2. Overview
• Introduction
• Surgical techniques
• Physiologic e
ff
ects of laparoscopy
• Anesthetic management
• Intraoperative complications
• Summary and recommendations
3. Introduction
• The laparoscopic approach standard of care for many surgical procedures.
• Can reduce postoperative pain
• Shorter recovery time
• Reduce the postoperative stress response.
• More expensive
• Longer operating time
• Di
ffi
cult when complicated
• Potential for major complication in inexperienced hands
4. IndicationsandContraindications
• Indications
• On the aggressive end of the spectrum of
indications is the concept that any patient
who would otherwise require laparotomy
and is hemodynamically stable can
undergo attempted laparoscopy (SAGES)
• Contraindications
• Each patient evaluated in risk bene
fi
t
basis
• General Contraindications
• Raised ICP
• Hypovolemia and profound hemodynamic
instability
• R to L Shunts
• Patent foramen Ovale
5. Reduced wound infection
Faster Recovery
Reduced Morbidity
Reduced Pain
Visceral and vascular damage
Positional Injury
Kidney injury
Cardiopulmonary and cerebral
insu
ffi
ciency
Gas Embolism
Well Leg compartment syndrome
6. SurgicalTechniques
• Pneumoperitoneum by insu
ffl
ation of gas,
usually CO2
• Open space in the abdomen for visualization
and allow surgical manipulation
• CO2 insu
ffl
ation can be performed blindly
using a Veress needle
• Port is than placed, and the laparoscope is
inserted
• video monitor connected to the laparoscope
to see intraabdominal contents and perform
the procedure
7. Preoperativeevaluation
• When evaluating to take into account physiologic changes that laparoscopy causes
• How these changes may impact certain comorbid states
• Take into account type and length of laparoscopic procedure
• In general evaluation about the same as for open procedure
10. Cardiovasculareffects
• IAP
SVR
mechanical compression of aorta and production of neurohumoral factors (vasopressin) and
activation of RAAS
• Compression of inferior vena cava
Reduced Preload
Reduced Arterial pressure
• Cephalid displacement of the diaphragm raises intra-thoracic pressure - aggravates
preload
• Reverse Trendelenburg - leg and pelvis blood pooling - hypotension
12. Pulmonaryeffects
•Respiratory changes occur due to raised IAP
and Trendelenburg positioning
•Abdomen is distended by CO2
Increased Intra-thoracic pressure
reduces pulmonary compliance ,FRC
Pulmonary atelectasis
Altered V/Q relationships
Hypoxemia
• Insu
ffl
ated Co2 is absorbed, causing increase in
PCO2 wich is further exacerbated by V/Q mismatch
13. Splanchniceffects
• Renal blood
fl
ow signi
fi
cantly compromised by increased IAP, important in patients
with comorbidities
• Persistent IAP> 20mm/hg - reduction of mesenteric and GI blood
fl
ow by up to 40%
- progressive tissue acidosis if pressure increases
• IAP of 20mm Hg will reduce GFR by 25%
• Impaired renal perfussion occurs from combination of impaired CO and reduced
renal
fl
ow due to increased renal venous pressure
14. Neurologicaleffects
• Increased IAP
• Increased ICP
• Cerebral Edema
Potentially temporary neurological dysfunction in emergence, particularly in long cases and
steep Trendelenburg
16. Anestheticmanagement
• Balanced general anesthesia is the best practice
• Local and regional anesthesia can be used if lower IAP and less steep positioning
• Maintenance of anesthesia - inhaled aneshtetics vs TIVA
• Controversial role of Nitrous Oxide
• Intraoperative Opioids
• Miorelaxants and reversal agents
• Mechanical ventilation
17. Anestheticmanagement
• General anesthesia is standard of care for laparoscopic surgery
• Endotracheal intubation allows ventilatory control and airway securing in Trendelenburg
position
• Regional anesthesia can be used for shorter procedures, which require lower IAP and
minimal head down tilt
• If used it needs to reach sensory level T4 to T6
• Induction mostly IV, related to patient based factors
• Airway devices - ETT standard to protect airways and to control ventilation;
• SGA use controversial - do not fully protect airways; however many studies describe
safe usage of 2nd generation of SGA for laparoscopic procedures*
Choice of Anesthesi
a
a
nd
a
nesthetics
Lim, Y., S. Goel, and J. R. Brimacombe. "The ProSeal™ laryngeal mask airway is an effective alternative to laryngoscope-guided tracheal intubation for gynaecological laparoscopy." Anaesthesia
and intensive care 35.1 (2007): 52-56.
18. Anestheticmanagement
• Maintenance with newer inhaled anesthetics mainstay
• Faster emergence than TIVA
• Some miorelaxant e
ff
ect
• TIVA lower risk of PONV, costlier and more di
ffi
cult to titrate
• Except for very high risk PONV patients, incidence
of PONV similar btw Inhaled and TIVA*
• N2O use is controversial because of distended bowels and increased PONV
• However studies have shown that intraoperative bowel distention was similar with
and without N2O in 3 to 3.5 hour long operations**
M
a
inten
a
nce of
a
nesthesi
a
*Joshi, Girish P. "Inhalational techniques in ambulatory anesthesia." Anesthesiology Clinics of North America 21.2 (2003): 263-272.
