IN ESTIMATING BLOOD LOSS
 PATIENT SPECIFIC

INTRA-ABDOMINAL
PRESSURE(IAP)
• IAP IS THE STEADY PRESSURE WITHIN THE CLOSED ABDOMINAL
CAVITY.
• NORMAL VALUES OF IAP ARE 0-5 MMHG.
• VALUES MORE THAN 12-14 MMHG COMPROMISES VENOUS
RETURN.

PNEUMOPERITONEUM
INITIAL ACCESS NECESSARY FOR CO2 INSUFLATION COULD BE
ACHIEVED EITHER THROUGH
 A BLIND INSERTION OF A VERESS NEEDLE
THAT CONSISTS OF A BLUNT TIPPED, SPRING LOADED INNER
STYLET AND SHARP OUTER NEEDLE THROUGH A SMALL
SUBUMBILICAL INCISION
OR
 A TROCAR INSERTED UNDER DIRECT VISION.

PNEUMOPERITONEUM
• A VARIABLE LOW ELECTRONIC INSUFLATOR THAT AUTOMATICALLY
TERMINATES GAS FLOW AT A PRESET INTRAABDOMINAL PRESSURE
IS USED TO ACHIEVE PNEUMOPERITONEUM.
• PRESET PRESSURES OF 15 MM HG OR LESS ARE SAFEST TO
MAINTAIN PNEUMOPERITONEUM AND ALLOW PERFORMANCE OF
LAPAROSCOPIC TECHNIQUES.
• THE GAS IS INTRODUCED AT 21°C WITH ALMOST ZERO PERCENT
HUMIDITY AND 14°C LOWER THAN BODY TEMPERATURE
• INITIAL FLOW : 4-6 L/MIN.
• MAINTENANCE : 200-400 ML/MIN

WHAT HAPPENS
VOLUME OF THE ABDOMEN INCREASES,
ABDOMINAL WALL COMPLIANCE DECREASES
INTRA-ABDOMINAL PRESSURE CLIMBS.
WHEN THE IAP EXCEEDS PHYSIOLOGICAL THRESHOLDS, BLOOD FLOW IN
INDIVIDUAL ORGAN SYSTEMS BECOME COMPROMISED, POTENTIALLY
INCREASING PATIENT’S MORBIDITY AND MORTALITY

PHYSIOLOGICAL CHANGES
DURING LAPAROSCOPY

CVS EFFECTS
PNEUMOPERITONEUM POSITION
HYPERCAPNIA ANAESTHESIA
VAGAL
TONE

IAP
INTRATHORACIC STIMULATION OF
PRESSURE PERITONEAL
RECEPTORS
IVC PERIPHERAL VENOUS
COMPRESSION POOLING RESISTANCE
ACTIVATION OF SNS/RAAS
RELEASE OF CATECHOLAMINES
VENOUS RETURN VASOPRESSIN
SVR BP
CARDIAC OUTPUT
INCREASED VASCULAR
RESISTANCE OF ABDOMINAL ORGANS

INCREASED SVR
 DUE TO NEUROHUMERAL RESPONSES
 PLASMA VASOPRESSIN LEVELS PARALLELS INCREASE IN SVR
 HYPERCAPNEA  DECREASE IN SVR , INCREASE IN PVR
 NEUROENDOCRINE RESPONSES >> HYPERCAPNEA INDUCED DEC IN SVR
 NORMAL HEART TOLERATES INC IN AFTER LOAD
 BUT DELETIRIOUS FOR CARDIAC PATIENTS
 INCRESE IN PVR DELETERIOUS FOR P HTN PATIENTS

DECREASED CO
EXAGGERATED IF
• HYPOVOLEMIC
• HEAD UP POSITION
• HAEMODYNAMIC CHANGES OCCUR AT BEGINNING OF PERITONEAL
INSUFFLATION
• CO LATER BECOMES NORMAL DUE TO SURGICAL STRESS

CARDIAC FILLING PRESSURES
• PARADOXICAL INCREASE
• DUE TO INC INTRA THORACIC PRESSURE DUE TO
PNEUMOPERITONEUM
• CVP, RT ATRIAL PRESSURE,PULM ARTERY OCCLUSION PRESSURE
 NOT RELIABLE

EJECTION FRACTION
• NO SIGNIFICANT DECREASE TILL 15 MMHG
HEART RATE
• REMAINS SAME OR SLIGHT INCREASE

WHAT CAN BE DONE ???....
VR & CO INCREASE CIRCULATING VOLUME BEFORE
PNEUMOPERITONEUM
PERIPHERAL POOLING FLUID LOADING/ HEAD DOWN BEFORE
PNEUMO/ IPC DEVICES
SVR VASODIALTORS . INHALATIONAL/ NTG/ NICARDIPINE
HAEMODYNAMIC CLONIDINE, DEXMED, BETABLOCKERS
RESPONSES

