Anaesthesia  for  laparoscopic  surgery_Dr. Tanmoy Roy
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Anaesthesia for laparoscopic surgery_Dr. Tanmoy Roy

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Anaesthesia  for  laparoscopic  surgery_Dr. Tanmoy Roy Anaesthesia for laparoscopic surgery_Dr. Tanmoy Roy Presentation Transcript

  • • A.k.a PERITONEOSCOPY, is a 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. • Term coined by HANS CHRISTIAN JACOBAEUS in 1910. • Air was the first gas to be used, followed by O2:- Discarded because of O2 being COMBUSTIBLE and Air being poorly soluble in blood causing EMBOLIC PHENOMENON. N2O also supported COMBUSTION , when mixed with the METHANE in the bowels. Inert gases like Helium, Argon & Xenon are EXPENSIVE and cause GAS EMBOLISM. • CO2 - 1924 by RICHARD ZOLLIKOFER – Inert, Cheap, Exhaled by Lungs, Relatively high blood-gas solubility (less chances of gas embolism).
  • INTRA-ABDOMINAL GYNAECOLOGICAL Cholecystectomy Vagotomy Appendectomy Colectomy Inguinal Hernia Repair Nephrectomy Adrenalectomy Splenectomy Diagnostic Fertility workup Tubectomy & Ligation Ovarian Cyst Puncture Hysterectomy INDICATIONS FOR LAPAROSCOPIC SURGICAL PROCEDURE Also has been used inAlso has been used in Breast surgeries (non-oncologic)Breast surgeries (non-oncologic) andand Thyroid surgeriesThyroid surgeries at our centerat our center
  • Contraindications for laparoscopy areContraindications for laparoscopy are relativerelative and include: •the uncooperative patient •uncorrectable coagulation defects •severe congestive heart failure •respiratory system compromise •metabolic disturbances – Severe DM & its complications, Thyro-metabolic diseases etc. •suspected acute diffuse peritonitis •the presence of distended bowel If tense ascites is present, large volume paracentesis can be performed as the preliminary step in the laparoscopy.
  • TRENDELENBERG POSITION of 10-15 degree for lower abdominal Sx REVERSE TRENDELENBERG POSITION in upper abdominal Sx. Reverse Trendelenberg Position Trendelenberg Position
  • Normal IAP is between 0-5mmHg; any value above 12 mmHg is considered as an increased IAP In LAPAROSCOPY, a standard IAP can be considered between 12-15 mmHg PATIENTPATIENT POSITIOPOSITIO NN BIOCHEMICBIOCHEMIC ALAL CHANGES(gCHANGES(g asas absorption)absorption) MECHANICAMECHANICA LL CHANGES(bCHANGES(b y raised IAP)y raised IAP) PHYSIOLOGICAL CHANGES DURINGPHYSIOLOGICAL CHANGES DURING PNEUMOPERITONEUMPNEUMOPERITONEUM
  • 1 2 34 5 6 7 8 9 10
  • GENERAL ANAESTHESIA UNDER CONTROLLED MECHANICAL VENTILLATION (CMV)GENERAL ANAESTHESIA UNDER CONTROLLED MECHANICAL VENTILLATION (CMV):: •Always preferred; pt is sedated, paralyzed, with full control of pt’s respirationAlways preferred; pt is sedated, paralyzed, with full control of pt’s respiration •Immobile field gives ease of operabilityImmobile field gives ease of operability •Protection from aspirationProtection from aspiration •Better psychological outcome for patients-less chances of intra-op awarenessBetter psychological outcome for patients-less chances of intra-op awareness •More hemodynamic stabilityMore hemodynamic stability •Pt has no intra-op discomfortPt has no intra-op discomfort •A compromised respiratory system may contradict GAA compromised respiratory system may contradict GA REGIONAL ANAESTHESIA-HIGH SPINAL / EPIDURAL:REGIONAL ANAESTHESIA-HIGH SPINAL / EPIDURAL: •Quicker recovery, decreased PONVQuicker recovery, decreased PONV •Can be planned in patients with contraindications to GACan be planned in patients with contraindications to GA •Abdominal discomfortAbdominal discomfort •Pneumoperitoneum + sedation = Hypoventilation; Hypoxia & HypercarbiaPneumoperitoneum + sedation = Hypoventilation; Hypoxia & Hypercarbia •Complete sensory block is not always assuredComplete sensory block is not always assured •Compelled low IAP inhibits field of visionCompelled low IAP inhibits field of vision
  • • Proper history and examination of patient, related to organ systems is of utmost importance • Review of investigation reports prior to commencement of surgery • Anticholinergic drugs – Atropine & Glycopyrrolate • Sedation and Analgesia- Midazolam and Fentanyl • Anti-acid and Antiemetic Prophylaxis • α2- agonists- Clonidine and Dexmedetomidine
  • • Oxygenation – Saturation; Pulseoximetry • Ventilation – Capnometry ( <2Hrs) Venous BGA (>2Hrs, >60yrs, Pulmonary disease) Transcutaneous CO2 monitoring (>2Hrs, Pulmonary disease, Extraperitoneal & Retroperitoneal procedures) • Haemodynamic Monitoring – ASA1 – ECG, NIBP Pts. With IHD – Automated ST analysis of ECG ASA3, ASA4 – IABP, Serial BGA, CVP, PAC, TEE, CO monitoring • Temperature Monitoring • Urine Output monitoring - >2Hrs, Elderly pts, Cardiopulmonary compromise • Neuromuscular Monitoring – TOF stimulation and TOF ratio
