Laparoscopic surgery involves insufflating the abdominal cavity with gas to provide space for visualization and instruments. Anesthesia aims to minimize the cardiovascular and respiratory effects of pneumoperitoneum and positioning. General anesthesia is most common to protect the airway and control gas flow. Care is taken with patient positioning, gas selection, and addressing risks like gas embolism, pneumothorax, or nerve injury. Special considerations exist for laparoscopy in children, pregnancy, and gasless techniques.

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