Prof. Panditrao takes you in the detailed discussion about the historical aspects, problems, altered physiology, preparation of and Anesthetic/ peri-operative management of the patients for various laparoscopic surgical procedures
Prof. Mridul Panditrao's Peri-operative MANAGEMENT OF Patients for Laparoscopy
PERI-OPERATIVEMANAGEMENT OF PATIENTS FOR LAPAROSCOPY
PROF. MRIDUL M. PANDITRAO ConsultantDepartment Of Anesthesiology & Critical Care Rand Memorial Hospital Freeport Grand Bahama
INTRODUCTION “LAPAROSCOPIC SURGEON” Laparos & scopos 1970s, 80s & 90s Reduction Of trauma, morbidity/mortality hospital stay, health care costs better maintenance of homeostasisSoper NJ, Barteau JA et al: Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy: Surg GynecolObstet 1992: 174:114Grace PA, Quereshi A, Coleman J, et al: Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 1991; 78:160.
INTRODUCTION Why Is It so Popular????? Day Care Anesthesia/ Surgery The majority of patient population: female Various pathological conditions Various specialties and super specialties Smooth Post-operative course Less pain and morbidity Turns out to be cost-effective
INTRODUCTION (CONTD.) SCOPE OF LAPAROSCOPIC PROCEDURES IN FEMALE PATIENTSN Specialty Procedure N Specialty Procedureo o1 Gynecological Diagnostic laparoscopy 2. General Surgical Laparoscopic cholecystectomy / Obstetric Laparoscopic sterilization Nissen’s Funduplication Laparoscopic assisted vaginal Diaphragmatic or Hiatus hernia repair hysterectomy Appendectomy Laparoscopic assisted fertilization Vagotomy procedures Adrenalectomy Removal of unruptured ectopic / tubal Inguinal hernia repair pregnancies Colectomy Ovarian cyst/rupture of ovarian cyst 3. Urological Ovarian apoplexy Nephrectomies : Partial / Radical Torsion of uterine appendages Living donor nephrectomy Reflux of menstrual blood Nephro Ureterostomy Differentiation between gynecological and Pyeloplasty surgical pathologies Pelvic lymph node dissection Total cystectomy with ileal conduit formation
PROBLEMS????1. Problems due to pneumoperitoneum & altered/ increased Intra Abdominal Pressure (IAP) : V/Q mismatch Gas in wrong place Cardiovascular system changes2. Problems due to improper patient selection/the actual procedure gone wrong/not performed properly3. Problems due to positioning of the patients for laparoscopic procedures4. Problems of peri-operative period inclusive of the anaesthetic techniques
PROBLEMS DUE TO PNEUMOPERITONEUM ‘Pneumoperitoneum’ : defined as an abnormal presence of air/gas either due to disease process or iatrogenic intervention, inside the peritoneal cavity Air / gas (CO2) is an unnatural, unwanted and interfering agent Patho physiologic changesWahba RW, Tessler MJ, Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominalsurgery. Can J Anaesth 1996; 43:77
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Ventilation/Perfusion changes (V/Q) Intra abdominal pressure (IAP) > 15 mm Hg- domes of diaphragm get elevated leading to ↓FRC ↓Thoraco-pulmonary compliance (30-50%) in healthy, obese as well as ASA III/IV Increased V/Q mismatches and chances of hypoxia. So it is recommended to keep the IAP to <15 mm Hg.Andersson LE, Baath M, Thorne A, et al: Effect of carbon dioxide pneumoperitoneum on development of atelectasis during anesthesia, examined by spiral computed tomography. Anesthesiology 2005; 102:293.Fahy BG, Barnas GM, Nagle SE, et al: Changes in lung and chest wall properties with abdominal insufflation of carbon dioxide are immediately reversible. Anesth Analg 1996; 82:501.7Odeberg-Wernerman S: Laparoscopic surgery—effects on circulatory and respiratory physiology: an overview. Eur J Surg (Suppl) 2000; 585:4.