CARDIAC ARRYTHMIAS
OCCURS DURING INSUFFLATION
BRADY/ARRYTHMIA/ASYSTOLE
CAUSES
1. REFLEX INCREASE IN VAGAL
TONE DUE TO SUDDEN
STRETCHING OF PERITONEUM
2. LIGHT PLANE OF ANAESTHESIA
3. EMBOLISM
4. HYPERCARBIA
5. HYPOXIA
6. PREEXISTING CARDIAC
DISEASE
 REVERSIBLE EVENT
 STOP INSUFFLATION
 ATROPINE
 DEEPEN PALNE AFTER
HR BECOMES NORMAL

PNEUMOPERITONEUM IN CARDIAC
PATIENTS
 PATIENTS (ASA CLASS III OR IV) WHO ARE VOLUME DEPLETED
EXPERIENCE THE MOST SEVERE HEMODYNAMIC CHANGES.
 PREOPERATIVE PRELOAD AUGMENTATION OFFSETS THE
HEMODYNAMIC EFFECT OF PNEUMOPERITONEUM.
 INTRAVENOUS NITROGLYCERIN, NICARDIPINE, OR DOBUTAMINE HAS
BEEN USED TO MANAGE THE HEMODYNAMIC CHANGES INDUCED BY
INCREASED IAP.
 ADV OF NICARDIPINE  ARTERIAL VASODILATOR . VR PRESERVED

CARDIOVASCULAR COLLAPSE
DURING LAPAROSCOPY
• PROFOUND VASOVAGAL REACTION
• CARDIAC DYSRHYTHMIAS
• EXCESSIVE INTRAABDOMINAL PRESSURE
• TENSION CAPNO(PNEUMO)THORAX
• CARDIAC TAMPONADE
• SIGNIFICANT GAS EMBOLISM
• ACUTE BLOOD LOSS
• MYOCARDIAL ISCHEMIA/INFARCTION
• SEVERE RESPIRATORY ACIDOSIS (HYPERCAPNIA)
• ANESTHETIC DRUG RELATED

RESPIRATORY EFFECTS
 DIAPHRAGM ELEVATED
 REDUCED
THORACOPULMONARY
COMPLIANCE
 FRC REDUCED
 BASAL ATELECTASIS
 INCRESAED MIN VENTILATION
 INC AIRWAY PRESSURE
 PULMONARY RESISTANCE
INCREASE
ELEVATED DIAPHRAGM
V/Q MISMATCH
POSITION

HYPERCARBIA
 CO2 IS ABSORBED FROM THE PERITONEAL CAVITY AND CARRIED BY BLOOD
THROUGH THE SYSTEMIC AND PORTAL VEINS AND EXCRETED VIA THE
LUNGS.
 INCREASES PULMONARY EXCRETION OF CO2 (VCO2) AND PACO2.
 ASBORPTION DEPENDS ON THE GASES DIFFUSIVITY, THE ABSORPTION AREA,
AND VASCULARITY OF INSUFLATION SITE. &
EXTRA OR INTRAPERTONEAL INSUFFLATION

PACO2 INCREASE
INCREASE OF PACO2
 ABSORPTION OF CO2 FROM THE PERITONEAL CAVITY,
 IMPAIRMENT OF PULMONARY VENTILATION AND PERFUSION BY
1. ABDOMINAL DISTENTION
2. PATIENT POSITION
3. VOLUME-CONTROLLED MECHANICAL VENTILATION
CARBON DIOXIDE ABSORPTION IS GREATER DURING
EXTRAPERITONEAL INSUFLATION THAN DURING INTRAPERITONEAL
INSUFLATION.

 THE CO2 ABSORPTION REACHES A PLATEAU WITHIN 10 TO 15
MINUTES AFTER INITIATION OF INTRAPERITONEAL INSUFLATION
AND NOT INLUENCED BY THE DURATION OF SURGERY.
 CONTINUES TO INCREASE PROGRESSIVELY THROUGHOUT
EXTRAPERITONEAL CO2 INSUFLATION.
 ANY SIGNIFICANT INCREASE IN PACO2 AFTER THIS PERIOD  CO2
SUBCUTANEOUS EMPHYSEMA.
 INCREASE IN PACO2 DEPENDS ON THE IAP.

• IF CONTROLLED VENTILATION IS NOT ADJUSTED IN RESPONSE TO
THE INCREASED DEAD SPACE, ALVEOLAR VENTILATION WILL
DECREASE AND PACO2 WILL RISE.
• CORRECTION OF INCREASED PACO2 CAN BE ACHIEVED BY A 10% TO
25% INCREASE IN ALVEOLAR VENTILATION.

