This document discusses the anesthesia considerations for laparoscopic surgery, covering indications, advantages, disadvantages, contraindications, and anesthetic techniques. It highlights various factors affecting anesthesia management, such as positioning, gas insufflation, and the effects of pneumoperitoneum on multiple bodily systems. The document concludes with insights on preoperative, intraoperative, and postoperative management to optimize patient outcomes.

1. Dr. Ali Bandar,MD, PHD
Anesthesia
for
Laparoscopic
Surgery

2. Objectives
2
A. Introdution
B. Indications of Laparoscopic surgeries.
C. Advantages over laparotomy
D. Disadvantages
E. Contraindications
F. Anesthetic Consideration
G. Anesthetic techniques
Dr. Ali Bandar, MD, PHD

3. Introduction
3Dr. Ali Bandar, MD, PHD

4. General surgery: appendix, colon, small bowel, gallbladder, bile ducts,
stomach, esophagus, liver, spleen, pancreas, adrenals, hernia repairs, diagnostic
laparoscopy, adhesiolysis
Gynecologic procedures: Salpengectomy, Miomectomy, infiltelity…
Thoracoscopic surgery: Sympatectomy…
Cardiac surgery: Coronary artery bypass, valve repair
Orthopedics
Urologic procedures
Neurosurgery
Transplant surgery
A. Indications of Laparoscopic surgeries
Dr. Ali Bandar, MD, PHD

5. Advantages of laparoscopy over Laparotomy
Patient Specific:
 More cosmetic
 Shortert recovery
 Earlier return home
 Faster Activity
 Less cost
Surgoen Specific:
 Better Visualization
 ⬇ medical risk
 ⬇ ileus
 ⬇ damage to healthy
tissue
 ⬇ wound infection
 ⬇ P/O complications
 Better outcomes
Anesthetist Sp
⬇ Incisional stress
response
⬇ Opioid requirment
⬇ P/O Pain
⬇ Fluid shift
⬇ P/O Resp Dysfun.

6. 6

7. Disadvantages:
 It needs well-trained surgeons.
 There is narrow, two-dimensional
visual field on video.
 General anesthesia is usually
needed.
 Higher costs (especially with
disposable instruments)Dr. Ali Bandar, MD, PHD

8. 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).
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Patient refusal.
Related to Anesthesia:
 Severe cardiovascular or pulmonary
diseases(including bullae).
 Increased ICP or space occupying
lesions.
 Impending renal shutdown.
 Hypovolemic shock
Dr. Ali Bandar, MD, PHD

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Anesthetic Considerations Of Laparoscopy:

10. Anesthetic Considerations Of Laparoscopy:
1. General considerations
2. Considertaions related to positioning.
3. Considerations of gas insuflation
4. Considerations of pneumo-peritoneum
10

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1. General Considerations
1. Dark Room
2. Trocar Injury(Vascular, Organs)
3. Potential conversion to open
4. Increased risk of PONV
Dr. Ali Bandar, MD, PHD

12. 12

13. Anesthetic Considerations Of Laparoscopy:
1. General considerations
2. Considertaions related to
positioning.
3. Considerations of gas insufflation
4. Considerations of pneumo-peritoneum
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Dr. Ali Bandar, MD, PHD

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Trendelenburg
(lower abdominal
procedures)
- Appendectomy
- Hernia repair
Anti-
Trendelenburg
(upper abdominal
procedures)
-Cholecystectomy
- LSG Dr. Ali Bandar, MD, PHD

15. Anti-Trendelenburg:
Favorable for
Respiration
Trendelenburg:
 ↓ Pulmonary compliance
 ↑ airway pressure
 ↓FRC
 Atelectasis
 Endobronchial intubation
15
Respiratory effect of
Positioning:

16. Anti-Trendelenburg:
 Blood Pooling
 Venous stasis
 Thromboembolism
 ↓ Venous Return
 ↓ CO
 ↓↔ BP
Trendelenburg:
 ↑ CVP, VR
 ↑ CO
 ↑ Cerebral Perfusion
• ↑ ICP
• ↑ IOP
16
Cardiovascular effect
of Positioning:

17. Brachial plexus palsy
effect of prolonged arm Abduction
17
Position – Nerve Injury:
Dr. Ali Bandar, MD, PHD

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Effect of prolonged positioning:
 Head and neck congestion. They become dusky.
 Conjunctiva and eyelid edema.
 Retinal hemorrhage and detachment with
increased intraocular pressure.
 Cerebral edema with increased ICP.
 Laryngeal, tongue, and airway edema.

