Anaesthetic implication of laparoscopic surgery will help medical students as well as doctors performing safe anaesthesia practice in laparosc opic surgery.

1. Anesthetic implication in laparoscopic
surgeries
dr.satyajitkumarsahoo
assistantprofessor,
dept.of anaesthesia,
ahpgic,cuttack

2. History of laparoscopic surgery
•1910-Hans Christian Jacobaeus-first laparoscopic procedure
in humans
•1983-Semm-first laparoscopic appendicectomy
•1985-Muhe-first laparoscopic cholecystectomy
•Decade of 90s-almost every GI surgery done laparoscopically
•2005-Rao and Reddy-first trans gastric appendicectomy
(NOTES)

3. introduction
It Involves insufflation of gas into peritoneal cavity and
Visualization of abdominal cavity through an endoscope.

4. Why Laparascopy ?
Advantages:-
 Significant less trauma compared to open
procedure.
 Reduce post operative pain.
 Reduce blood loss.
 Short recovery time and shorter hospital stay.
 Better cosmetic result.
 Reduced wound complication.
 Better post operative respiratory function.
 More rapid return to normal activity.
 Cost savings.

5. Other benefits
 Less stress response
 Hyperglycaemia
 Cortisol release
 IL-6
 Avoid intestinal handling and reduces peritoneal
irritation
 Diagnostic lap.

6. Disadvantages:-
Long duration of surgery
Loss of 3D view and impaired touch sensation.
Risk of visceral /vessel injury (may go
unrecognised).
Long learning curve of surgeons.

7. Contra indication of laparoscopy
Diaphragmatic hernia
Acute or recent MI
Severe obstructive lung disease
Raised ICP
V-P shunt
Hypovolemia
CCF
Valvular heart disease.

8. PROPERTIES OF THE insufflating GAS

9. GAS ADVANTAGES DISADVANTAGES
AIR • Easily available
• Inexpensive
• Less soluble in blood(BGS .016) → air embolism
→ poor absorption → shoulde pain
• Supports combustion
NITRO
GEN
• Does not support combustion
• Avoids hyper capnia
Less soluble in blood → gas embolism
N₂O • No hypercabia
• No arrhythmia
• BGS 0.47
• Minimal shoulder pain
• Supports combustion more than air
• Intra peritoneal explosion if mixed with methane(bowel injury)
• Bowel distension
• PONV
He/Ar • Inert
• No hyper carbia
• Does not support combustion
• Low blood solubility → gas embolization
• Not easily available
• Not cost effective
CO₂ • Easily available
• Nontoxic/non inflammable
• High BGS (.8) →highly soluble
in blood → minimal gas
embolism
• High carriage by bicarb buffer
and combining with
Hb→rapidly cleared by lungs
• Inert/ non irritant
• Arrhythmia
• acidosis

10. Physiological changes during laparoscopy
Effects of pneumo peritoneum and
positioning
↑ IAP

11. Question -1
Q. Which of the following is NOT TRUE
following pneumoperitoneum ?
A. Closing volume increased
B. Airway resistance increased
C. Thoracic compliance decreased
D. Shape of press- vol. loop altered.
s
Ans. Shape of press- vol. loop not altered

12. RESPIRATORY system
Effect exaggerated in - obese patient
ASA grade II /III
Respiratory dysfunction
Elevated diaphragm →
↓ FRC
↑ closing vol. → basal atelectasis
↑V/Q mismatch → hypoxemia
↑ airway resistance
↓ thoracic compliance 30 – 50 %
Hyper carbia – after CO₂ insufflation progressive increase in
PaCO₂ and reaches plateau level by about 15 minutes.

13. Contd…..
At IAP <15 CO₂ absorption ∝ IAP
IAP ˃ 15 peritoneal circulation drops and rate of
CO₂ absorption drops.
Lack of consistency in relation between PaCO₂ and
EtCO₂
Increased IAP → cephalad movement of carina
and diaphragm → possibility of endo bronchial
intubation
especially in head low position.