CAPNOGRAPHY DURING
LAPAROSCOPY
 NON-INVASIVE MONITOR OF PACO2 DURING CO2 INSUFFLATION.
 HELPS IN DETECTION OF ACCIDENTAL INTRAVASCULAR
INSUFFLATION OF CO2
ETCO2 INCREASES IN
ENDO-BRON.INTUBATION,
SUB. CUT.EMPHYSEMA
CAPNOTHORAX
DECREASES IN
PNEUMOTHORAX
CO2 EMBOLISM

 MEAN GRADIENTS (ΔA-ETCO2) DO NOT CHANGE SIGNIFICANTLY
DURING PERITONEAL INSUFFLATION OF CO2
 LESS CORRELATION BETWEEN PACO2 AND ETCO2 IN THOSE WITH
IMPAIRED CO2 EXCRETION CAPACITY, AND CARDIOPULMONARY
DISTURBANCES.

RESPIRATORY COMPLICATIONS
 CO2 SUBCUTANEOUS EMPHYSEMA
 PNEUMOTHORAX
 ENDOBRONCHIAL INTUBATION
 GAS EMBOLISM

CO2 SUBCUTANEOUS
EMPHYSEMA
 ACCIDENTAL EXTRAPERITONEAL INSUFFLATION
 EXTENSIVE SUBCUTANEOUS EMPHYSEMA CAN DEVELOP INVOLVING
THE ABDOMEN, CHEST, NECK, AND GROIN.
 IF THE EMPHYSEMA EXTENDS TO THE CHEST WALL AND THE NECK,
THE CO2 CAN TRACK TO THE THORAX AND MEDIASTINUM,
CAPNOTHORAX OR CAPNOMEDIASTINUM

 PREDICTORS OF SUBCUTANEOUS EMPHYSEMA
OPERATIVE TIME OF >200 MINUTES AND
USE OF SIX OR MORE SURGICAL PORTS
 ANY INCREASE IN PETCO2 OCCURRING AFTER PETCO2 HAS
PLATEAUED SHOULD SUGGEST THIS COMPLICATION.
 IF THERE IS NECK OR FACE EMPHYSEMA, A CHEST XRAY SHOULD BE
OBTAINED TO RULE OUT CAPNOTHORAX OR CAPNOMEDIASTINUM.

MANAGEMENT
 IN MOST CASES, NO SPECIFIC INTERVENTION IS REQUIRED,
SUBCUTANEOUS EMPHYSEMA RESOLVES SOON AFTER THE ABDOMEN IS
DEFLATED.
SIGNIFICANT HYPERCARBIA DESPITE AGGRESSIVE HYPERVENTILATION
 TEMPORARILY STOP….!
 SUBCUTANEOUS EMPHYSEMA READILY RESOLVES ONCE INSUFFLATION HAS
CEASED.
 RESUMED AFTER CORRECTION OF HYPERCAPNIA USING A LOWER
INSUFFLATION PRESSURE.
 NOT A CONTRAINDICATION FOR TRACHEAL EXTUBATION AT THE
END OF SURGERY

PNEUMOTHORAX
PNEUMOMEDIASTINUM
PNEUMOPERICARDIUM
• MOVEMENT OF GAS DURING THE CREATION OF A
PNEUMOPERITONEUM

CAUSES
 PERITONEAL CAVITY ---POTENTIAL CHANNELS--- PLEURAL
AND PERICARDIAL SACS.
 DEFECTS IN THE DIAPHRAGM OR WEAK POINTS IN THE
AORTIC AND ESOPHAGEAL HIATUS
 PLEURAL TEARS OCCURS DURING LAPAROSCOPIC SURGICAL
PROCEDURES
 RUPTURE OF A LUNG BULLA OR BLEB COULD PRODUCE A
TENSION PNEUMOTHORAX INDEPENDENT OF THE
PNEUMOPERITONEUM

PRESENTATION
 UNDETECTED INTRAOPERATIVELY
 UNEXPLAINED INCREASE IN AIRWAY PRESSURE
 HYPOXEMIA
 HYPERCAPNIA
 SURGICAL EMPHYSEMA
 INEQUALITY IN CHEST EXPANSION
 REDUCED AIR ENTRY
 BULGING DIAPHRAGM
 SEVERE CARDIOVASCULAR COMPROMISE WITH PROFOUND
HYPOTENSION IN TENSION PNEUMOTHORAX
CONFIRMED BY CXR

MANAGEMENT
 DEFLATION OF THE ABDOMEN
 SUPPORTIVE TREATMENT
 CONSERVATIVE IF MINIMUM PHYSIOLOGIC COMPROMISE
 HYPERVENTILATION
 PEEP  REDUCE THE PRESSURE GRADIENT BETWEEN THE ABDOMEN
AND THE THORAX DURING BOTH INSPIRATION AND EXPIRATION
INFLATE THE LUNG
 INTERCOSTAL CANNULA IN SEVERE COMPROMISE ,
 CHEST DRAIN IF REACCUMULATION OCCURS.
 AFTER STABILIZATION  CAN BE RESUMED AT LOWER IAP
OR CONVERSION TO AN OPEN PROCEDURE .
NO PEEP IN BULLAE RUPTURE
THORACOCENTESIS MANDATORY

