Laparoscopic surgery & it's anaesthetic management

1. DR ZIKRULLAH

2. HISTORY
- first introduced in 20th century
- 1970 – used in gynaecological
procedures
- 1975 – first lap. Salphingectomy
- 1981 – lap appendicectomy
- 1989 – first lap. Cholecystectomy

3. Main concerns:
• gas insufflation
• pneumoperitoneum and increased IAP
• patient’s posture and frequent change in
positions
• PONV

4. ADVANTAGES
• Minimally invasive
• Minimal post op pain
• Shorter hospital stay
• Faster recovery rapid return to work
• Less wound complications
• Done as day care surgery

5. DRAWBACKS
• Longer duration of surgery
• 3D view is not possible
• Impaired touch sensation
• Requires expertise

6. LAPAROSCOPIC PROCEDURES
• GIT
• Gynaecological
• Urological
• Neurosurgery
• Thoracic surgery
• Spinal surgery

7. LAPAROSCOPIC SURGERIES
GIT : cholecystectomy , appendicectomy ,
colectomy
hiatal , inguinal & diaphragmatic hernia
Nissens fundoplication
lysis of adhesions
GYNAECOLOGICAL : ovarian cystectomies ,
LAVH
B/L salphingo oopherectomy , tubal ligations,
ectopic /tubal pregnancy , fibroidectomy,
diagnostic procedures

8. UROLOGICAL : nephrectomy, pyeloplasty
adrenelectomy, prostatectomy
NEUROSURGERY : lumbar peritoneal shunt
ventriculo peritoneal shunt
THORACIC SURGERIES
SPINAL SURGERY : lumbar discectomy

9. INSUFFLATING GAS OF CHOICE
The ideal gas should be
• Colourless
• Non flammable
• Inert
• Easily available
• Inexpensive
• Readily soluble in blood and easily
removed

10. Gases used:
CO2
helium
argon
air
oxygen
nitrogen

11. Gas Oswalds B:G
solubility coef.
complications
1 Helium 0.00098 Embolism, expensive
2 Air 0.017 Supports combustion, Gas embolism
3 Oxygen 0.036 Supports combustion
4 Nitrogen Gas embolism
5 N2O 0.042 Supports combustion (if mixed with
methane from bowel), Bowel
distension, PONV, Explosion with
cautery
6 CO2
0.49 Hypercarbia, Pain abdomen ,Shoulder
tip pain, Arrhythmia, Promotion of port
site tumour growth, peritoneal irritant
7 Argon Embolism, expensive

12. CONTRA INDICATIONS
No absolute contra indications
Relative :
Severe COPD
Recent MI
Increased ICT
V-P shunt
Valvular heart diseases

13. GAS INSUFFLATION & CO2 RETENTION
Inc. in PaCO2 can be due to
• absorption of CO2 from the peritoneal cavity
• impairment of pulmonary ventilation
PaCO2 increases progressively and
reaches a plateau in 15 – 30 minutes.

14. • Hypercarbia - peripheral vasodilation
myocardial depression
hypotension
bradycardia
• Peritoneal stretch - vagal response
bradyarrythmias

15. hypercarbia
adrenal sympathetic stimulation
in HR, SVR, CO, BP
tachyarrythmias
Sensitizes the myocardium to the
catecholamines and sympathomimetic
effects of inhalational agents

16. Other effects:
• Dec. the mesenteric blood flow
• Activates ADH there by dec. the urine
output
• Can cause cerebral vasodilation and
inc. ICP

17. TEMPERATURE
o Cont. flow of dry gas
olavage with cold fluids

18. PNEUMOPERITONEUM
CVS:
If IAP >15 mmHg cardiac output decreases by 10-30%
IAP
IVC compression (pooling of blood in LL)
VR to heart
CO

19. IAP
intra thoracic pressure
release of neurohumoral factors
systemic vascular resistance
BP

20. inc. IAP
venous stasis in lower limbs
thromboembolic events

21. Respiratory system:
Decrease the thoracopulmonary
compliance by 30 to 50%
inc. IAP
splinting of the diaphragm
dec. in TLV , VC, FRC
CO2 retention & decrease in
oxygen saturation

