Laparoscopy ( Greek λάπάРά =flank or λάЛάРОδ =soft σκОЛήтν = to look) has revolutionized surgical procedures because of the important advantages it offers namely less tissue trauma,decreased post operative pain as well as shorter hospital stay with minimized post operative morbidity and mortality.
Gyanecological laparoscopic surgery has been started since 1970’s.In 1987, Phillipe Mouret described the first laparoscopic cholecystectomy in France.Literature about low IAP and modern anaesthetic technique has started publishing after 1990’s.
During an uneventful CO2 pneumoperitneum ,PCO2 rises till it reaches a plateau at 15 to 30 min after insufflation .Rise of PCO2 is mainly due to peritoneal absorption. Some other factors which also contributes to raise PCO2 are :
Va/Q mismatch – increased physiologic dead space due to
*position of patient (steep head down)
Controlled mechanical ventilation
Reduced cardiac output
(All these mechanism are attenuated in sick person like obese ,ASA2 and ASA3 )
Insufficient plan of anesthesia
Transfusion of more glucose containing fluid
3. Depression of ventilation by anesthetics in case spontaneous breathing
Patient under going laparoscopy are considered at high risk acid aspiration syndrome .I t might be due to increased intragrastic pressure consequent to Increased IAP .
The visceral vascular bed is the primary site of compression during raised IAP resulting in organ dysfunction .Other contributing factor sympathetically mediated vasoconstriction and mechanical compression of abdominal organ.
Both ICP and IOP are raised due to vasodialating action of CO2 . In normal individual these changes are tolerable but in patient with SOL or glaucoma may show some deleterious effects .
During laparoscopy continuous flow of dry gases over peritoneal surface under pressure can lead to fall of core body temperature .ie joule Thompson effect . some aggravating factors are higher flow rate ,prolong duration of surgery, leakage through port ,peritoneal lavage etc .
There is 0.30 c fall in core temperature per 50l volume flow of carbondio
CAN LAPAROSCOPY BE PERFORMED IN ALL PATIENT ???????
Following groups of patient need careful consideration :
Patient with in ICP , SOL and CVA
Patient having ventriculoperitoneal and juguloperitoneal shunt .
INERT GASES : Use of inert gases like helium ,argon can reduce hypercarbia but other changes due to increased IAP remain same .Since solubility of these gases is low, there is always a chance of gas embolism.
GASLESS LAPAROSCOPY:Here the peritoneal cavity is expanded with a fan retractor.this technique avoids hemodynamic and respiratory repercussions.Post operative PONV and port site metastasis are reduced.This thing is very appealing in severe cardiac and pulmonary diseases.Disadvantages are poor surgical site and increased technical difficulty.Combined this technique with low IAP(<5mm of Hg) is an interesting prospect .
Despite multiple advantages, Laparoscopy is not a synonym for risk free operation. The death rate during laparoscopic surgery is 0.1 to 1 per 1000 cases. Anesthesiologist must be aware, able to detect and manage those life threatening complication. .Capnography is one of the most important tool to tackle these complication and every one should know how to interrelate ETCO2 with other important findings