Monitor closely and intervene early if needed 40

1. University of Gondar
College of medicine and health
science
SCHOOL OF MEDICINE
DEPARTMENT OF ANAESTHESIA
Misganaw M
Gynecologic tumors and
Laparoscopic surgery
1

2.  Gynecologic cancer is any cancer that starts in a
woman's reproductive organs.
 Patients presenting for oncological surgery pose complex
issues, and often undergo repeat or complex surgical
procedures
2

3. CONTI..
 Five main types of gynecological cancer are
Ovarian cancer
 Uterine (endometrial) cancer
 Cervical cancer
Vulvar cancer
Vaginal cancer
3

4. OVARIAN CANCER
 Ovarian cancer is cancer that forms in the tissue of
the ovary
 and it Called “the overlooked disease” or “the silent
killer
4

5. EPIDEMIOLOGY
 Older women are at highest risk (frequently in
women between 55 and 75 years of age).
 75% will survive one year and about 25% will
survive 5 years after treatment.
5

6. PATHOPHYSIOLOGY
 Ovarian cancer, the cause of which is unknown,
can originate from different cell types.
 Most ovarian cancers originate in the ovarian
epithelium.
 They usually present as solid masses that have
spread beyond the ovary.
6

7. STAGES
 stage 1 the cancer is limited to the ovaries.
 stage 2 the growth involves one or both ovaries,
with pelvic extension.
 Stage 3 cancer has spread to the lymph nodes and
other organs or structures inside the abdominal
cavity.
 stage 4, the cancer has metastasized to distant
sites 7

8. TREATMENT
 Bilateral salpingo-opherectomy
 Hysterectomy
 Omentectomy and surgical debulking of the tumor
8

9. ENDOMETRIAL CANCER
 Endometrial cancer also known as (uterine cancer) is
malignant neoplastic growth of the uterine lining.
 Epidemiology
 Approximately 95% of these malignancies are
carcinomas of the endometrium.
 Most common in women > age 50 years.
 75% of uterine cancers occur in postmenopausal
women.
 Incidence is highly dependent on age 9

10. STAGES
 stage 1, it has spread to the muscle wall of the
uterus.
 In stage 2, it has spread to the cervix.
 In stage 3, it has spread to the bowel or vagina,
with metastases to pelvic lymph nodes.
 In stage 4, it has invaded the bladder mucosa with
distant metastases to the lungs , inguinal,
supraclavicular nodes, liver, and bone 10

11. INVESTIGATION
 Pap Smear • Only 30-50% patients with cancer will
have an abnormal result
 Endometrial Biopsy
 Transvaginal Ultrasound
 Fractional Dilation and Curettage
11

12.  Treatment consists of
 total abdominal hysterectomy and
 bilateral salpingo ophorectomy with full pelvic
lymphadenectomy
12

13. CERVICAL CANCER
 Cervical cancer is cancer of the uterine cervix.
 Epidemiology
 Approximately 570,000 cases expected worldwide
each year
 275,000 deaths Number one cancer killer of
women worldwide
 With the advent of the Pap smear, the incidence of
cervical cancer has declined
13

14. CERVICAL CANCER ETIOLOGY
 • Cervical cancer is a sexually transmitted disease.
 HPV is the primary cause of cervical cancer.
Some strains of HPV have a predilection to the
genital tract and transmission is usually through
sexual contact (15, 19 age High Risk)
14

15. DIAGNOSIS
 Colposcopy
 A procedure in which a colposcope (a lighted,
magnifying instrument) is used to check the vagina and
cervix for abnormal areas. Tissue samples may be
taken using a curette (spoon-shaped instrument) or a
brush and checked under a microscope for signs of
disease.
pap smear
15

16. STAGES
 Stage 0:Abnormal cells in the innermost lining of the
cervix.
 Stage I: Invasive carcinoma that is strictly confined to
the cervix.
 Stage II: Locoregional spread of the cancer beyond the
uterus but not to the pelvic sidewall or the lower third of
the vagina.
 Stage III: Cancerous spread to the pelvic sidewall or
the lower third of the vagina,
 Stage IV: Cancerous spread beyond the true pelvis or
16

17. TREATMENT
 Patients with early invasive disease -simple
hysterectomy
 Whilst those with later stages undergo-radical
hysterectomy which involves removal of the
uterus, vagina, the uterosacral and uterovesical
ligaments, parametrium and pelvic node
dissection 17

18. VAGINAL CANCER
 Vaginal cancer is malignant tissue growth arising in
the vagina.
18

19. EPIDEMIOLOGY
 It is rare, representing less than 3% of all genital
cancers.
 This type of cancer usually occurs in women over
age 50.
 Vaginal cancer can be effectively treated, and
when found early it is often curable.
 The etiology of vaginal cancer has not been
identified. 19

