Anesthesia management of Laparoscopic Assisted Surgery. Dr. Mohammed Mahdy Consultant in Anaesthesiology Al Bukariya general hospital

Introduction Laparoscopy introduced in 20 th Century 1962 : first laparoscopic tubal ligation 1970 -- 80 : used for gyne procedures 1989: laparoscopic cholecystectomy Rapid advances in technology

Laparoscopy introduced in 20 th Century

1962 : first laparoscopic tubal ligation

1970 -- 80 : used for gyne procedures

1989: laparoscopic cholecystectomy

Rapid advances in technology

Total No of cases from 3 / 1421 to 11 / 1425 75.2% 11.9% 6.3% 4.7% Total cases: 1260

Laparoscopic Procedures General Surgery: Cholecystectomy Appendicectomy Varicocoelectomy Hernioplasty Diagnostic laparoscopy Hiatus hernia repair Adhesiolysis OBG: Ectopic pregnancy Myomectomy LAVH Endometriosis Thoracic Surgery: Sympathectomy Mediastinoscopy

General Surgery:

Cholecystectomy

Appendicectomy

Varicocoelectomy

Hernioplasty

Diagnostic laparoscopy

Hiatus hernia repair

Adhesiolysis

OBG:

Ectopic pregnancy

Myomectomy

LAVH

Endometriosis

Thoracic Surgery:

Sympathectomy

Mediastinoscopy

Advantages of Laparoscopy Shorter hospital stay Faster recovery Rapid return to normal activities Minimal pain Small scar Less post-op ileus

Shorter hospital stay

Faster recovery

Rapid return to normal activities

Minimal pain

Small scar

Less post-op ileus

Contraindications for Laparoscopy Increased ICP V – P shunt Hypovolemia CCF Valvular heart diseases

Increased ICP

V – P shunt

Hypovolemia

CCF

Valvular heart diseases

Anaesthetic Plan Pre-operative assessment Pre-medication Anxiolytics H2 receptor blockers Gastro-kinetic drugs Monitoring: Pulse oximetry Capnography ECG NIBP FiO2

Pre-operative assessment

Pre-medication

Anxiolytics

H2 receptor blockers

Gastro-kinetic drugs

Monitoring:

Pulse oximetry

Capnography

ECG

NIBP

FiO2

Anaesthetic Management Preoxygenation Induction Intubation – mandatory NG tube placement Stomach decompression Maintenance of anaesthesia Muscle relaxants Volatile anaesthetic agents Reversal of NM blockade Recovery room

Preoxygenation

Induction

Intubation – mandatory

NG tube placement

Stomach decompression

Maintenance of anaesthesia

Muscle relaxants

Volatile anaesthetic agents

Reversal of NM blockade

Recovery room

Anesthetic Problems of Laparoscopy Due to pneumo peritoneum Due to patient positioning Cardiovascular effects Respiratory effects Gastro intestinal effects Unsuspected viseral injuries Difficulty in estimating blood loss Darkness in the OR

Due to pneumo peritoneum

Due to patient positioning

Cardiovascular effects

Respiratory effects

Gastro intestinal effects

Unsuspected viseral injuries

Difficulty in estimating blood loss

Darkness in the OR

Pneumo Peritonium Preferred gas : CO2 Working pressure : 12 to 14 mm Hg Slow inflation of 1 litre / minute

Preferred gas : CO2

Working pressure : 12 to 14 mm Hg

Slow inflation of 1 litre / minute

CO2 as Insufflator Gas More soluble in blood than air Carriage is high due to bicarbonate buffering and combination with Hb Rapidly eliminated by lungs Inert & not irritant to tissues

More soluble in blood than air

Carriage is high due to bicarbonate buffering and combination with Hb

Rapidly eliminated by lungs

Inert & not irritant to tissues

Ventilatory problems during Laparoscopy Increase in PaCO2 Pneumothorax Gas-embolism

Increase in PaCO2

Pneumothorax

Gas-embolism

Causes for Increased PaCO2 Absorption of PaCO2 –peritoneal cavity V/Q mismatch Increased physiological dead space Abdominal distention Patient’s position Controlled ventilation Reduced cardiac output Lighter planes of anaesthesia

Absorption of PaCO2 –peritoneal cavity

V/Q mismatch

Increased physiological dead space

Abdominal distention

Patient’s position

Controlled ventilation

Reduced cardiac output

Lighter planes of anaesthesia

Pneumothorax Patent pleuro-peritoneal channels Pleural injuries Ruptured emphysematous bullae

Patent pleuro-peritoneal channels

Pleural injuries

Ruptured emphysematous bullae

Management of Pneumothorax Recommended Guidelines Stop N2O Adjust vent settings to correct hypoxemia Apply PEEP Reduce intra-abdominal pressure Communicate with surgeon Avoid thoracocentesis

Stop N2O

Adjust vent settings to correct hypoxemia

Apply PEEP

Reduce intra-abdominal pressure

Communicate with surgeon

Avoid thoracocentesis

Gas Embolism Most feared & fatal complication Seen frequently when laparoscopy is associated with hysteroscopy Intra vascular injection of gas following direct trocar placement into vessel