22. GIT:
IAP – intragastric pressure
- lower esophageal sphincter tone
- decreases mesenteric blood flow
RENAL:
IAP – RBF and GFR by <50%
- oliguria or anuria
urine output increases soon after deflation

23. CEREBRAL:
Cerebral blood flow increases during CO2
pneumoperitoneum in response to the
increased PaCO2 ↑ the ICP
inc IAP – dec. lumbar plexus drainage
- ↑ the ICP

24. PATIENT POSITION
done to produce displacement of other
visceras from the surgical site
Commonly used:
• Lap chole – Trendelenberg, reverse
Trendelenberg
• Urological – Trendelenberg/ lateral
• OBG – lithotomy with head down
• Thoracoscopies – lateral decubitus

25. Trendelenberg :
• 15-20⁰ head down
• CVS – VR, CO, cerebral blood flow
• Resp. – VC, FRC, compliance, atelectasis
• Inc. intraocular pressure
Reverse Trendelenberg:
• 20-30⁰ head up
• CVS – VR , CO , cerebral blood flow
• Predisposes to DVT

26. Anaesthetic Management

27. ANAESTHETIC GOALS
Fulfill surgical requirements and
physiological changes during surgery.
Vigilant monitoring for early detection of
complications.
Rapid recovery
Conversion to open laparotomy

28. CHOICE OF ANAESTHESIA
 General anaesthesia
 Regional anaesthesia - SAB, epidural,
CSE
 GA combined with RA
 Local anaesthesia

29. PRE-OPERATIVE ASSESSMENT
Detailed pre operative evaluation
Special attention to the cardiac and pulmonary
status of all patients
INVESTIGATIONS
Complete hemogram
RBS
Na , K
B.Urea , S. Creatinine
Coagulation profile
CXR , ECG
ABG

30. PRE MEDICATIONS
• Anxiolytics
• Antiemetic
• H2 receptor blockers
• Gastro-kinetic drugs
• Atropine to prevent vagally
mediated bradyarrhythmias

31. MONITORING
• Continuous ECG
• Intermittent NIBP
• Pulse oximetry (SpO2)
• Capnography (EtCO2)
• Temperature
• Intraabdominal pressure
Optional Monitoring
• Oesophageal stethoscope
• Precordial doppler
• Transoesophageal echocardiography

32. GENERAL ANAESTHESIA
• Preloading with crystalloid solution
is recommended
• Pre-oxygenation
• During induction of Anaesthesia,
avoid stomach inflation
• Tracheal intubation – mandatory
• NG tube placement for stomach
decompression and prevent
aspiration

33. MAINTENANCE OF ANAESTHESIA
• Intermittent positive pressure ventilation
(IPPV) .
• Normocarbia (35-40mmHg) to be maintained
• Use of nitrous oxide is controversial
• Halothane increases the incidence of
arrhythmias
• Isoflurane / sevoflurane comparatively better
REVERSAL :
neostigmine (0.05 mg/kg)
glycopyrollate (0.01 mg/kg)

34. ADVANTAGES :
• Provides good muscle relaxation & ventilation,
normocarbia
• Field of exposure decreasing risk of perforation
by instruments
• Protection against aspiration
• Trendelenburg position may cause resp .
compromise & dyspnoea in awake spon .
breathing

35. REGIONAL ANAESTHESIA
• Epidural anaesthesia for gynaecological
laparoscopic procedures to reduce
complications and shorten recovery time
after anaesthesia .
• Been reported for laparoscopic
cholecystectomy in patients with cystic
fibrosis and COPD.

36. ADVANTAGES
 Pt is awake - easier detection of
complications
 Excellent postop . analgesia
 Less PONV
 No IPPV induced cardiovascular changes

37. DISADVANTAGES
• Extensive and dense block (T4-L5) needed to
abolish discomfort d/t handling.
• Sympathetic block may exaggerate
pneumoperitoneum induced vagal reflexes
• Pain at shoulder tip remains unrelieved
intraop as well.

38. COMBINED EPIDURAL AND GA
Epidural anaesthesia used as an adjunct
to GA can reduce
 untoward physiologic responses,
 dosage of GA and LA drugs,
 perioperative morbidity.

