Anaesthesia For Laparoscopic Assisted Surgery Dr. Shailendra

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Anesthesia problems for Laparoscopic surgeries

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Anaesthesia For Laparoscopic Assisted Surgery Dr. Shailendra

  1. 1. Anesthesia management of Laparoscopic Assisted Surgery. Dr. Mohammed Mahdy Consultant in Anaesthesiology Al Bukariya general hospital
  2. 2. Introduction <ul><li>Laparoscopy introduced in 20 th Century </li></ul><ul><li>1962 : first laparoscopic tubal ligation </li></ul><ul><li>1970 -- 80 : used for gyne procedures </li></ul><ul><li>1989: laparoscopic cholecystectomy </li></ul><ul><li>Rapid advances in technology </li></ul>
  3. 3. Total No of cases from 3 / 1421 to 11 / 1425 75.2% 11.9% 6.3% 4.7% Total cases: 1260
  4. 4. Laparoscopic Procedures <ul><li>General Surgery: </li></ul><ul><ul><li>Cholecystectomy </li></ul></ul><ul><ul><li>Appendicectomy </li></ul></ul><ul><ul><li>Varicocoelectomy </li></ul></ul><ul><ul><li>Hernioplasty </li></ul></ul><ul><ul><li>Diagnostic laparoscopy </li></ul></ul><ul><ul><li>Hiatus hernia repair </li></ul></ul><ul><ul><li>Adhesiolysis </li></ul></ul><ul><li>OBG: </li></ul><ul><ul><li>Ectopic pregnancy </li></ul></ul><ul><ul><li>Myomectomy </li></ul></ul><ul><ul><li>LAVH </li></ul></ul><ul><ul><li>Endometriosis </li></ul></ul><ul><li>Thoracic Surgery: </li></ul><ul><ul><li>Sympathectomy </li></ul></ul><ul><ul><li>Mediastinoscopy </li></ul></ul>
  5. 5. Advantages of Laparoscopy <ul><li>Shorter hospital stay </li></ul><ul><li>Faster recovery </li></ul><ul><li>Rapid return to normal activities </li></ul><ul><li>Minimal pain </li></ul><ul><li>Small scar </li></ul><ul><li>Less post-op ileus </li></ul>
  6. 6. Contraindications for Laparoscopy <ul><li>Increased ICP </li></ul><ul><li>V – P shunt </li></ul><ul><li>Hypovolemia </li></ul><ul><li>CCF </li></ul><ul><li>Valvular heart diseases </li></ul>
  7. 7. Anaesthetic Plan <ul><li>Pre-operative assessment </li></ul><ul><li>Pre-medication </li></ul><ul><ul><li>Anxiolytics </li></ul></ul><ul><ul><li>H2 receptor blockers </li></ul></ul><ul><ul><li>Gastro-kinetic drugs </li></ul></ul><ul><li>Monitoring: </li></ul><ul><ul><li>Pulse oximetry </li></ul></ul><ul><ul><li>Capnography </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>NIBP </li></ul></ul><ul><ul><li>FiO2 </li></ul></ul>
  8. 8. Anaesthetic Management <ul><li>Preoxygenation </li></ul><ul><li>Induction </li></ul><ul><li>Intubation – mandatory </li></ul><ul><li>NG tube placement </li></ul><ul><ul><li>Stomach decompression </li></ul></ul><ul><li>Maintenance of anaesthesia </li></ul><ul><ul><li>Muscle relaxants </li></ul></ul><ul><ul><li>Volatile anaesthetic agents </li></ul></ul><ul><li>Reversal of NM blockade </li></ul><ul><li>Recovery room </li></ul>
  9. 9. Anesthetic Problems of Laparoscopy <ul><li>Due to pneumo peritoneum </li></ul><ul><li>Due to patient positioning </li></ul><ul><li>Cardiovascular effects </li></ul><ul><li>Respiratory effects </li></ul><ul><li>Gastro intestinal effects </li></ul><ul><li>Unsuspected viseral injuries </li></ul><ul><li>Difficulty in estimating blood loss </li></ul><ul><li>Darkness in the OR </li></ul>
  10. 10. Pneumo Peritonium <ul><li>Preferred gas : CO2 </li></ul><ul><li>Working pressure : 12 to 14 mm Hg </li></ul><ul><li>Slow inflation of 1 litre / minute </li></ul>
  11. 11. CO2 as Insufflator Gas <ul><li>More soluble in blood than air </li></ul><ul><li>Carriage is high due to bicarbonate buffering and combination with Hb </li></ul><ul><li>Rapidly eliminated by lungs </li></ul><ul><li>Inert & not irritant to tissues </li></ul>
  12. 12. Ventilatory problems during Laparoscopy <ul><li>Increase in PaCO2 </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Gas-embolism </li></ul>
  13. 13. Causes for Increased PaCO2 <ul><li>Absorption of PaCO2 –peritoneal cavity </li></ul><ul><li>V/Q mismatch </li></ul><ul><ul><li>Increased physiological dead space </li></ul></ul><ul><ul><li>Abdominal distention </li></ul></ul><ul><ul><li>Patient’s position </li></ul></ul><ul><ul><li>Controlled ventilation </li></ul></ul><ul><ul><li>Reduced cardiac output </li></ul></ul><ul><li>Lighter planes of anaesthesia </li></ul>
  14. 14. Pneumothorax <ul><li>Patent pleuro-peritoneal channels </li></ul><ul><li>Pleural injuries </li></ul><ul><li>Ruptured emphysematous bullae </li></ul>
  15. 15. Management of Pneumothorax Recommended Guidelines <ul><li>Stop N2O </li></ul><ul><li>Adjust vent settings to correct hypoxemia </li></ul><ul><li>Apply PEEP </li></ul><ul><li>Reduce intra-abdominal pressure </li></ul><ul><li>Communicate with surgeon </li></ul><ul><li>Avoid thoracocentesis </li></ul>
