good information for PG students

1. PRESENTER : DR. R. LALRINMAWIA
MODERATOR : PROF. S. SARAT SINGH
ANESTHESIA IN
LAPAROSCOPIC
SURGERY

2. INTRODUCTION
 Laparoscopic Surgery is a minimal invasive surgical procedure
which allows endoscopic access to the peritoneal cavity after
insufflation of gas (CO2 etc.) 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
 CO2 - 1924 by RICHARD ZOLLIKOFER – Inert, Cheap,
Exhaled by Lungs, relatively high blood-gas solubility (less
chances of gas embolism).

3. INDICATIONS
 GYNAECOLOGICAL
 Diagnostic Fertility workup
 Tubectomy & Ligation
 Ovarian Cyst Puncture
 Hysterectomy
 INTRA-ABDOMINAL
 Cholecystectomy
 Vagotomy
 Appendectomy
 Colectomy
 Inguinal Hernia Repair
 Nephrectomy
 Adrenalectomy
 Splenectomy

4. Advantages of laparoscopy
over Laparotomy
 Patient Specific:
 ⬇ Incisional stress response
 More cosmetic
 Shorter recovery
 Earlier return home
 Faster Activity
 ⬇ P/O Pain
 ⬇ Opioids requirement
 ⬇ P/O Resp Dysfunction
Surgeon Specific:
Better Visualization
⬇ medical risk
⬇ ileus
⬇ damage to healthy tissue
⬇ wound infection
⬇ P/O complications
Better outcomes

5. Risks:
 Visceral and vascular damage
 Complications associated with extremes of positioning
 Acute kidney injury
 Cardio cerebral vascular insufficiency
 Pulmonary atelectasis
 Venous gas embolism
 Well leg compartment syndrome

6. CONTRAINDICATIONS
 Related to Anesthesia:
 Severe cardiovascular or
pulmonary diseases.
 Increased ICP or space
occupying lesions.
 Impending renal shutdown.
 Hypovolemic shock
Related to Surgery :
Diaphragmatic hernia.
History of extensive surgery.
Large intra-abdominal masses.
Tumor of the abdorninal wall .
Peritonitis.
Coagulopathies.
Surgeon inexperience (is the
strongest contraindication).

7. Anaesthetic Considerations
Of Laparoscopy:
 1. General considerations
 2. Considerations related to positioning.
 3. Considerations of gas insufflation
 4. Considerations of pneumo-peritoneum

8. General considerations
 Darkness in the OR
 Difficulty in estimating blood loss
 Potential conversion to open
 Unsuspected visceral injuries
 Increased risk of PONV

9. Considerations related to
positioning
 Trendelenburg
lower abdominal procedures
Reverse Trendelenburg
upper abdominal procedures

10. Respiratory effect of
Positioning
 Reverse-Trendelenburg:
 Favorable for
Respiration
 Trendelenburg:
 ↓ Pulmonary
compliance
 ↑ airway pressure
 ↓FRC
 Atelectasis
 Endobronchial
intubation

11. Cardiovascular effect
of Positioning
 Reverse-Trendelenburg:
 Blood Pooling
 Venous stasis
 ↓ Venous Return
 ↓ CO
 ↓ ↔ BP
 Thromboembolism
Trendelenburg:
↑ CVP, VR
↑ CO
↑ Cerebral Perfusion
↑ ICP
↑ IOP

12. Position – Nerve Injury
 Brachial plexus Injury : over extension of arm must be
avoided
 Common peroneal nerve injury- Lithotomy
 Prolonged Lithotomy – Lower extremity Compartment
Syndrome
Effect of prolonged positioning:
 Head and neck congestion.
 Conjunctiva and eyelid edema.
 Retinal hemorrhage and detachment with increased
intraocular pressure.
 Cerebral edema with increased ICP.
 Laryngeal, tongue, and airway edema.
Deep vein thrombosis

13. Considerations of gas
insufflation
 What gases can be used?
Air N2O
O2
Helium
Argon
Xenon
CO2

14. Issues with Gas
Insufflation
 Subcutaneous Emphysema
 Direct Peritoneal irritation
 CO2 produces postoperative shoulders pain
 Hypercarbia and respiratory Acidosis
 Hypothermia
 Pneumothorax, Pneumomediastinum
 Gas Embolism and acute PE
 EndoBronchial Intubation

15. Considerations of
pneumo-peritoneum

16. Cardiovascular effects

20. Conduct of anaesthesia
 The most common technique used for laparoscopic surgeries is
General anaesthesia.
 protects against gastric acid aspiration,
 Allows optimal control of CO2, and facilitates good surgical access.
Pre-anesthetic Check up
 Pneumo-peritoneum stresses cardiovascular and respiratory
system more.
 For patients with heart disease the postoperative benefits of
laparoscopy must be balanced against the intraoperative risks.
 PFT is advisable in preoperatively poor pulmonary reserve like
individuals with COPD

21. Pre-medication
 • Anxiolytics
 Inj. Midazolam 1-2 mg iv.
 Or T.Alprazolam 0.5mg oral
Antiemetic
 Inj. Ondansetron 4 mg iv.
Antacids
 Inj. Ranitidine 50 mg iv.
 Inj. Pantoprazole 40 mg iv.
Pro-kinetic drugs
 Inj. Metoclopromide 10 mg iv.
 • Preemptive analgesia with NSAIDs.
 • Glycopyrrolate/Atropine to prevent vagally mediated
bradyarrhythmias or as antisialogogues