14. •Depends on
patients pre existing CV status
anaesthetic technique
IAP
CO₂ absorption
patient position
duration of surgical procedure
Effect On Cardio Vascular System

15. Contd….
IAP upto 5mm Hg→ minimal effect
IAP ˃ 10 mm Hg → subdiaphragmatic narrowing of IVC
Compression of venous capacitance vessels & arterial
resistance vessels
↑ PVR & ↑ SVR
↑ MAP
Initial ↑ pre load & ↑ afterload
 cardiac output not affected
Later preload may decrease
Further rise in IAP ˃ 15
Decline in LV function
CI reduced by 30- 40%
peripheral pooling of blood

16. Effect on CVS…..
• BRADY ARRHYTHMIA
oLess common
oNeedle insertion
oPeritoneal stretch
oFast insufflation
oCO₂ embolization
• Tachy arrhythmia
oHigh PaCO₂ & catecholamine release
oHypoxia
oGas embolism
oLight plane of anaesthesia

17. Management
Adequate pre load improves CO
Intermittent pneumatic compression
Use of ꭤ₂ agonist dexmedetomidine & ꞵ
blockers
Use of atropine
Deepening plane of anaesthesia
Mild hyper ventilation

18. Effect on liver
•Decreased hepatic & sup mesenteric A. blood flow
•↑ portal venous blood flow
•Transient ↑ of liver enzymes
•Minimal elevation of CRP & IL-6 compared to
laparotomy

19. Effect on RENAL SYSTEM
•↑ IAP → ↓ RBF (both cortical & medullary)
↑ADH, RENIN& aldosterone secretion
↓ GFR & ↓ UO
↓Creatinine clearance

20. Effect on CNS
• INCREASED CBF
•INCREASED ICP

21. EFFECT ON GIT
•↑ incidence of regurgitation & aspiration
•PONV 40-75%
Other system
•Peripheral pooling of blood
• venous stasis
•Risk of DVT
•Prolonged head low position → ↑ IOP % Visual
loss

22. HEMODYNAMIC REPURCUSSIONS OF PNEUMOPERITONEUM IN
HEALTHY PATIENTS

23. Effects of pt position

24. PROBLEMS RELATED TO PATIENT POSITION
• Pelvic and lower abdominal surgeries-Trendelenberg
• Upper abdominal surgery- Reverse Trendelenberg
• Gynaecological procedure - lithotomy

25. RESPIRATORY CHANGES
•Trendelenberg ( head down)
 ↑WOB & Atelectasis in spont breathing pt.
 FRC
 TLV
 Pulmonary compliance
Endobronchial intubation
More marked in obese, elderly and debilitated
•Reverse Trendelenberg (head up)
Improves pulmonary dynamics

26. CARDIOVASCULAR EFFECTS
• Trendelenberg h(head down)
 ↑ CVP
 ↑ CO
 ↑ CBF
 ↑ ICP
 ↑ IOP
Reverse Trendelenberg (head up)
Compounds the hemodynamic changes induced by pneumoperitoneum
Further blood pooling in legs
↓ Venous return
↓ CO
↓ MAP
Legs must be freely supported, not tightly strapped and pressure on
popliteal space must be prevented

27. Nerve injuries
•Brachial plexus injury
•Common peroneal n. injury → lithotomy
position
•Arm by side of patient preferred

28. Anaesthetic management

29. Question- 2
Q. pts with VP shunts and Foramen
ovale are contraindications for
laparoscopic procedures
A.True
B.Relative contraindication
C.false
Ans. B

30. PREOPERATIVE EVALUATION
Routine evaluation
Cardio respiratory functional status & co morbidities
I. Absolute contraindications -rare
II. Relative contraindications
1. ICP
2. Hypovolemia
3. Cardiac disease
• Patients with CHF & terminal valvular insufficiency are more prone to develop cardiac
complications.
• Rt → Lt shunt. → paradoxical air embolism.
• Risk benefit ratio should be compared-laparoscopy versus laparotomy
4.Advance pulmonary disease
5. Glaucoma
6. Renal disease
• Optimize hemodynamics
• Nephrotoxic drugs to be avoided
Safe in patients with VP shunt and PJ shunt with unidirectional valve
Obesity – no more a contra indication
DVT prophylaxis