ENDOBRONCHIAL INTUBATION
CEPHALAD DISPLACEMENT OF
THE DIAPHRAGM DURING
PNEUMOPERITONEUM
CEPHALAD MOVEMENT OF THE
CARINA
ENDOBRONCHIAL INTUBATION.
 DECREASE IN THE OXYGEN
SATURATION
 INCREASE IN PLATEAU
AIRWAY PRESSURE.
 INCREASE IN ETCO2

GAS EMBOLISM
INTRAVASCULAR INJECTION OF GAS DIRECT NEEDLE PLACEMENT
INTO A VESSEL
GAS INSUFFLATION INTO AN ABDOMINAL
ORGAN.
DURING THE INDUCTION OF PNEUMOPERITONEUM
LETHAL DOSE OF EMBOLIZED CO2 IS APPROXIMATELY FIVE TIMES GREATER THAN
THAT OF AIR
EFFECTS DETERMINED BY
SIZE OF BUBBLES
RATE OF INSUFFLATION

RAPID INSUFFLATION OF GAS UNDER
HIGH PRESSURE
GAS LOCK IN THE VENA CAVA AND
RIGHT ATRIUM
OBSTRUCTION TO VENOUS RETURN
WITH A FALL IN CARDIAC OUTPUT
CIRCULATORY COLLAPSE

ACUTE RIGHT VENTRICULAR HYPERTENSION MAY OPEN THE
FORAMEN OVALE, ALLOWING PARADOXICAL GAS EMBOLIZATION
 CARDIAC ARRHYTHMIA,
 HYPOXEMIA,
 HYPOTENSION,
 DECREASE IN ETCO2.
 CEREBRAL CO2 EMBOLISM
ECG 
A RIGHT STRAIN
PATTERN AND
WIDENING OF THE QRS
COMPLEX.

DIAGNOSIS
• DETECTION OF GAS EMBOLI IN
THE RIGHT SIDE OF THE
HEART
• RECOGNITION OF THE
PHYSIOLOGIC CHANGES FROM
EMBOLIZATION
• EARLY EVENTS, OCCURRING
WITH 0.5 ML/KG OF AIR OR
LESS, INCLUDE CHANGES IN
DOPPLER SOUNDS AND
INCREASED MEAN PULMONARY
ARTERY PRESSURE.
• WHEN THE SIZE OF THE
EMBOLUS INCREASES (2 ML/KG
OF AIR)
TACHYCARDIA
CARDIAC ARRHYTHMIAS,
HYPOTENSION,
INCREASED CVP
ALTERATION IN HEART TONES
(I.E., MILLWHEEL MURMUR),
CYANOSIS
ECGCHANGES OF RIGHT-SIDED
HEART STRAIN

MANAGEMENT
 STOP INSUFFLATION
 RELEASE OF PNEUMOPERITONEUM
 STEEP HEAD DOWN . LEFT LATERAL (DURRANT)
 100% O2
 HYPERVENTILATE
 CENTRAL VENOUS/PAC – GAS ASPIRATED
 EXTERNAL CARDIAC MASSAGE – FRAGMENTS EMBOLUS INTO SMALL
BUBBLES
 CPCR
 CPB
 HBO IN CEREBRAL EMBOLUS

HOW DURANT POSITION HELPS
 HEAD-DOWN POSITION KEEPS A LEFT-VENTRICULAR AIR BUBBLE
AWAY FROM THE CORONARY ARTERY OSTIA (WHICH ARE NEAR THE
AORTIC VALVE) SO THAT AIR BUBBLES DO NOT ENTER AND
OCCLUDE THE CORNONARY ARTERIES.
 LEFT LATERAL DECUBITUS POSITIONING HELPS TO TRAP AIR IN THE
NON-DEPENDENT SEGMENT OF THE RIGHT VENTRICLE, PREVENTING
IT ENTERING THE PULMONARY ARTERY & ALSO PREVENTS THE AIR
FROM PASSING THROUGH A PATENT FORAMEN OVALE.

RISK OF ASPIRATION OF GASTRIC
CONTENTS
 AT RISK FOR ACID ASPIRATION SYNDROME
 THE INCREASED IAP RESULTS IN CHANGES OF THE LOWER
ESOPHAGEAL SPHINCTER THAT ALLOW MAINTENANCE OF THE
PRESSURE GRADIENT ACROSS THE GASTROESOPHAGEAL JUNCTION
AND THAT REDUCE THE RISK OF REGURGITATION.
 THE HEAD-DOWN POSITION SHOULD HELP TO PREVENT ANY
REGURGITATED FLUID FROM ENTERING THE AIRWAY.

