The document discusses anesthetic considerations for laparoscopic surgery, highlighting concerns related to pneumoperitoneum, impacts on cardiopulmonary function, and patient preparation. It outlines various patient groups who may have increased risk of complications, the physiological changes observed during surgery, and the necessary monitoring and techniques required for anesthesia. Emphasis is placed on effective communication between anesthetists and surgeons, along with the management of intra-operative and postoperative complications.

1. Anesthetic considerations in
Laparoscopic Surgery

2. Prof. Dr. Md. Nur Hossain Bhuiyan
Prof . Of Surgery
DMCH

3. Anesthetic considerations in
Laparoscopic Surgery
• The Anesthetic problems during minimal access
surgery are related to the cardiopulmonary
effects of –
• Pneumoperitoneum
• Carbon dioxide absorption
• Extraperitoneal gas insufflation
• Venous embolism and
• Inadvertent injury to intra-abdominal organs

4. • Good anesthetic technique facilitates –
• Risk free surgery
• Allows early detection and reduction of
complications
• Adequate anesthesia and analgesia
• Endotracheal intubation and controlled
ventilation should be considered

5. Evaluation and preparation of
patient for laparoscopic surgery
1st group of patient’s -
Young women undergoing gynecological
laparoscopy at high risk of postoperative
nausea and vomiting due to –
• Stretching of the abdominal cavity
• Residual irritant effects of retained carbon
dioxide

6. 2nd group of patients
• Those with significant cardiac disease
• Insuflation can be associated with –
• Reduced cardiac index
• Increased cardiac filling pressure
• Increased systemic blood pressure and
• Increased systemic vascular resistance
• Hypercarbia

7. • Third group of patients of concern are those
with –
• Severe emphysema
• Asthma
• Cystic fibrosis or
• Other pulmonary disease. These patients
need to be in optimal medical condition prior
to having surgery

8. • Those patients suffering with upper
respiratory tract infection or other pulmonary
conditions
• Prior preparation with a course of
bronchodilators, steroids and or antibiotics
may be necessary
• Intra-arterial catheter for gas analysis and
for pressure monitoring

9. • Laparoscopic surgeon should develop communication
and understanding with anesthetist
• Necessary measures should be undertaken to correct
any metabolic or hematologic abnormalities like –
• Hypokalaemia, hyponatraemia, hyperglycemia
• Azotemia
• Anemia and
• Coagulation defects
• All the required pre anesthetic laboratory data should
be available

10. Physiological changes during
laparoscopy
• The introduction of gas into the peritoneal
cavity may cause –
• Pain
• Respiratory distress
• Cardiac embarrassment
• Extreme Trendelenburg’s position

11. • Pneumoperitoneum at the time of
laparoscopic surgery cause upward
displacement of the diaphragm resulting in –
• Reduction in lung volumes including
functional residual capacity
• Pulmonary compliance is reduced and
• Airway resistance is increased

12. • Insuflation of the pneumo peritoneum is
accompanied by a decrease of some 30% of
pulmonary compliance.
• Airway resistance increases same proportion
• IAP also predisposes to regurgitation of gastric
contents and pulmonary aspiration

13. • Venous gas embolism is a fatal complication
of pneumoperitoneum that may occur by -
• Veress needle or the trocar, if directly
puncture the arteries
• Blood flow across an opening in an injured
vessel may draw gas into the vessel

14. • Elevated intra-abdominal pressure –produces
hemodynamic changes
• Venous return initially increases with IAP below 10 mm
Hg by reduction in the blood volume sequestrated in
the splanchnic vasculature
• Increased CO and Increased arterial pressure
• When IAP exceeds 20 mm Hg the IVC is compressed.
• Venous return from the lower half of the body is
impeded resulting in a fall in CO

15. • A slow infusion of air less than 1 L/min.
• At higher infusion rates the gas bubbles lodging---
neutrophil clumping---activation of coagulation
cascade---and platelet aggregation.
• This may lead to pul. Vasoconstriction-----
• Rapid stretching of the peritoneum may
sometimes leads to stimulation of vagus nerve
and provoke arrhythmia such as AV dissociation---

16. • The circulation of the kidney becomes much
compromised with increased IAP
• Renal blood flow and GFR decreases
• Increased IAP produces lactic acidosis

17. • Faulty pneumoperitoneum may give rise to –
• Subcutaneous emphysema
• Pneumomediastinum
• Pneumopericardium and
• Pneumothorax

18. Regional anesthesia
• Spinal anesthesia
• Bilateral lower intercostal nerve block

19. General anesthesia
• General anesthesia:
• Balanced anesthesia,
• A variety of muscle relaxants
• TIVA : for outpatient laparoscopy, full
colonoscopy
• Halothane should be avoided or used
sparingly in patients with several previous
operations and in the presence of liver disease

20. Local anesthesia
• Local anesthesia with I/V adequate sedation and
analgesia
• Keep the patient somnolent but responsive and
continuous monitoring
• Anesthetist being present to monitor the patient’s
cardiac and respiratory functions
• Preferred local anesthetic agent is 1% lignocaine
without adrenaline or lidocaine without epinephrine
• “Vocal local technique”
•

21. Anesthetist’s Role in Laparoscopy
• The role of anesthetist in laparoscopic surgery is
vital
• The following monitoring device should
routinely used –
• Electrocardiogram
• Sphygmomanometer
• Airway pressure monitor
• Pulse oximeter
• End tidal CO2 concentration monitor
• Body temperature probe

22. • The prophylactic heparin---DVT and
pulmonary embolism
• Intermittent inflated pneumatic cast
compression---
• Now epidural anesthesia---alternative to GA

23. Intra operatrive complications
• Arrhythmia
• Bradycardia- atropine has proven effective in
restoring Vagal tone
• Carbon dioxide gas embolus
• Pulmonary edema

24. Postoperative considerations
• Antagonism of the residual muscle relaxation
• Nausea
• The urine output
• Pain

25. Anesthetist should keep following
points in mind at the time of LS
• The patient voids urine just prior to entering
the operating room
• No shaving is necessary
• All patients undergoing laparoscopy should
have an empty bowel
• The position of leg is important
• Pressure stocking prevent DVT
• Good muscle relaxation reduces the IAP---

26. • The inflation of stomach should be avoided
• The distended stomach also hampers the
visibility of Calot’s triangle
• Halothane increases the incidence of
arrhythmia
• Isoflurane is the preferred volatile anesthetic
agent
• Excessive IV sedation should be avoided

27. • Monitoring of pet CO2 is mandatory
• Airway pressure monitor is mandatory

28. • All procedures under anesthesia carry small
but inherent risks and patient should
understand these before agreeing to undergo
the procedure
• However, the risks of anesthesia for elective
surgery under modern conditions are very
small indeed

29. Thanks