39. LOCAL ANAESTHESIA
• Local anaesthesia with IV sedation
• Quick recovery
• Less PONV
• Less haemodynamic changes
• Early diagnosis of complications
DISADV:
• Sedation and pneumoperitoneum – hypovent - hypercarbia
and desaturation
• Requires precise and gentle surgical technique

40. COMPLICATION OF LAPAROSCOPY
 Due to trochar injury
 Positioning and compression effect
 CVS and Respiratory complications
 Thermal injuries
 Gas embolism

41. COMPLICATIONS
Subcutaneous Emphysema
• Occur if the tip of the Veress needle does not
penetrate the peritoneal cavity prior to
insufflation of gas.
• During fundoplication for hiatus hernia repair
• Extraperitoneal insufflation - sudden rise in the
EtCO2, excessive changes in airway pressure and
respiratory acidosis

42. COMPLICATIONS
Pneumothorax, Pneumomediastinum And
Pneumopericardium
• Patent pleuro - peritoneal channels
• Pleural injuries
• Ruptured emphysematous bullae

43. Diagnosis
• Sudden hypoxia
• Rise in peak airway pressure
• Hypercarbia
• Abnormal movement of the hemidiaphragm

44. Management:
• Stop N2O
• Adjust ventilator settings to correct hypoxemia
• If due to pleuro peritoneal channel route apply PEEP
• Communicate with surgeon
• Reduce intra-abdominal pressure
• Avoid PEEP if there is rupture of emphysematous bulla and
thoracocentesis is mandatory

45. COMPLICATIONS
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
• Gas insufflation into abdominal organ

46. 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

47. Diagnosis of gas embolism:
• Detection of gas in right side of Heart –
foamy blood aspirated in the central
venous catheter
• Recognition of physiological changes
secondary to emboli
• Doppler & TEE ---- very sensitive
(0.5ml/kg)

48. Management
• Immediate cessation of insufflation
• Release of pneumo-peritoneum
• Patient in head down and left lateral
decubitus (Durant’s) position
• Cessation of N2O
• Give 100% oxygen
• CVP insertion and aspiration of gas

49. COMPLICATIONS
Postoperative Pain
• abdominal and shoulder tip pain
• Complete removal of the gas is essential
• Infiltration of the portal sites with a local
anaesthetic
• Right-sided subdiaphragmatic
instillation with a local anaesthetic

50. COMPLICATIONS
Post Operative Nausea & Vomiting (PONV)
• Peritoneal insufflation, bowel manipulation and
pelvic surgery are some of the causative factors .
Nerve Injury
• Hyper extension of arm --- brachial plexus injury
• Lithotomy position --- common peroneal injury

51. GASLESS LAPAROSCOPY
• Alternative to gas insufflation
• Peritoneal cavity is expanded using abdominal wall
lift with a fan retractor
• Avoids haemodynamic and respiratory compromises
of inc. IAP
• Port site metastasis is less

52. LAPAROSCOPY IN PREGNANT PATIENTS
Special considerations:
• Abdominal surgeries increases the risk of
miscarriage and premature labour
• Damage to the gravid uterus
• Hypercarbia induced significant fetal acidosis

53. Recommendations for safe laparoscopy
• Surgery should be done in 2nd trimester – before 23rd
week of pregnancy
• Open laparoscopy should be used
• Use of tocolytics
• Fetal monitoring by TVS
• Maintain physiologic maternal alkalosis

54. LAPAROSCOPIC SURGERIES IN CHILDREN
 Small abdominal surface and organs
 The abdominal wall in children is
pliable
 The trans umbilical open laparoscopic
technique for insufflation under direct
vision is recommended
 Gasless laparoscopic surgery

55. • In infants < 5 kg , peri umbilical area should
not be used for port access.
• Cold, non-humidified CO2 contributes to a
major risk of hypothermia.
• A fluid bolus of 20 ml/kg can be used to offset
hemodynamic effects.

56.  In neonates, the foramen ovale or the ductus
arteriosus is potentially patent and may
reopen during the procedure.
 The pulmonary arterial resistance is relatively
high, predisposing to reverse flow through a
patent ductus arteriosus or foramen ovale.

57.  CO2 absorption is more intense and faster in infants
 Volume of gas for creation of pneumo peritoneum
is less
 IAP should be limited to 5 – 10 mm Hg in neonates
& infants and 10 – 12 mm Hg in older children.

58. THANKS