REGIONAL PERFUSION
 INCREASED CEREBRAL PERFUSION AND INTRACRANIAL PRESSURE
 CAUTION IN PATIENT WITH BRAIN TUMOR OR
VENTRICULOPERITONEAL SHUNT
 DECREASED SPLANCHNIC BLOOD LOW
 DECREASED HEPATIC BLOOD LOW
 VARIABLE (DECREASED OR NO CHANGE) IN BOWEL PERFUSION,
MECHANICAL PNEUMOPERITONEUM COMPRESSION BALANCED BY
HYPERCARBIC VASODILATATION )

 REDUCED RENAL PERFUSION AND URINE OUTPUT (REDUCED DURING
PNEUMOPERITONEUM/RECOVERY FOLLOWING DELATION)
 THE URINE OUTPUT GENERALLY NORMALIZES FOLLOWING
PNEUMOPERITONEUM DEFLATION WITH NO CONSEQUENT RENAL
DYSFUNCTION.
 INCREASED IAP AND THE HEAD-UP POSITION RESULT IN LOWER
LIMB VENOUS STASIS.
 DECREASED FEMORAL VEIN FLOW
 INCREASED POTENTIAL FOR DEEP VEIN THROMBOSIS AND
PULMONARY EMBOLISM

RENAL FUNCTION DURING LAPAROSCOPY
 URINE OUTPUT REDUCED DURING LAPAROSCOPY
DECREASED RENAL BLOOD LOW
COMPRESSION OF RENAL PARENCHYMA
NEUROENDOCRINE
 FACTORS THAT INFLUENCE U/O
PREEXISTING RENAL COMPROMISE
LONGER INSUFFLATION TIMES
HIGH INTRAABDOMINAL PRESSURES
 INTRAOPERATIVE OLIGURIA REVERSIBLE WITHIN 2 H
POSTOPERATIVELY
 IAP <15 MM HG SAFE EVEN IN PATIENTS WITH RENAL DISEASE

PROBLEMS RELATED TO PATIENT
POSITION
PATIENT POSITIONING DEPENDS ON THE SITE OF SURGERY
 HEAD-DOWN TILT  PELVIC AND LOWER ABDOMINAL SURGERY
 HEAD-UP POSITION  UPPER ABDOMINAL SURGERY.
POSITIONS MAY BE RESPONSIBLE FOR, OR CONTRIBUTE TO, THE
DEVELOPMENT OF PATHOPHYSIOLOGIC CHANGES OR INJURY
DURING LAPAROSCOPY
THE STEEPNESS OF THE TILT ALSO AFFECTS THE MAGNITUDE OF THESE
CHANGES.

CVS EFFECTS
NORMOTENSIVE IN HEAD DOWN
CVP CO
SYSTEMIC VASODILATATION , BRADYCARDIA
EXAGGERATED CHANGES IN CARDIAC PATIENTS
CARDIAC WORK & MVO2
PROLONGED HEAD DOWN  CEREBRAL & UPPER AIRWAY EDEMA
INCREASE IOP

HEAD UP
VENOUS RETURN
CO MAP
STEEPER THE TILT CARDIAC OUTPUT
VENOUS STASIS IN HEAD UP , LITHOTOMY

RESPIRATORY
 HEAD DOWN  FACILITATES THE DEVELOPMENT OF ATELECTASIS.
DECREASES IN THE FRC
TOTAL LUNG VOLUME
PULMONARY COMPLIANCE
 MORE MARKED IN OBESE, ELDERLY, AND DEBILITATED PATIENTS.
 IN HEALTHY PATIENTS NO MAJOR CHANGES ARE SEEN.
 THE HEAD-UP POSITION IS USUALLY CONSIDERED TO BE MORE
FAVORABLE TO RESPIRATION

NERVE INJURY
 POTENTIAL COMPLICATION DURING THE HEAD-DOWN POSITION.
 OVEREXTENSION OF THE ARM MUST BE AVOIDED.
 SHOULDER BRACES SHOULD BE USED WITH GREAT CAUTION AND MUST NOT
IMPINGE ON THE BRACHIAL PLEXUS.
 LOWER EXTREMITY NEUROPATHIES (E.G., PERONEAL NEUROPATHY,
MERALGIA PARESTHETICA, FEMORAL NEUROPATHY) HAVE BEEN REPORTED
AFTER LAPAROSCOPY.
 THE COMMON PERONEAL NERVE IS PARTICULARLY VULNERABLE AND MUST
BE PROTECTED WHEN THE PATIENT IS PLACED IN THE LITHOTOMY
POSITION.
 PROLONGED LITHOTOMY POSITION CAN RESULT IN LOWER EXTREMITY
COMPARTMENT SYNDROME.