  16. 16. Gas Embolism <ul><li>Most feared & fatal complication </li></ul><ul><li>Seen frequently when laparoscopy is associated with hysteroscopy </li></ul><ul><li>Intra vascular injection of gas following direct trocar placement into vessel </li></ul>
  17. 17. Suspicion of Gas Embolism <ul><li>Blood on aspiration from Vere’s needle </li></ul><ul><li>Pulsation of flow meter pressure gauge </li></ul><ul><li>Disappearance of abdominal distention despite sufficient volume of gas </li></ul>
  18. 18. Effects of Massive Air Embolism <ul><li>Rapid insufflation of gas into blood </li></ul><ul><li> </li></ul><ul><li>Gas lock in RA & venacava </li></ul><ul><li> </li></ul><ul><li>Fall in cardiac output </li></ul><ul><li>High pressure in RA </li></ul><ul><li> </li></ul><ul><li>Open foramen ovale </li></ul><ul><li> </li></ul><ul><li>Embolus in cerebral & coronary beds </li></ul><ul><li> </li></ul><ul><li>Paradoxical embolism </li></ul>
  19. 19. Diagnosis of Gas-embolism <ul><li>Detection of gas in right side of Heart </li></ul><ul><li>Recognition of physiological changes secondary to emboli: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Cardiac arrhythmia </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>CVP rise </li></ul></ul><ul><ul><li>Mill-wheel murmur </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Right heart strain pattern in ECG </li></ul></ul><ul><ul><li>Pulmonary edema </li></ul></ul><ul><li>Doppler & TEE ---- very sensitive </li></ul>
  20. 20. Treatment of Gas Embolism <ul><li>Immediate cessation of insufflation </li></ul><ul><li>Release of pneumo-peritoneum </li></ul><ul><li>Patient in Durrent’s position </li></ul><ul><li>Cessation of N2O </li></ul><ul><li>Give 100% oxygen </li></ul><ul><li>CVP insertion and aspiration of gas </li></ul>
  21. 21. Risk factor for Regurgitation <ul><li>Increased intra-abdominal pressure </li></ul><ul><li>Decreased lower oesophageal sphincter tone </li></ul><ul><li>Head down position </li></ul><ul><li>NG tube mandatory </li></ul>
  22. 23. Cardiac Arrhythmias during Laparoscopy <ul><li>Volatile anaesthetic agents </li></ul><ul><li>Hypercarbia </li></ul><ul><li>Sudden stretching of peritoneum </li></ul><ul><li>Electro coagulation of fallopian tubes </li></ul><ul><li>Light planes of anaesthesia </li></ul>
  23. 24. Problems related to patient’s positioning <ul><li>Head – Down tilt for pelvic and sub meso-colic surgery </li></ul><ul><li>Head -Up tilt for supra mesocolic surgery </li></ul><ul><li>Lithotomy position for gynec procedures </li></ul>
  24. 25. Position – Respiratory Effects <ul><li>Head-down position </li></ul><ul><ul><li>Promotes atelectasis </li></ul></ul><ul><ul><li>Decreases FRC </li></ul></ul><ul><ul><li>Decreases TLC </li></ul></ul><ul><ul><li>Decreases pulmonary compliance </li></ul></ul><ul><li>Head-Up position: </li></ul><ul><ul><li>Endo-bronchial intubation </li></ul></ul>
  25. 26. Position- Cardio-Vascular Effects <ul><li>Head down Position: </li></ul><ul><ul><li>Increases CVP </li></ul></ul><ul><ul><li>Increases cardiac output </li></ul></ul><ul><ul><li>Increases cerebral circulation </li></ul></ul><ul><ul><ul><li>Increased ICP </li></ul></ul></ul><ul><ul><ul><li>Increased intra-ocular pressure </li></ul></ul></ul><ul><li>Head up Position: </li></ul><ul><ul><li>Decreased cardiac output </li></ul></ul><ul><ul><li>Decreased mean arterial pressure </li></ul></ul><ul><ul><li>Decreased venous return </li></ul></ul>
  26. 27. Positions : Nerve Injury <ul><li>Hyper extension of arm --- brachial plexus injury </li></ul><ul><li>Lithotomy position --- common peroneal injury </li></ul>
  27. 28. Bibilography: <ul><li>Short practice of anaesthesia – Churchill Davidson </li></ul><ul><li>Synopsis of anaesthesia – Atkinson & Lee </li></ul><ul><li>Text book of anaesthesia – Ronald Miller </li></ul><ul><li>Anaesthesia & coexisting diseases - Stoelting </li></ul>
  28. 29. Thank you
  29. 30. Haemodynamic Repurcussions of Pneumo - Peritoneum <ul><li>↑ Intraabdominal pressure </li></ul><ul><li>↓ Venous return ↑ Intrathoracic pressure </li></ul><ul><li>↑ Pulmonary vascular resistance </li></ul><ul><li> </li></ul><ul><li> Cardiac output </li></ul>
  30. 31. Haemodynamic Repurcussions Of Pneumoperitoneum <ul><li>↑ Intra abdominal pressure </li></ul><ul><li> </li></ul><ul><li>↑ Venous resistance </li></ul><ul><li> </li></ul><ul><li>↑ Systemic vascular resistance </li></ul><ul><li> </li></ul><ul><li>↑ Arterial pressure </li></ul>

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