20.  About 80% of vaginal cancers are metastatic,
primarily from the cervix and endometrium.
 Tumors in the vagina commonly occur on the
posterior wall and spread to the cervix or vulvavv
20

21. VAGINA CANCER STAGING
 Stage 1: Confined to Vaginal Wall
 Stage 2: Subvaginal tissue but not to pelvic
sidewall
 Stage 3: Extended to pelvic sidewall
 Stage 4: Bowel or Bladder
 Stage 5: Distant metastasis
21

22. TREATMENT
 Treatment of vaginal cancer depends on the type
of cells involved and the stage of the disease.
 If the cancer is localized, radiation, laser surgery,
or both may be used.
 If the cancer has spread, radical surgery might be
needed, such as a hysterectomy, or removal of the
upper vagina with dissection of the pelvic nodes in
addition to radiation therapy 22

23. VULVAR CANCER
 Vulvar cancer is an abnormal neoplastic growth on
the external female genitalia
 Vulvar cancer epidemiology • It is responsible for
0.6% of all malignancies in women and 4% of all
female genital cancers.
 It is the fourth most common gynecologic cancer,
after endometrial, ovarian, and cervical cancers 23

24.  Approximately 90% of vulvar tumors are squamous
cell carcinomas.
 This type of cancer forms slowly over several years
and is usually preceded by precancerous changes.
 These precancerous changes are termed vulvar
intraepithelial neoplasia (VIN).
24

25.  The two major types of VIN are classic
(undifferentiated) and simplex (differentiated).
 Classic VIN, the more common one, is associated
with HPV infection
 In contrast to classic VIN, simplex VIN usually
occurs in postmenopausal women and is not
associated with HPV
25

26. TREATMENT
 Surgery
 Chemotherapy
 Radiotherapy
26

27. PREOPERATIVE CONSIDERATIONS FOR
GYNECOLOGICAL TUMOR
 Consider anesthetic implications of
chemotherapeutic agents- toxic effects
 Evaluation of organ system affliction by the
malignancy/metastasis
 Problems due to ascites
 DVT prophylaxis
 Options of perioperative pain management
27

28.  All routine investigations including complete
hemogram, renal function tests, liver function
tests, serum electrolytes and coagulation profile
need to be done.
 Ovarian cancer patients have an increased
propensity to develop VTE
28

29. LAPAROSCOPIC SURGERY AND ANESTHESIA
29

30.  Laparoscopic surgery has improved greatly during
the last years, mainly thanks to
advances in both anaesthetic and surgical
techniques
30

31.  Abdominal laparoscopy is normally perceived to be
associated with few risks. However,
clinicians should be aware of inherent dangers such
as
 gaseous embolism,
 a potential inability to control haemorrhage,
 an increase in carbon dioxide arterial partial
pressure,
 and changes in arterial blood pressure and heart
31

32.  Modern laparoscopic surgery is performed in the
abdomen or pelvis via small incisions.
 Usually 0.5–1.5 cm incisions.
 Use of fiber-optic system.
 The abdomen usually insufflated with gas.
 Both diagnostic and operative procedures 32

33. ADVANTAGES
Reduced tissue trauma, wound size, and post
operative pain
 Analgesic consumption.
 Improved postoperative respiratory function.
 Good hemostasis
 Reduced postoperative ileus
 Minimize infection risk
 Earlier mobilization
 Shorter hospital stay
 Improved cosmetic result
33

34.  The anesthetists must have a deep understanding
of the pathophysiological
consequences derived from the
pneumoperitoneum, to be prepared to prevent,
detect and
address the possible alterations that can occur
during the intervention
34

35. HEMODYNAMIC AND RESPIRATORY ALTERATIONS
IN LAPAROSCOPIC SURGERY
Both of them derived from the same three origins:
 Intra-abdominal pressure created by the
pneumoperitoneum
 The existence of an insufflation gas that is
absorbed by the blood
 The Trendelemburg or anti-Trendelemburg positioning
of the patient
35

36. CARDIOVASCULAR SYSTEM
 The pneumoperitoneum increases the abdominal
pressure, which in turn
 elevates the diaphragm and can
compress both small and big blood vessels.
 The intra-abdominal pressure obtained during
these procedures, which is usually 12mmHg ,
increases central venous pressure
(CVP), heart rate (HR), systemic vascular
resistances (SVR) up to a 65%, 36

37. CARDIOVASCULAR SYSTEM
 and the pulmonary vascular resistances can rise up to
a 90%. Cardiac output (CO) can increase on a healthy
patient in Trendelemburg position,
 but can also decrease to a 50% on patients in
antiTrendelemburg position or with a low
cardiovascular reserve.
 All those changes are usually well tolerated in healthy
patients but it can be different in patients with systemic
diseases. 37