WELL LEG COMPARTMENT
SYNDROME
 COMPLICATION OF PROLONGED STEEP TRENDELENBERG POSITION
 CAUSES
IMPAIRED PERFUSION TO LOWER LIMBS
VENOUS COMPRESSION BY STIRRUPS
FEMORAL VENOUS DRAINAGE DUE TO PNEUMOPERITONEUM
 PRESENTATION
DISPROPORTIONATE LOWER LIMB PAIN AFTER SURGERY
RHABDOMYOLYSIS
MYOGLOBIN ASSOCIATED RENAL FAILURE

 RISK FACTORS
SURGERY > 4 HRS
MUSCULAR LOWER LIMBS
OBESITY
PERIPHERAL VASCULAR DISEASE
HYPOTENSION
STEEP TRENDELENBERG
 PREVENTION
IPC /COMPRESSION STOCKINGS
HEEL –ANKLE SUPPORTS (OVER CALF KNEE SUPPORTS)
MOVING PATIENTS LIMBS DURING SX
PULSE OXIMETER IN GREAT TOE TO ASSESS ADEQUECY OF
LOWER LIMB PERFUSION

POST OP BENEFITS
STRESS RESPONSE
 LOW PLASMA CONCENTRATIONS OF C-REACTIVE PROTEIN AND INTERLEUKIN-
6 – LESS TISSUE DAMAGE
 REDUCED METABOLIC RESPONSE ( HYPERGLYCEMIA ,LEUKOCYTOSIS)
 NITROGEN BALANCE AND IMMUNE FUNCTION BETTER PRESERVED.
 AVOIDS PROLONGED EXPOSURE AND MANIPULATION OF THE INTESTINE
 POSTOPERATIVE ILEUS AND FASTING, DURATION OF INTRAVENOUS
INFUSION, AND HOSPITAL STAY ARE SIGNIFICANTLY REDUCED

POST OP PAIN
 REDUCTION IN POSTOPERATIVE PAIN AND ANALGESIC
 PREOPERATIVE NSAIDS AND COX -2 INHIBITORS DECREASES PAIN
 VISCERAL TYPE OF PAIN
 SHOULDER TIP PAIN
 MULTIMODAL ANALGESIA
PRE OP NSAIDS
LOCAL INFILTRATION
INTRAPERITONEAL LA
OPIATES
COMPLETE EVACUATION
OF CO2 PNEUMOPERITONEUM

PULMONARY DYSFUNCTION
 UPPER ABDOMINAL SURGERY  POSTOPERATIVE CHANGES IN PULMONARY
FUNCTION
 LESS SEVERE AND RECOVERY IS QUICKER AFTER LAPAROSCOPY.
 GREATER REDUCTIONS IN EXPIRATORY VOLUMES AND SLOWER RECOVERY
OF PULMONARY FUNCTION MAY BE SEEN IN
OLDER PATIENTS
OBESE PATIENTS
SMOKERS
PATIENTS WITH COPD

PONV
 LAP – RISK FACTOR FOR PONV
 PERI OP OPIODS – RISK FACTOR
 PREVENTION
PROPOFOL ANAESTHESIA
5 HT3 ANTAGONISTS

LAP IN PREGNANCY
 INCREASES THE RISK OF MISCARRIAGE OR PREMATURE LABOR AND THE RISK
OF DAMAGING THE GRAVID UTERUS.
 AVOIDED BY ALTERNATIVE ENTRY SITES FOR THE VERESS NEEDLE AND
TROCARS.
 CO2 PNEUMOPERITONEUM INDUCES SIGNIFICANT FETAL ACIDOSIS.
 FETAL HEART RATE AND ARTERIAL PRESSURE INCREASE, BUT MINIMAL.
 PROVIDED MATERNAL PACO2 IS AT NORMAL LEVELS,
FETAL PLACENTAL PERFUSION PRESSURE AND BLOOD FLOW,
PH, AND BLOOD GAS TENSIONS ARE UNAFFECTED BY INSUFFLATION OR
DESUFFLATION.
 HEMODYNAMIC CHANGES OF PNEUMOPERITONEUM ARE SIMILAR IN
PREGNANT AND NONPREGNANT WOMEN.

RECOMMENDATIONS
1. SURGERY DURING THE SECOND TRIMESTER, IDEALLY BEFORE THE
23RD WEEK OF PREGNANCY, TO MINIMIZE THE RISK OF PRETERM LABOR AND
TO MAINTAIN ADEQUATE INTRA-ABDOMINAL WORKING ROOM.
2. TOCOLYTICS ARE BENEFICIAL TO ARREST PRETERM LABOR, BUT THEIR
PROPHYLACTIC USE IS DEBATABLE
3. OPEN LAPAROSCOPY SHOULD BE USED FOR ABDOMINAL ACCESS TO
AVOID DAMAGING THE UTERUS.
4. FETAL MONITORING USING TRANSVAGINAL ULTRASONOGRAPHY
5. MECHANICAL VENTILATION MUST BE ADJUSTED TO MAINTAIN A
PHYSIOLOGIC MATERNAL ALKALOSIS