22. Monitoring
 1.Routine Patient Monitoring Include
 Continuous ECG
 Intermittent NIBP
 Pulse oximetry (SpO2)
 Capnography (EtCO2)
 Temperature
 Intraabdominal pressure
 2. Optional Monitoring Include
 Pulmonary airway pressure
 Oesophageal stethoscope
 Precordial doppler
 Transoesophageal echocardiography

23. Induction
 • Propofol : 2-2.5 mg/kg.
 • Thiopentone : 4-6 mg/kg.
 Advantages of propofol:
 significantly quicker recovery
 an earlier return of psychomotor function compared with
thiopental or methohexital.
 incidence of nausea and vomiting is markedly less than
other IV anaesthetics.
 because of its pharmacokinetics, it is superior to
barbiturates for maintenance of anaesthesia

24. Inhalational agents
 Maintaining deep level of anaesthesia with agents like
Halothane, Isoflurane & Sevoflurane blunt the haemodynamic
response to pneumoperitoneum.
 Nitrous oxide causing nausea & vomiting is controversial. But
it may distend the bowel, in patients with intestinal
obstruction.

25. 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
 Succinylcholine 1-2mg/kg iv.
 Non depolarizing muscle relaxants
Vecuronium 0.04-0.05mg/kg or
Atracurium: 0.5mg/kg,
Rocuronium: 0.6-1mg/kg iv.
Reversal :
 Inj. Neostigmine : 0.05 mg/kg IV
 Inj. Glycopyrolate : 0.01 mg/kg IV

26. Regional anaesthesia
 Avoids risk of bronchospasm due to intubation
 Excellent intraoperative and postoperative analgesia
 Problems:
 Spontaneous ventilation may lead to hypoventilation
 Hypercarbia and acidosis can increase PVR
 Inadequate muscle relaxation, coughing / bucking
 High levels of spinal / epidural block
 Increase parasympathetic tone and cause bronchospasm
 Decrease ERV by ~50%, detrimental for active expiration
 Hypotension
 Prolonged procedure, patient discomfort, shivering
 Heavy sedation may be worse than light GA

27. Intra operative complications
 Injury from surgical instruments.
 Arrythmias
 Congestive cardiac failure & cardiac arrest.
 Gas embolism.
 Pneumothorax & pneumopericardium.
 Subcutaneous emphysema.
 Gastric aspiration

28. Diagnosis of Respiratory complication during
Laparoscopy

29. CO2 s/c emphysema
Causes
 a) accidental extraperit insufflation (malpositioned veress needle)
 b) deliberate extraperitoneal insufflations- retroperitoneal surg, .
fundoplication, pelvic lymphadenectomy
 Treatment
 1. stop CO2 insufflation, interrupt lap temporarily
 2. MV continued till hypercapnia resolves
 3. resume lap at low insufflation Pressure thereafter

30. Pneumothorax /
pneumomediastinum
 Causes
 1. pleuroperitoneal communications (R>L)
 2. Diaphragm defects( aortic, esophageal,
GE jn surg)
 3. Rupture of preexisting bullae

31. CO2 embolism (rare but
potentially fatal)
 Risk factors - hysteroscopies, previous abd surg.
 Consequences- GAS LOCK in vena cava ,RA → ↓ VR →©
collapse
 - Acute RV HTN → opens foramen ovale → paradoxical gas
embolism
 Diagnosis
 Detection of gas emboli in right side of heart and change of
Doppler sound with Echo
 Tachycardia, ↓BP, ↑ CVP, hypoxia, cyanosis, Millwheel murmur
 Decrease eTCO2
 ECG- Rt heart strain
 Aspiration of gas/ foamy blood from CVP line

32.  Treatment of CO2 embolism:
 Immediate cessation of insufflation and release
pneumoperitoneum
 Position – steep head low + durrant position
 Stop N2O
 Give 100%O2 to correct hypoxemia and reduce the sixe of
gas emboli
 Hyperventilation
 CVP/PA catheter to aspirate CO2
 Cardiac massage may break embolus- rapid absorption
 CPR must be started if necessary
 Hyperbaric O2 – if cerebral embolism suspected

33. Endobronchial intubation
 Due to cephalad movement of diaphragm with
head down tilt and IAP
 Diagnosis - Sp O2 ↓; ↑ airway Pressure
 Treatment – Repositioning of ETT

34. Aspiration
 Mendelson syndrome
 At IAP>20 mmHg
 Changes in LES due to IAP that maintain trans
sphincteric Pressure gradient + head down position
protect against entry of gastric content in airways

35. Nerve injuries
 Prevented by
 avoid overextension of arms
 padding at Pressure points

36. LAPROSCOPY IN CHILDREN
 Physiological changes = adults
 PaCo2 & EtCo2 increase but ETco2 overestimates
PaCo2
 Co2 absorbed more rapid and intense due to larger
peritoneal SA / body wt.
 More chances of trauma to liver during trocar insertion
 More chances of bradycardia , maintain IAP to as low as
possible

37. LAPROSCOPY IN PREGNANCY
 Indications- adnexal surgery, appendicectomy, cholecystectomy
 Risk – preterm labour, miscarriage, fetal acidosis
 Timing – II trimester (< 23 wk)
 Lap technique – HASSANS tech
 Special considerations
 prophylactic- antithrombolytic measures + tocolytics
 operating time to be minimised
 IAP as low as possible
 Continous fetal monitoring (TVS)
 Lead shield to protect foetus if intra operative cholangiography needed

38. GASLESS LAPAROSCOPY
 Peritoneal lift is optained using fan retractor
 Avoids hemodynamic and respiratory repercussions of increase
IAP
 Renal and splanchnic perfusion is not altered
 Problems :
 Compromised surgical exposure
 Increases technical difficulty