38. CARDIOVASCULAR SYSTEM
 The pulmonary vascular resistances can rise up to a
90%. Cardiac output (CO) can increase on a health
patient in Trendelenburg position,
 but can also decrease to a 50% on patients in anti
Trendelenburg position or with a low cardiovascular
reserve.
 All those changes are usually well tolerated in healthy
patients but it can be different in patients with systemic
diseases. 38

39. CARDIOVASCULAR SYSTEM
 When intra-abdominal pressure riches 15mmHg,
 because of excessive insufflations or
 because the patient activates the abdominal wall
muscles (due to a lack of muscle relaxants)
that causes an increase of the abdominal wall
resistance to the insufflations,
 cough or tube rejection),
 a compression of the cava vein can occur, causing a
blood return reduction and a decrease in the cardiac
output
39

40. CARDIOVASCULAR SYSTEM
Factors affect hemodynamics
 Pneumo-pericardium
 Gas embolism
 Hemorrhage
 Position
 Anesthesia
 Hypercapnia,Vagal stimulation and Arrhythmias
40

41. CONSEQUENCES
 Decreased venous return
 Increased systemic vascular resistance
 Normal to decompensated cardiac output
 Increased risk of arrhythmia and sinus
bradycardia.
41

42. WHAT CAN WE DO???
 Pre-load
 Slightly head down
 Vasodilators
 Intermittent pneumatic compression device
 Wrapping the legs with elastic bandage
 Vagolytics
 adequate depth of anesthesia
42

43. RESPIRATORY
Decreased pulmonary compliance (30-50%).
 Increased air way resistance
 Decreased FRC
 Increased V/Q mismatch
 Hypo-ventilation and atelectasis
 Hyper-carbia
43

44.  Subcutaneous emphysema.
Accidental or intentional.
 Pneumo-thorax and pneumo mediastinum.
 Endo-bronchial intubation
 Capnothorax ??
44

45. 45

46. CAUSES OF INCREASED PACO2 DURING
LAPAROSCOPY PROCEDURES ARE
MULTIFACTORIAL
46

47. CAPNOTHORAX
 Reduces thoraco pulmonary compliance and airway
pressures increase.
 PaCO2 and PEtCO2 also increases.
 When capnothorax develops during laparoscopy
 .
47

48. Stop CO2 administration.
- Adjust ventilator settings to correct hypoxemia.
- Apply positive end-expiratory pressure (PEEP).
- Reduce IAP as much as possible.
- Maintain close communication with the surgeon.
- Avoid thoracocentesis unless necessary, because
pneumothorax spontaneously resolves
after exsufflation
48

49. GAS EMBOLISM
 Rare but the most feared and dangerous.
 Accidental insufflations of gas into vascular
space.
 Manifestations :
- Hypotension - Arrhythmias
- Tachycardia - Increased CVP
- Cyanosis - increased EtCO2 49

50. HOW TO MANAGE??
50

51. EFFECT ON REGIONAL CIRCULATIONS
51

52.  CNS
 GIT
 Endocrine changes
52

53. CONDUCT OF ANAESTHESIA
 Airway
 Mainly involves placement of ETT, neuromuscular
relaxation and positive pressure ventilation.
 This protects against gastric acid aspiration, allows
optimal control of CO2, and facilitates surgical
access.
• Bag and mask ventilation before intubation should
be minimized to avoid gastric distension 53

54. CONT…
 Insertion of a nasogastric tube may be required to
deflate the stomach, improve surgical view, to avoid
gastric injury on trochar insertion
 LMA in laparoscopic surgery remains
controversial
 Difficulties encountered when trying to maintain
effective gas transfer while delivering the higher
airway pressures required during
pneumoperitoneum.
54

55. VENTILATION
 The use of pressure controlled modalities affords
higher instantaneous flow peaks, minimizing peak
pressures, and provides improved alveolar
recruitment and oxygenation in laparoscopic surgery
for obese patients.
 Titrated levels of PEEP can be used to minimize
alveolar de-recruitment, but causious,increasing
PEEP may further compromise cardiac output in
addition to the effects of pneumoperitoneum
55

56.  Analgesia
 Antiemetics
56

57. POSTOPERATIVE MANAGEMENT
 All patients should receive supplemental oxygen
while in recovery to mitigate the effects of
pneumoperitoneum on respiratory function
 Alveolar recruitment techniques, using short-term
CPAP or high flow oxygen delivery systems
particularly in patients with existing respiratory
disease or those having prolonged surgery.
57

58. THE END
58