LAP IN CHILDREN
 LAPAROSCOPY IS FREQUENTLY PERFORMED IN INFANTS AND CHILDREN
 CO2 PNEUMOPERITONEUM INDUCES THE SAME CHANGES IN RESPIRATORY
MECHANICS TO THOSE REPORTED IN ADULTS.
 PACO2 AND PETCO2 INCREASE DURING PNEUMOPERITONEUM.
 THE HEMODYNAMIC CHANGES OBSERVED IN CHILDREN ARE SIMILAR TO
THOSE REPORTED IN ADULTS.

PREOP EVALUATION
 DONE IN THE USUAL MANNER
 PARTICULAR ATTENTION TO CARDIOVASCULAR AND RESPIRATORY STATUS
 CARDIAC EVALUATION IN PATIENTS WITH CARDIAC DISEASE
 RISK VS BENEFIT IN CARDIAC PATIENTS
 NEPHROTOXIC DRUGS AVOIDED IN RENAL IMPAIRMENT
 ALWAYS CONSIDER THE FACT THAT THERE IS CHANCE OF CONVERTING TO
OPEN PROCEDURE
 UNDESIRABLE IN PATIENTS WITH INCREASED INTRACRANIAL PRESSURE AND
HYPOVOLEMIA

 IN A PATIENT WITH POOR PULMONARY RESERVE MORE EXTENSIVE
PREOPERATIVE EVALUATION INCLUDING PFT IS ADVISABLE.
 PULMONARY FUNCTION TESTS (PFT) IDENTIFY PATIENTS WHO ARE LIKELY
TO EXPERIENCE HYPERCARBIA AND ACIDOSIS
 PROPHYLAXIS OF DEEP VEIN THROMBOSIS
 ROUTINE INVESTIGATIONS

PREMEDICATION
ADAPTED TO THE DURATION OF THE LAPAROSCOPY AND TO THE NECESSITY
FOR QUICK RECOVERY
 ANXIOLYTICS  MIDAZOLAM , ALPRAZOLAM
 ANTI EMETICS  ONDANSETRON , PROMETHAZINE, DEXAMETHASONE
 ANTACIDS  RANITIDINE ,PANTOPRAZOLE
 PROKINETICS  METOCLOPRAMIDE
 ANTICHOLINERGICS  TO PREVENT VAGALLY MEDIATED BRADY
 ALPHA 2 AGONISTS  REDUCE INTRA OP STRESS & IMPROVE
HAEMODYNAMICS
 ANALGESICS  PRE OP NSAIDS REDUCE POST OP PAIN ,OPIODS

PATIENT POSITIONING
 POSITIONED WITH GREAT CARE TO PREVENT NERVE INJURIES
 PADDING SHOULD PROTECT FROM NERVE COMPRESSION, AND SHOULDER
BRACES, PLACED OVERLYING THE CORACOID PROCESS.
 PATIENT TILT SHOULD BE REDUCED AS MUCH AS POSSIBLE AND SHOULD
NOT EXCEED 15 TO 20 DEGREES.
 TILTING MUST BE SLOW AND PROGRESSIVE TO AVOID SUDDEN
HEMODYNAMIC AND RESPIRATORY CHANGES

MONITORING
 ALL STANDARD MONITORS
 ARTERIAL LINE
 TEE – IN SIGNIFICANT CARDIOPULMONARY DISEASE
TO MONITOR RESPONSE TO PNEUMOPERITONEUM &
POSITION
 ABG - IN PRE EXISTING PULMONARY DISEASE
PERSISTANT REFRACTORY INTROP HYPERCAPNIA
 CEREBRAL OXIMETRY – HIGH RISK PATIENT /PROLONGED SX/ HEAD UP/DOWN
PROVIDES INFO ON BRAIN OXYGENATION

ANESTHETIC TECHNIQUES
 GA
 REGIONAL
 LOCAL

GA – CONDUCT OF ANAESTHESIA
 GENERAL ANESTHESIA WITH ENDOTRACHEAL INTUBATION AND
CONTROLLED VENTILATION IS THE SAFEST AND MOST COMMONLY
USED
 HELP REDUCE THE INCREASE IN PACO2 AND AVOID VENTILATORY
COMPROMISE FROM PNEUMOPERITONEUM AND POSITION CHANGES
 PROSEAL LMA CAN ALSO BE USED
 INSERTION OF A NASOGASTRIC TUBE MAY BE REQUIRED TO
DEFLATE THE STOMACH-IMPROVE SURGICAL VIEW, AVOID GASTRIC
INJURY ON TROCHAR INSERTION.