  • PREOXYGENATION: 100% o2 in 3mins of TV breathing OR 8 VC breaths in 1 min INDUCTION: Thiopentone Sod. 4-5 mg/kg; Propofol 2-2.5 mg/kg RELAXATION AND INTUBATION: Succinylcholine 1-2 mg/kg & appropriate size of ETT NG tube/Ryle’s tube MAINTAINANCE: O2 + N2O + NDPMR(Vecc / Atra) + PPV Maintain MV to an ETCO2 of 30 – 40mmHg Choice of Inhalational Agent: ISO>DES>SEVO>ENF; HALO is contraindicated N2O may cause distension of hollow viscera, causes PONV REVERSAL: Neostigmine + Glycopyrrolate
  •  INCREASED PaCO2 (Hypercapnia): • Influenced by duration of Pneumoperitoneum • Causes are – absorption of CO2 from peritoneal cavity V/Q mismatch; pt position • Chances are more in procedures under regional anaesthesia • Usual initial presentations are tachycardia, HTN, pt triggering, mild desaturation, wound oozing, increased body temperature • Can lead to accidental events like tachyarrhythmias, CO2 emphysema, capnothorax, CO2 embolism • Usually prevented by maintaining alveolar ventilation to a PaCO2 of 30-40mmHg
  •  RESPIRATORY COMPLICATIONS: CO2 subcutaneous emphysema: • d/t accidental Extraperitoneal insufflation • An increase in PetCO2 after Pet CO2 has plateaued should raise the suspicion • CO2 pressure determines the extent of the emphysema and the magnitude of CO2 absorption • Temporary halt of the procedure and the route of extraperitoneal rent is to be looked for Capnothorax, capnomediastinum and capnopericardium: •via embryonic remnants of communication between the peritoneal cavity, pleural and pericardial spaces •There is reduced thoracopulmonary compliance and increased Paw •PaCO2, PetCO2 all increase •Confirmed by chest auscultation and CXR •Capnothorax is treated by stopping N2O administration, reducing IAP, adjust ventilator settings to correct hypoxia, applying PEEP
  • Gas Embolism: •Most serious complication of laparoscopic surgery •Pathophysiology is determined by the size of the bubbles and the rate of intravenous gas entry •Gas embolism into an artery, termed arterial gas embolism (AGE), is a more serious matter than in a vein, because a gas bubble in an artery may directly stop blood flow to an area fed by the artery •Mayer, et al. described a mortality of 60% at a continuous intravenous carbon dioxide infusion rate of 1.2 mL/kg/min, which is equivalent to a rate of 72 mL/min for a 60 kg person. That volume is only 5% of the volume of carbon dioxide that may be infused into a vein, intentionally cannulated by a Veres needle, in one minute at a low-flow rate. Mayer KL, Ho HS, Mathiesen KA, Wolfe BM. Cardiopulmonary responses to experimental venous carbon dioxide embolism. Surg Endosc. 1998;12:1025–1030. •Signs and symptoms – With 0.5ml/kg of gas or less – Changes in Doppler sound and increased mean PAP. With 2ml/kg of gas – Dysrhythmias, Hypotension, desaturation, increased CVP, millwheel murmur(A temporary loud, machinery-like, churning or splashing sound due to blood mixing with air in the right ventricle, best heard over the precordium) •TEE >Doppler USG for detecting intracardiac gas •Rx – Stop insufflation, head down with left lateral decubitus, 100% O2 hyperventilation, gas aspiration if a CV catheter is present, pericardiac message to fragment gas bubbles, HBOT if cerebral gas embolism is suspected
  •  CARDIAC DYSRHYTHMIAS: • Bradydysrhythmia leading to asystole is the most common, due to vagal stimulation by peritoneal distension • Tachydysrhythmia and ventricular ectopic, due to SNS activation by hypercarbia or hypoxia  RISK OF ASPIRATION  HEMORRHAGE  INTERNAL ORGAN INJURY  PERIOPERATIVE PERIPHERAL NEUROPATHY
  •  POST LAPAROSCOPY PAIN & PAIN RELIEF: • Incidence is 35%-63% • Sites are upper abdomen, lower abdomen, back or shoulder • Most common site being upper abdomen • From transient to up to 3 days • Pain relief by:  Pre-op NSAIDS  Abdominal drain for 6 hrs to release the residual CO2  Pre-incisional infiltration of trocar sites with LA  Thoracic epidural analgesia  Intraperitoneal instillation of LA solution prior removing trocars  0.25% of Intrapleural Bupivacaine injection reduces shoulder pain Mechanism • Trocar Insertion • Intra-abdominal trauma • Rapid distension of peritoneum causing traumatic traction on vessels and nerves • Irritation of phrenic nerve • Release of inflammatory mediators
  • Laparoscopic surgery tends to set conditions that leads the exaggeration of the normal physiological aspect of the human body. Those with able and stable physiology tend to cope up with the scenario with minor supports, while the lesser counterparts need substantial support. With the help of newer monitoring and advent in the field of anaesthesia, this procedure can be made safe for the patient population as well as provide ease of operability on the part of the medical fraternity .