31. Patient preparation
NPO 6-8hrs
Anxiolytics
Tab Alprazolam 0.25 mg night before surgery.
Antacids
Tab Ranitidine 150 mg
Prokinetics
Anti emetics
Drugs to decrease the intraoperative stress response.
dexmedetomidine very useful

32. monitoring
• Stetho – endo bronchial intubation
• ECG – arrythmia
• Pulse oximetry
• IAP (insufflator)—
avoid rapid rate of insufflation
• Temp –
• Capnometry
sudden decrease in EtCO₂ → ↓ CO
Gas embolism
• Neuro muscular monitoring

33. Question-3
Q. INCORRECT statement about
capnography during laparoscopy
A.Paco₂- PetCO₂ gradient is always < 2-6 mm Hg
B. Paco₂ may be underestimated by PetCO₂
C. Sudden reduction in PetCO₂ indicates
obliterated pulmonary circulation
D.Reduced PetCO₂ may indicate low cardiac
output.
Ans. A. Gradient not always maintained

34. Anaesthetic technique
•General anesthesia with ET intubation and controlled
ventilation-safest and most common
•Protects against gastric aspiration, allows optimal CO2
control.

35. • Supra glottic airway devices
Allows controlled ventilation and accurate monitoring of ETco2
But risk of aspiration of gastric contents persists
Proseal LMA, baska mask ( 2nd gen SGD) preferred
• Regional anaesthesia
Blockade T₄ to L₅.
 NOT PREFERRED

36. •Goals
1. Smooth induction
2. Good relaxation
3. Quick recovery
4. Early discharge
Precautions
Deflate stomach with RT
Bladder emptying
Prevent nerve injuries
Protection of eye
Fasten patient to OT table.
Slow progressive tilt
PaCO₂ 30-35 mm of Hg.

37. VENTILATION STRATEGIES
• During pneumo
- peak & plateau pr. ↑ by 50%
- dynamic & static compliance ↓ by 50 %
- basal lung collapse.
- ↓ FRC
- ↑ V/Q mismatch
PCV preferred
- lowers airway pressure
- greater dynamic lung compliance
• Protective MV
oLow TV -- 6-8 ml /kg ideal body wt
oPlateau pr. < 16 cm of H₂O
oModerate PEEP
oAlveolar recruitment maneuver
• IPPV must be adjusted to maintain PETco2 between 30 to 35 mm hg, this needs an
increase in minute ventilation
• I/E ratio 1:1 or 1:2

38. PATIENT POSITIONING AND MONITORING
• Nerve injuries to be prevented-padding
• Patient tilt-should not exceed 15 to 20 degrees, slow and
progressive
• Pneumoperitoneum-induction and release must be slow and
progressive
• Position of ET tube must be confirmed after any change in
patient position
• BP, HR, ECG, Capnometry ,pulse oximetry and ABG must
be continuously monitored

39. RECOVERY AND POST OPERATIVE MONITORING
• Hemodynamic monitoring should be continued in the PACU
• Oxygen to be administered post operatively
• Prevention and treatment of nausea ,vomiting and pain

40. INTRA OPERATIVE COMPLICATIONS
•Bowel perforation
•Vascular injuries
•Burns
•Retroperitoneal hematoma
•Co2 subcutaneous emphysema
•Gas embolism
•Pneumothorax, pneumomediastinum,
pneumopericardium
•Endobronchial intubation
•Risk of aspiration

41. GAS EMBOLISM
• Though incidence very less (< .6), most feared and fatal
complication
• Hysteroscopy- due to intra vascular injection of gas.
• Embolus size ˃ 2 ml/kg
Features-
Tachycardia
Arrhythmia
Hypotension
Mill wheel murmur
ECG- rt ventricular strain pattern
Capnography- ↓ EtCO₂
Management-
Stop CO₂, release pneumo
Durant`s position- steep head down &lt lateral tilt
Stop N₂O, 100 % O₂
Aspirate

42. Question. 4
Q. the manifestation of gas embolism
may include all except
1. Tachycardia
2. Hypotension
3. Millwheel murmur
4. Left ventricular strain pattern on ECG
Ans. Rt ventricular strain pattern

43. Question -5
Q. The treatment of gas embolism
includes all except
A.Stop CO₂ insufflation
B.Release of pneumoperitoneum
C.Steep head down
D.Right lateral tilt
Ans. D. Left lateral tilt

44. CO2 Subcutaneous Emphysema
•Accidental extraperitoneal insufflation
•Renal surgery , hernia repair , fundoplication
•Any increase in PEtCO₂ after plateau phase.
•VCO2,PaCO₂ and PEtCO₂ increase
•Laparoscopy must be temporarily interrupted
•Resumed after correction of hypercapnia with a lower
insufflation pressure
•Keep the patient mechanically ventilated.