LMA FOR LAP
CONTROVERSIAL
• LESS SORE THROAT
• ALLOWS CONTROLLED
VENTILATION
• ETCO2 CAN BE MONITORED
• LESS AMOUNT OF RELAXANTS
• ASPIRATION
THE MOST IMPORTANT PARAMETER TO
SECURE AN ADEQUATE VENTILATION
AND OXYGENATION FOR THE LMA
UNDER PNEUMOPERITONEUM
IS ITS SEAL PRESSURE OF AIRWAY.
A GOOD SEALING PRESSURE, NOT
ONLY STATE CORRECT PATIENT
VENTILATION, BUT IT REDUCES THE
POTENTIAL RISK OF ASPIRATION DUE
TO THE BETTER SEAL OF AIRWAY
LMA WITH GASTRIC PORT BETTER

INDUCTION
ADVANTAGES OF PROPOFOL IN LAP
 SIGNIFICANTLY QUICKER RECOVERY
 AN EARLIER RETURN OF PSYCHOMOTOR FUNCTION
 ANTI EMETIC ACTION .

MAINTENANCE
 MAINTAINING DEEP LEVEL OF ANAESTHESIA WITH INHALATIONAL AGENTS
BLUNT THE HAEMODYNAMIC RESPONSE TO PNEUMOPERITONEUM.
 NITROUS OXIDE CAUSING NAUSEA & VOMITING IS CONTROVERSIAL.
 BUT IT MAY DISTEND THE BOWEL, IN PATIENTS WITH INTESTINAL
OBSTRUCTION.
 AIR OXYGEN USED
 OPIODS – SHORT ACTING PREFERRED
MINIMIAL OPIODS
 ESMOLOL OR LABETALOL MAY BE MORE APPROPRIATE TO TREAT
PNEUMOPERITONEUM HYPERTENSION.

MUSCLE RELAXANTS
 PREVENTS HIGH INTRA-ABDOMINAL AND INTRA-THORACIC
PRESSURES DUE TO PNEUMOPERITONEUM
 MUSCLE PARALYSIS REDUCES THE IAP NEEDED FOR THE SAME
DEGREE OF ABDOMINAL DISTENTION
 RESIDUAL BLOCKADE CAN CAUSE PONV

VENTILATION
 LUNG PROTECTIVE VENTILATION STRATEGIES INCLUDE THE USE OF PRESSURE
CONTROLLED VENTILATION WITH LOW TIDAL VOLUMES (6 TO 8 ML/KG IDEAL BODY
WEIGHT) AND PEEP OF 5 TO 10 CM WATER .
 USE OF PEEP HAS BEEN SHOWN TO IMPROVE ARTERIAL OXYGENATION DURING
PROLONGED PNEUMOPERITONEUM.
 DURING PNEUMOPERITONEUM, CONTROLLED VENTILATION MUST BE ADJUSTED TO
MAINTAIN PETCO2 BETWEEN 35 AND 40 MM HG.
 INCREASE OF RESPIRATORY RATE RATHER THAN OF TIDAL VOLUME MAY BE PREFERABLE
IN PATIENTS WITH COPD AND IN PATIENTS WITH A HISTORY OF SPONTANEOUS
PNEUMOTHORAX OR BULLOUS EMPHYSEMA TO AVOID INCREASED ALVEOLAR INFLATION
AND REDUCE THE RISK OF PNEUMOTHORAX.

FLUIDS
 U/O REDUCED  USING IT AS A GUIDE  OVERLOAD
 STROKE VOLUME OR SYSTOLIC OR PULSE PRESSURE VARIATION PREFERRED

REGIONAL ANESTHESIA
• ADVANTAGES
• METABOLIC RESPONSE IS REDUCED
• REDUCES THE NEED FOR SEDATIVES AND NARCOTICS
• PRODUCES BETTER MUSCLE RELAXATION.
• POST OP ANALGESIA
• LESS CHANCE OF PONV

LOCAL ANAESTHESIA
ADVANTAGES
 QUICKER RECOVERY,
 DECREASED PONV,
 EARLY DIAGNOSIS OF COMPLICATIONS, AND
 FEWER HEMODYNAMIC CHANGES
DISADVANTAGES
 REQUIRES PRECISE AND GENTLE SURGICAL TECHNIQUE AND MAY RESULT IN
INCREASED PATIENT ANXIETY, PAIN, AND DISCOMFORT DURING THE
MANIPULATION OF PELVIC AND ABDOMINAL ORGANS.
 MAY REQUIRE SEDATION

POSTOPERATIVE MANAGEMENT
 POSTOPERATIVE SHOULDER-TIP PAIN
 ALL PATIENTS SHOULD RECEIVE SUPPLEMENTAL OXYGEN
 HAEMODYNAMIC MONITORING
 PREVENTION OF PONV
 DVT PROPHYLAXIS

REFERENCES
• MILLER 7TH
• BARASH 7TH
• YAO
• CEACP

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