Most feared & fatal complication

Seen frequently when laparoscopy is associated with hysteroscopy

Intra vascular injection of gas following direct trocar placement into vessel

Suspicion of Gas Embolism Blood on aspiration from Vere’s needle Pulsation of flow meter pressure gauge Disappearance of abdominal distention despite sufficient volume of gas

Blood on aspiration from Vere’s needle

Pulsation of flow meter pressure gauge

Disappearance of abdominal distention despite sufficient volume of gas

Effects of Massive Air Embolism Rapid insufflation of gas into blood  Gas lock in RA & venacava  Fall in cardiac output High pressure in RA  Open foramen ovale  Embolus in cerebral & coronary beds  Paradoxical embolism

Rapid insufflation of gas into blood



Gas lock in RA & venacava



Fall in cardiac output

High pressure in RA



Open foramen ovale



Embolus in cerebral & coronary beds



Paradoxical embolism

Diagnosis of Gas-embolism Detection of gas in right side of Heart Recognition of physiological changes secondary to emboli: Tachycardia Cardiac arrhythmia Hypotension CVP rise Mill-wheel murmur Cyanosis Right heart strain pattern in ECG Pulmonary edema Doppler & TEE ---- very sensitive

Detection of gas in right side of Heart

Recognition of physiological changes secondary to emboli:

Tachycardia

Cardiac arrhythmia

Hypotension

CVP rise

Mill-wheel murmur

Cyanosis

Right heart strain pattern in ECG

Pulmonary edema

Doppler & TEE ---- very sensitive

Treatment of Gas Embolism Immediate cessation of insufflation Release of pneumo-peritoneum Patient in Durrent’s position Cessation of N2O Give 100% oxygen CVP insertion and aspiration of gas

Immediate cessation of insufflation

Release of pneumo-peritoneum

Patient in Durrent’s position

Cessation of N2O

Give 100% oxygen

CVP insertion and aspiration of gas

Risk factor for Regurgitation Increased intra-abdominal pressure Decreased lower oesophageal sphincter tone Head down position NG tube mandatory

Increased intra-abdominal pressure

Decreased lower oesophageal sphincter tone

Head down position

NG tube mandatory

Cardiac Arrhythmias during Laparoscopy Volatile anaesthetic agents Hypercarbia Sudden stretching of peritoneum Electro coagulation of fallopian tubes Light planes of anaesthesia

Volatile anaesthetic agents

Hypercarbia

Sudden stretching of peritoneum

Electro coagulation of fallopian tubes

Light planes of anaesthesia

Problems related to patient’s positioning Head – Down tilt for pelvic and sub meso-colic surgery Head -Up tilt for supra mesocolic surgery Lithotomy position for gynec procedures

Head – Down tilt for pelvic and sub meso-colic surgery

Head -Up tilt for supra mesocolic surgery

Lithotomy position for gynec procedures

Position – Respiratory Effects Head-down position Promotes atelectasis Decreases FRC Decreases TLC Decreases pulmonary compliance Head-Up position: Endo-bronchial intubation

Head-down position

Promotes atelectasis

Decreases FRC

Decreases TLC

Decreases pulmonary compliance

Head-Up position:

Endo-bronchial intubation

Position- Cardio-Vascular Effects Head down Position: Increases CVP Increases cardiac output Increases cerebral circulation Increased ICP Increased intra-ocular pressure Head up Position: Decreased cardiac output Decreased mean arterial pressure Decreased venous return

Head down Position:

Increases CVP

Increases cardiac output

Increases cerebral circulation

Increased ICP

Increased intra-ocular pressure

Head up Position:

Decreased cardiac output

Decreased mean arterial pressure

Decreased venous return

Positions : Nerve Injury Hyper extension of arm --- brachial plexus injury Lithotomy position --- common peroneal injury

Hyper extension of arm --- brachial plexus injury

Lithotomy position --- common peroneal injury

Bibilography: Short practice of anaesthesia – Churchill Davidson Synopsis of anaesthesia – Atkinson & Lee Text book of anaesthesia – Ronald Miller Anaesthesia & coexisting diseases - Stoelting

Short practice of anaesthesia – Churchill Davidson

Synopsis of anaesthesia – Atkinson & Lee

Text book of anaesthesia – Ronald Miller

Anaesthesia & coexisting diseases - Stoelting

Thank you

Haemodynamic Repurcussions of Pneumo - Peritoneum ↑ Intraabdominal pressure ↓ Venous return ↑ Intrathoracic pressure ↑ Pulmonary vascular resistance  Cardiac output

↑ Intraabdominal pressure

↓ Venous return ↑ Intrathoracic pressure

↑ Pulmonary vascular resistance

 Cardiac output

Haemodynamic Repurcussions Of Pneumoperitoneum ↑ Intra abdominal pressure  ↑ Venous resistance  ↑ Systemic vascular resistance  ↑ Arterial pressure

↑ Intra abdominal pressure



↑ Venous resistance



↑ Systemic vascular resistance



↑ Arterial pressure