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Gas in Wrong place “Verress needle” Wrong point of insertion Wrong plane of insertion Wrong direction of insertion Subcutaneous and retro-peritoneal emphysema In laparoscopic procedures like inguinal hernia repair (TEPP), intentional production of extra peritoneal emphysema is imperative Lew JKL, Gin T., Oh TE., Anaesthetic Problems during Laparoscopic cholecystectomy, Anaesth Intensive care, 1992,20, 91
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Gas in Wrong place Pneumothorax Pneumomediastinum Pneumopericardium Operator related Through congenital / potential communications Rarely actual rupture of pericardium or dome of diaphragm. The detection of these, entirely depends upon: High degree of suspicion Progressively increasing ETCO2 levels in spite of good/adequate controlled ventilation If ABG done: increased PaCO2 – ETCO2 gradient Clinically / radiologically evident gas in these areasSpielman FJ: Laparoscopic surgery. In: Kirby DD, Hood RR, Brown DL, ed. Problems in Anesthesia: Anesthesia in Obstetrics and Gynecology, Philadelphia: JB Lippincott; 1989:151.Knos GB, Sung YF, Toledo A: Pneumopericardium associated with laparoscopy. J Clin Anesth 1991; 3:56.Whiston RJ, Eggers KA, Morris RW, et al: Tension pneumothorax during laparoscopic cholecystectomy. Br J Surg 1991; 78:1325.
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Gas in Wrong place CO2 absorption via peritoneal cavity Increased levels of PaCO2 in laparoscopy : from various sites & not from problems in ventilation or V/Q mismatch ASA I-II Patients : not significant , initially In patients with pre-existing cardio-respiratory involvement, problem becomes significant with, increased morbidity & mortality CO2 embolism Accidental intravascular entry of needle or trocar Excessive intra abdominal insufflations leading to puncture of vesselFitzgerald SD, Andrus CH, Baudendistel LJ, et al: Hypercarbia during carbon dioxide pneumoperitoneum. Am J Surg 1992; 163:186.Wulkan ML, Vasudevan SA: Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonateswith cyanotic congenital heart disease?. J Pediatr Surg 2001; 36:1234
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Cardiovascular System changesEtiology: Effects of pneumoperitoneum & ↑I A P Position of the patient Preoperative cardio respiratory status of the patient & state of intravascular volume Levels of CO2 absorption and its effects The effects of Anaesthesia / Anaesthetic agents Autonomic response of the patient‟s body to these manipulations
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Cardiovascular System changesEffects Increased preload (due to indirect increase in IAP) Increased afterload due to increased systemic vascular resistance & pulmonary vascular resistance Decreased myocardial contractility usually as a result of general anaesthesia decreased effective cardiac output, initially decreased MAP, increased heart rate, and later on increased blood pressureSmith I., Benzie RJ, Gordon NLM, et al, Cardiovascular effects of peritoneal insufflations of carbon dioxide for laparoscopy Br. Med. J. 1971,:3: 410Joris J, Honore P, Lamy M, Changes in oxygen transport and ventilation during laparoscopic cholecystectomy, Anesthesiology, 1992, 77, A149
PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.) Cardiovascular System changesHow to offset them: Adequately preloading the patient Using vasoconstrictors (alpha 2 agonists),p.r.n. Adequate analgesia / good sedation with Opioids Rarely drugs like beta blockers : esmolol, metoprolol vasodilators like Clonidine or glyceryl trinitrateRarely, acute hypoxemia, hypotension, cardiac dysrrythmias leading to cardio-vascular collapselife threatening ventricular dysrrythmias due to vagal stimulation, or lighter planes of general anaesthesia Shifren Jl, Adelstein L, Finkler NJ, Asystolic cardiac arrest: a rare complication of laparoscopy. Obstet. Gynaecol.1992, 79: 840 Beck DH, McQuillon PJ, Fatal carbon Dioxide embolism and severe haemorrhage during laparoscopic cholecystectomy, Br. J. Anaesth.1994:72: 243
PROBLEMS DUE TO IMPROPER PATIENT SELECTION/ INCOMPETENTLY CONDUCTED PROCEDURE/OPERATOR ORIENTED PROBLEMS Conversion of closed to open procedure “Improper trocar insertion” Trocar site hernia formation Implantation of aggressive malignant tumors Bile duct injuries, accidental division, resection and obstruction due to accidental clamping with haemostatic clamps
PROBLEMS DUE TO IMPROPER PATIENT SELECTION/ INCOMPETENTLY CONDUCTED PROCEDURE/OPERATOR ORIENTED PROBLEMS Improper trocar insertion Haematomas due to injuries to inferior epigastrics, iliac vessels Gastro-intestinal hollow visceral perforations leading sepsis and mortality. Intra abdominal solid organ injuries like hepatic/splenic tears. Major vessel (IVC/ abdominal aorta) injuries. Peritoneal/omental/mesenteric injuries. Retroperitoneal haematomas especially in post operative period. Hasson‟s mini laparotomy techniqueHasson H: A modified instrument and method for laparoscopy. Aus. J. Obste.t Gynecol. 1971:70: 886
PROBLEMS DUE TO POSITIONING OFPATIENTS FOR LAPAROSCOPIC PROCEDURES Trendelenberg/head down for pelvic/lower abdominal surgeries, While reverse or rT/ head up for upper abdominal quadrant surgeries eg. Cholecystectomy, Nissen‟s funduplication…. In addition lithotomy in Gynecological lateral posture for Cholecystectomies
PROBLEMS DUE TO POSITIONING OFPATIENTS FOR LAPAROSCOPIC PROCEDURES Respiratory system Head down tilt: respiratory embarrassment, rarely endo bronchial intubation Head up tilt/lateral tilt: may increase the dead space & V/Q mismatch compromising an already compromised patient.