19. Anesthetic problems Of Laparoscopy:
1. General considerations
2. Considertaions related to positioning.
3. Considerations of Gas insufflation
4. Considerations of pneumo-peritoneum
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Air N2O O2
Helium
Angon
CO2
What gases can be used?
Dr. Ali Bandar, MD, PHD

21. Why a Carbone Deoxide ??
 Non-flammable and does not support combustion.
 Readily diffuses through membranes & rapidly removed by
lungs
 Highly soluble; so, the risk embolization is minimal.
 CO2 levels in blood and expired air can be easily measured.
 High CO2 concentration of blood can be tolerated. As long as 02
requirements are met.
 Medical CO2 gas is readily available and inexpensive.
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3. Considerations of GAS Insufflation
 Direct Peritonial irritation
CO2 produces postoperative shoulders pain
 HyperCarbia and respiratory Acidosis
 Hypothermia
 Subcutaneous Emphesyma
 Pneumothorax, Pneumomediastinum
Gas Embolism and acute PE
 Bronchial Intubation
Dr. Ali Bandar, MD, PHD

23. Anesthetic Considerations Of Laparoscopy:
1. General considerations
2. Considertaions related to positioning.
3. Considerations gas insufflation
4. Considerations of pneumo-peritoneum
23Dr. Ali Bandar, MD, PHD

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Rapid Stretchening of the Peritonium:
It causes stimulation of the vagal reflexes leading to
bronchospasm and bradycardia up to sinus arrest especially
in young women
Avoid increased gas flow rates> 6L/ min. Normally, CO2 is
initially insufflated at a rate of 4-6L/min or less, but after the
initial pneumo-peritoneum, a constant gas flow of 200-
400mL/min is maintained to compensate for leaks during the
procedure.
Be ready with a vagolytic drug such as atropine. It may be
given prophylactically.

25. Effect Pneumo-peritonium CNS:
 The induction of pneumoperitoneum itself increases middle
cerebral artery blood flow
 Increased ICP:
o Increased lumbar spinal pressure → Decreased drainage
from lumbar plexus
o Hypercapnia, high systemic vascular resistance and head
low position combine to elevate intracranial pressure.
25

26. CardioVascular Effect of
Pneumo-Peritonium:
 ⬆ IAP up to 15-20 mm Hg, ⬆ venous return ⬇ ⬆ CVP, and
⬆CO.
 ⬆ IAP >20 mm Hg, compresses the IVC resulting ⬇ , ⇨ ⬇ CVP
and, CO.
 ⬆ IAP ⬇ femoral venous blood flow, which ⬆ the incidence of
deep venous thrombosis.
26Dr. Ali Bandar, MD, PHD

27. Respiratory Effect of
Pneumo-peritonium:
 Limitation of diaphragmatic and anterior abdominal
wall movement cause decreased lung volume,
atelectasis and dead space ventilation
 FRC ⬇ 20-25%
 Respiratory Compliance ⬇ 30-50%
 Respiratory Resistance ⬇
27

28. Gastro intestinal effect
of Pneumo-peritonium
 Risk factor for regurgitation
 Decreased mesenteric circulation
 Decreased total hepatic blood flow
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29. Renal Effect of
Pneumo-Peritonium:
An Increased IAP decreases the GFR and urine output
about 50% (renal compartmental syndrome) due to
the following causes:
 Compression of renal vein and inferior vena cava.
 Reduction of renal cortical blood flow up to 60%.
 Renal parenchymal compression.
29Dr. Ali Bandar, MD, PHD

30. Anesthetic
Management
30Dr. Ali Bandar, MD, PHD

31. Anesthetic goals:
▪ Accommodate surgical requirments
▪ Monitoring for early detection of complication
▪ Recovery from anesthesia should be rapid
with minimal residual effect
▪ Consider to convert to open
31Dr. Ali Bandar, MD, PHD

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Preoperative management:
1-Complete history, examination, and investigations
2- Consent for laparotomy .
3-Complete bowel preparation.
4-Premedications:
•Anti-emetics e.g., ondansetron (S-HT3 receptor antagonists).
•Antacids and H2 antagonists to decrease aspiration effects.
• Anticholinergics may be given to decrease the possibility of bradycardia
5- Pharmacological DVT prophylaxis ( as per surgeon )
Dr. Ali Bandar, MD, PHD

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Intraoperative management:
 Monitoring as ASA standards
 Mechanical DVT prophylaxis
 General Anaesthsia:conducted by intubation, volatile agents ,
opioids, and controlled ventilation.
 Good muscle relaxation
 Positioning
 Naso-or orogastric tube
 Extubation: In addition to the usual criteria of extubation, extubation should be
delayed if venous congestion and edema are observed in the head, neck, upper chest,
eye, tongue...etc.

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Post-operative management:
•Postoperative nausea and vomiting:
There is an increased incidence of postoperative nausea and
vomiting (the incidence is 42%).
•Postoperative pain:
postoperative pain (Multi-modal)
- local anesthetic infiltration of port site
-Paracetamol
-NSAIDs
-Opioids (+/-)
•Respiratory distress: It may occur if pneumothorax is not
detected intraoperatively.
NB . Don`t under-estimate surgical emphysema

35. Take Home Message
 Pt. selection
 Considerations
General
Positioning
Pneumoperitoneum
Gas insufflation
 Post op. pain management
 Post op. N&V
35Dr. Ali Bandar, MD, PHD

36. 36Dr. Ali Bandar, MD, PHD