APA
**Tramer, M., A. Moore, and H. McQuay. "Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative awareness and postoperative emesis in randomized controlled trials." British Journal of
Anaesthesia 76.2 (1996): 186-193.
19. Anestheticmanagement
• Changes in pulmonary function may require adjustment of ventilation accordingly
• Typically TV need to increas for 20-30% while maintaining tidal volume
• It is recommended to use lung protective strategies
• Low tidal + higher RR + normal PEEP
• Avoid hyperventilation to avoid potential barotrauma
• Mild hypercapnia ETCO2 = 40 mmHg can improve tissue oxygenation
Mech
a
nic
a
l Ventil
a
tion
20. Anestheticmanagement
• Standard monitoring
• In patient with CP issues it is important to monitor CV response to
pneumoperitoneum and positional changes
• Arterial waveform analysis
• ABG
• Cerebral Oximetry useful in high risk patients in steep head up or head down
procedures
Monitoring
21. Anestheticmanagement
• High incidence of PONV - distressing, worsen pain, extends hospital stay
• Prophylaxis - multimodal approach example,
• All patients -dexamethasone (4-8 mg preop) and ondasteron (4 mg before the
end of op)
• High risk patients - additionaly preop scoplamine patch 1.5 mg, TIVA
maintenance of aneshtesia
• Rescue therapy - immediate post op promethazine (6.25 mg IV, slowly) or
dimenhydrinate (1 mg/kg IV)
Antiemetics
22. Anestheticmanagement
• Low to moderate pain procedure
• Best is multi modal approach
• PROSPECT Study of ESRA provided guidelines
for pain management of laparoscopic
cholecystectomy in 2017
• Epidurals found to increase length of hospital stay
•
P
a
in M
a
n
a
gement
25. Hemodynamiccomplications
• During insu
ffl
ation
• Gas embolism
• Solid organ injury
• Hemodynamic instability
• Treatment: exclude other causes and
supportive therapy; in some cases defalte
and/or convert to open
• During surgery
• Hemorrhage
• Unexplained hypotension may be the only
clue
• Hyperventilation
• Increases intra-thoracic pressure; reduced
venous return; hypotension
• Positioning
• Head up - reduced venous return;
hypotension
27. PulmonaryComplications
• Hypercarbia
• Hyperventilate
• Check for subcutanous emphysema
• If persists Co2>50 mmHg reduce pressure or convert to open
• Hypoxia
• Physiologic changes, positioning or anesthetic causes
• PEEP and FiO2 optimised, if persists release pneumoperitoneum
28. Carbondioxideinsuf
f
lation
• Subcutaneous emphysema
• Improperly placed Veress needle intraperitoenaly;
extraperitoneal laparascopy; upper laparascopy
(Nissen fundoplication)*
• Surgery longer than 200 min
• Six or more surgical ports Age>65
• Nissen Fundoplication
• Readjustment of ports, reduction of IAP or
conversion
• Mostly resolved after abdomen de
fl
ated
• If external swelling severe: asses airways,
extubate through exchanger, delay extubation
several hours to have CO2 absorbed
• Capnothorax, Capnomediastinum and
capnopericardium
• Unexplained hypercapnia, hypoxemia,
increased airway pressures (often Nissen F.)
• If severely compromised de
fl
ate,
• Gas embolism
• Studies reported subclinical gas embolism
between 17-100% **
• Through insu
ffl
ation rarely and entring through
damaged veins
• Symptomatology typical
*Wolf, J. Stuart, et al. "The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery."
The Journal of urology 154.3 (1995): 959-963.
**Pareek, Gyan, et al. "Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques." The journal of urology 175.4 (2006):
1208-1213.
29. WellLegCompartmentSyndrome
• Complication of prolonged steep Trendelenburg position
• Causes
• Impaired perfusion to lower limbs
• Venous compression by stirrups
• Reduced femoral venous drainage due to pneumoperitoneum
• Presentation
• Severe limb pain after surgery
• Rhabdomyolysis
• Myoglobin associated renal failure
30. Othercomplications
• Complications from surgical instrumentation
• Half during placement of Veress needle
• Through dissection as to other procedures
• Complications related to positioning
• Prolonged steep Trendelenburg - potential facial organs and laryngopharingeal edema,
postextub laryngospasm
• Extreme and prolonged Head Up positioning - potential venous pooling in lower extremities -
hypovolemia- hypotension
• Particularly vulnerable older patients, hypovolemic and with preexisting ICD and CVD
• Other typical positional injuries
31. SummaryandRecommendations
• Laparoscopic surgery standard of care
• CO2 insu
ffl
ation creates space for
visualisation and at the same time induces
many physiological changes
• General anesthesia with ETT intubation is
preferred choice of anesthesia
• Regional anesthesia is safe for short
procedures
• It is recommended lung protective
ventilation to mitigate potential for
barotrauma
• If complications occur it is important to
communicate with surgeon and eventually
to reduce IAP or convert it to open surgery
• PONV prophylaxis is suggested to all
patients
• Low to moderate pain procedure
controlled with multi modal approach