PROBLEMS DUE TO POSITIONING OFPATIENTS FOR LAPAROSCOPIC PROCEDURES Cardiovascular system Head up tilt: fall in preload due to peripheral pooling of blood increased systemic vascular resistance Isoflurane offsets this effect in healthy patients Head down tilt: congestion to head, neck, face leading to intracranial congestion increased ICP, increased IOPOdeberg S, Ljungqvist O, Svenberg T, et al: Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthesiol Scand 1994; 38:276.Batra MS, Driscoll JJ, Coburn WA, et al: Evanescent nitrous oxide pneumothorax after laparoscopy. Anesth Analg 1983; 62:1121.
PROBLEMS DUE TO POSITIONING OFPATIENTS FOR LAPAROSCOPIC PROCEDURES Hepato/Renal and splanchnic blood flow decreased RBF, GFR, urinary output by nearly 50% Similarly elevated hepatic enzymes and bilirubin levels Peripheral problems femoro-popliteal venous stasis, deep venous thrombosis and thrombo-embolization Peripheral nerve/Plexus injuries in „head down, arm over extended, Common peroneal nerve injury due to improperly padded lithotomic positions.
PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC TECHNIQUES Related to nitrous oxide administration Related to intravenous drugs especially opioids Related to anaesthetic technique specifically.
ANAESTHETIC PROBLEMS???? Role of nitrous oxide Riddled with controversies?!?!?! Available evidence: Does not interfere!!!!!Krogh B, Jensen PJ, Henneberg Sw, et al. Nitrous Oxide does not influence operating conditions or post operative course in colonic surgery. Br. J. Anaesth. 1994; 72:55.Taylor E, Feinstein R, White PF, Sopor N. Anesthesia for laparoscopic cholecystectomy: is nitrous oxide contraindicated? Anesthesiology; 1992: 76:541Lemaire BM, van Erp WF: Laparoscopic surgery during pregnancy. Surg Endosc 1997; 11:15.Sukhani R, Lurie J, Jabamoni R: Propofol for ambulatory gynecologic laparoscopy: Does omission of nitrous oxide alter postoperative emetic sequelae and recovery?. Anesth Analg 1994; 78:831.
ANAESTHETIC PROBLEMS???? Intravenous anaesthetics Propofol as TIVA and its cardio inhibitory effects Fentanyl and the spasm of sphincter of Oddi/PONV Addition of isoflurane improves overall outcome Nalbuphine with minimal biliary stasis activity Parenteral NSAIDs may actually make the use of opioids redundant.Humphrey HK, Fleming NW. Opioid induced spasm of the Sphincter of Oddi apparently reversed by nalbuphine. Anesth analg 1992; 74: 308
ANAESTHETIC PROBLEMS???? Anaesthetic techniques Which technique to use: General regional combination local Choice is yours!
ANAESTHETIC TECHNIQUE OF CHOICEBalanced General Anaesthesiaintravenous/inhalational inductionoxygen, nitrous oxide,muscle relaxant, endo tracheal intubation and an opioid!
PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC TECHNIQUESInclusion Criteria Before opening abdomen Female patients in reproductive age group ASA I- II grade Upper abdominal procedures Pelvic surgical procedures Moderate Obesity Adequate infra structure and surgical skill level
PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC TECHNIQUESExclusion Criteria Emergent, suspected coagulopathy/Sepsis Cardiopulmonary disorders:IHD, Asthma, COPD H/O Old surgical operations in the lower part of the abdominal cavity/ Total adhesive process in abdominal cavity Third trimester of pregnancy Sizeable pathological formation Decompensated internal hemorrhage
INTRA-OPERATIVE MANAGEMENT Preoperative evaluation ASA I and II patients - routine In IHD or COPD- proper evaluation with 2D ECHO and dynamic pulmonary function tests; minimal requirement of LVEF in IHD patients is < 30% Hepato renal compromising drugs- avoided: halothane, anti- biotics… Precautions for prevention of venous stasis, nerve injury : deep vein thrombosis prophylaxis, padding with elastic bandages Monitoring: Routine ---- to ---- TEE, Pre-induction oxygenation: To avoid need of mask ventilation inadvertent stomach inflation & accidental puncture during trocar placement & to reduce incidence of PONV
TECHNIQUE OF CHOICE Induction with intravenous agent in compromised patients sevoflurane Cuffed ET tube: using newer non depolarizing muscle relaxants like rocuronium Controlled ventilation, ETCO2 , NMBD and Isoflurane/ Desflurane Preemptive preloading with a suitable crystalloid or colloid
TECHNIQUE OF CHOICE Nasogastric tube, urinary catheter which decrease: the problems of bladder puncture, GI puncture improved visualization post operative gastric distension and PONV. Positioning of patient requires meticulousness Reconfirmation of endotracheal tube position insertion of needle, production of pneumoperitoneum: gentle and gradual Trocar placement :professionally perfect
TECHNIQUE OF CHOICE IPPV adjusted to avoid hyperventilation & paradoxical pressure increase: to increase the rate than tidal volume The ETCO2 to be maintained between 35-40 mm Hg intravenous fluids, colloids, dobutamine/ inotropic support, Isoflurane will help in decreasing SVR If required glyceryl trinitrate infusion to be used arrhythmias due to peritoneal stretching : stoppage of insufflations atropine or glycopyrrolate deepening the plane of anaesthesia Continuous monitoring of IAP
TECHNIQUE OF CHOICE Complications like subcutaneous emphysema, pneumothorax or pneumomediastinum must be kept in mind If not possible to monitor PaCO2 with Serial ABG: signs of hypercapnia: unexplained tachycardia, hypertension, dysrrythmias, without significant rise in ETCO2, : high degree of suspicion. Multimodal analgesia : preoperative / intraoperative opioids like Butorphanol / Nalbuphine, intramuscular/ intravenous parenteral NSAIDs/paracetamol at the end of surgery local infilteration using Bupivacaine ExtubationMichaloliakou C, Chung F, Sharma S. Pre-operative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth analg; 1996: 82: 44-51.
INTRA-OPERATIVE MANAGEMENTlaparoscopy in its true sense is a team approachRespect for each member specialty of the team! Absolutely essential!!!!!
POST-OPERATIVE MANAGEMENT Monitoring Pain Management is easier Road worthiness of Day cases Follow up or Decision to admission and inpatient care
RECENT ADVANCESLaparoscopy & it’s anaesthesia have not yet matured !Surgical techniques: Robotic laparoscopy Noble gases for insufflations: Inert gases like helium and argon Laplift / Gasless laparoscopy Combination of laplift with low IAP< 5 mm Hg with CO2
RECENT ADVANCES Anaesthetic management: Suitable number of young healthy patients : laryngeal mask airway, spontaneous respiration Local analgesic solutions infusion: intra-peritoneal, port site or in abdomen layers Local / regional techniques; patient discomfort, shoulder pain, high level & CVS instabilty Local / regional techniques: Combination of spinal bupivacane 0.75%+ I V Propofol (bolus- .4mg/kg & infusion .1- 1.5 mg/kg/hr) or I V ketamine (bolus- .1mg/kg & infusion .3- 1.0 mg/kg/hr or Ketofol (Their combination)Ali Y, El masry MN et al: The feasibility of Spinal anesthesia with sedation for laparoscopic general abdominal proceduresin moderate riskpatients: MEJ Anaes 19 (5)Yi JW, Choi SE: Laparoscopic cholecystectomy performed under regional anesthesia in a pt undergone pneumonectomy: Korean J.Anesthesiol 56 (3) 330-33.
CONCLUSION Laparoscopy has come in as a boon Conventional/ Open methods definitely have higher morbidity and mortality Should not be taken lightly Deep circumspection of patho physiologic changes involved, complications that can happen and how to prevent them and overcome them.
CONCLUSIONA problem oriented team approach Interdisciplinary respect total peri-operative management dispel myths / auras very precise, clear cut and evidence based guidelines