45. QUESTION 6
•Embryonic remnants-potential channels-
•The opening of pleuro- peritoneal duct due to
CO₂ pneumoperitoneum causes mainly
A.Right sided pneumothorax
B.Left sided pneumothorax
Ans. Right sided pneumothorax
.

46. PNEUMOTHORAX,PNEUMOMEDIASTINUM,
PNEUMOPERICARDIUM
•Embryonic remnants-potential channels
-right sided
•Defects in the diaphragm
•Secondary to pleural tears-left sided
Management-
 100% oxygen
Stop N₂O
Allow PEEP
Decrease IAP
Pneumo will resolve after exsufflation.

47. capnograp
hy
normal ↑ETCO₂ ↑ETCO₂ ↓ETCO₂ ↓ETCO₂
Pulse
oximetry
↓SpO₂ normal ↓SpO₂ ↓SpO₂ ↓SpO₂
Airway
pressure
↑ paw normal ↑ paw ↑ paw normal
Reduced
air entry
yes no yes yes murmur
Hyper
resonance
no no yes yes ↓BP
crepitus no yes May be May be ECG changes
diagnosis
Endo
broncheal
Subcutaneous
emphysema
Capno-
thorax
Pneumo
thorax
CO₂
embolism

48. POST OPERATIVE NAUSEA AND VOMITING( PONV)
•40 – 70%
•Opioids increase
•Propofol anesthesia reduces
•Intraoperative drainage of gastric contents reduces
PONV
•Intraopertive droperidol and 5-HT (type 3)
•Transdermal scopolamine

49. Laparoscopy v/s laparotomy

50. STRESS RESPONSE
•Reduction of acute phase reaction
•Reduced metabolic response
•Nitrogen balance and immune functions better preserved
•Reduced duration of post operative ileus,IV infusion, fasting
and hospital stay
•Hemodynamic disturbances and ventilatory changes induced
by pneumoperitoneum may contribute to stress response of
laparoscopy
•Preoperative administration of ꭤ₂-agonists can reduce stress
response

51. POST OPERATIVE PAIN
•Multi modal approach.
• paracetamol /NSAID
•Local anaesthetic infiltration-intraperitoneal and
port site.
•Regional analgesia.
•Preemptive analgesia
•Dexamethasone-reduces post operative pain

52. REGIONAL ANAESTHESIA
•Both epidural and spinal can be used with slight sedation
•Extensive sensory block (T4-L5)

53. LAPAROSCOPY DURING PREGNANCY AND IN CHILDREN
•Adenexal surgery, appendectomy, cholecystectomy
•Hemodynamic changes are similar
•Increased risk of miscarriage and premature labour. So
operation should be done during 2nd trimester (ideally
before 23rd week of pregnancy)
•Risk of damaging the gravid uterus can be avoided by
alternative entry sites
•Induces significant fetal acidosis

54. •FHR and arterial pressure increase, but these
changes are minimal
•Capnography is adequate to guide ventilation
•Mechanical ventilation must be adjusted to maintain
a physiologic maternal alkalosis
•Fetal monitoring –TVS
•Gasless laparoscopy is an alternative
•In children –hemodynamic and ventilatory changes
are the same

55. Gasless laparoscopy
•Peritoneal cavity is expanded using abdominal wall lift
obtained with a fan retractor
•No hemodynamic and respiratory repercussions of increased
IAP and problems due to co₂
•Compromises surgical exposure
•Combining it with low pressure co2 pneumoperitoneum
(5 mmHg)may improve surgical conditions

56. conclusion
•General anesthesia with controlled ventilation is the
most accepted and safest technique
•Regional anesthesia with slight sedation can also be
used