Laparoscopic surgery involves inserting specialized tubes into the abdominal cavity to perform minimally invasive surgery. Carbon dioxide gas is used to insufflate the abdomen and create pneumoperitoneum. This causes physiological changes including increased heart rate and blood pressure due to hypercapnia and raised intra-abdominal pressure. It can also decrease lung volumes and compliance. The anesthesiologist must carefully manage ventilation and monitor for potential complications like subcutaneous emphysema, capnothorax, and venous gas embolism during laparoscopic surgery. Patient positioning, temperature control, and multimodal postoperative pain management are also important considerations for the anesthesiologist.

1. ANAESTHETIC CONSIDERATIONS
IN LAPAROSCOPIC SURGERY
PRESENTER : Dr Shalini Pathak
MODERATOR : Dr Shilpa Tiwari mam

2. What is LAPAROSCOPY?
• Laparoscopy is the visualization of abdominal cavity through an
endoscope.

3. What is LAPAROSCOPIC SURGERY?
• Laparoscopic surgery is a minimally invasive surgical technique where
specialized tubes are inserted for surgical access.

4. SURGICAL APPROACH
• Laparoscopic surgery involves insufflation of a gas ( usually carbon
dioxide) into peritoneal cavity under pressure to seperate abdominal
organs from abdominal wall.
• This produces a pneumoperitoneum which causes an increase in
intraabdominal pressure.
Gas is insufflated at a rate of 4-6 litres per minute which gets cut off when
intra-abdominal pressure exceeds pressure limits set by clinician ( 12-14
mmHg). After that pneumoperitoneum is maintained by constant gas flow
of 200-400 ml per minute.

6. Desirable Properties of Gas used for insufflation
1. It should not cause significant physiological changes.
2. Minimal absorption from the peritoneal cavity.
3. If absorbed, it should be rapidly excreted.
4. Should not support combustion.
5. Should be highly soluble in blood to minimize risk of gas embolism.

7. Advantages and Disadvantages of Gases-

8. Advantages and Disadvantages of Laparoscopic
Surgery:
ADVANTAGES DISADVANTAGES
PATIENT SPECIFIC Improved cosmetic results Risk of PONV
Shorter recovery time Reffered pain from CO2 insufflation
Less cost
SURGEON SPECIFIC Better clinical outcomes Highly specialized training
Earlier return of bowel function Limited tactile sense
Less postoperative complications Longer operating time
Complex equipment and setup
ANESTHESIOLOGIST SPECIFIC Less incisional stress response Pneumoperitoneum induced stress
response
Less opioid requirements Mechanical ventilatory challenges
Less pain Extraperitoneal CO2 related
complication
Less postoperative respiratory
dysfunction
Limited access to patient in robotic
surgery

9. PHYSIOLOGICAL IMPACT OF LAPAROSCOPY
CARDIOVASCULAR SYSTEM-
• Effect of hypercapnia-
It activates sympathetic nervous system leading to increase in blood
pressure , heart rate , myocardial contractility and arrhythmia.
• Effect of raised intra abdominal pressure(IAP)-
- At IAP <15 mm Hg , venous return is augmented as blood is squeezed
out of splanchnic venous bed thereby increasing cardiac output.

10. - At IAP > 15 mm Hg , cardiac output decreases due to –
1. Decreased venous return
a. Compression of inferior venacava
b. Pooling of blood in legs
c. Increased venous resistance
2. Myocardium depression due to anesthetic induction agents
3 . Raised systemic vascular resistance
a. Release of neuro- humoral factor
b. Increased vascular resistance of organ

11. RESPIRATORY SYSTEM-
• Effect of raised IAP-
FRC and compliance decreases by 30-50%
peak airway pressures and plateau pressure rises by 50% and 80%
increase in airway resistance and work of breathing.
Hypoxia may result from atelectasis and intrapulmonary shunting .

12. • Increase in partial pressure of CO2 –
- Insufflation of carbon di oxide gas results in progressive increase in
PaCO2 which reaches plateau 20 to 30 min .
- Hypercarbia routinely develops in all patients from absorption of
intraperitoneal carbon di oxide into circulatory system.
- The concentration gradient that develops preferentially drives CO2
from pulmonary capillaries into alveolar network where it is removed
during exhalation and measured by capnography as end tidal CO2 .
- Exhaled CO2 and degree of gas absorption vary based on route of
insufflation, preoperative comorbidities and acute intraoperative
pathology.

13. • Change in minute ventilation-
- Hypercapnia during laparoscopic surgeries in patients may be
normalized by increasing minute ventilation about 25% above
baseline.
- Use of alveolar recruitment maneuvers with application of PEEP may
help in keeping alveoli open and prevent ventilator induced lung
injury.

14. • RESPIRATORY COMPLICATIONS –
1. Subcutaneous emphysema
2. Capnothorax
3. Venous gas embolism
4. Aspiration of gastric content

15. 1. SUBCUTANEOUS EMPHYSEMA –
• Inadvertent introduction of CO2 gas into subcutaneous , periperitoneal or
retroperitoneal tissue leads to trapped gas pockets called subcutaneous
emphysema.
• Risk factors - longer operative time
greater number of surgical ports
lower BMI, older patient age
higher IAP, high insufflation rates
nissen fundoplication
• Early signs - unexplained sudden or persistent hypercarbia
acute hypotension
• Treatment – peritoneal deinsufflation

16. 2. CAPNOTHORAX –
• Carbon dioxide gas accumulation within pleural space is called
capnothorax.
• Tension capnothorax may occur from uncontrolled pressurization of
thoracic cavity leading to increase in intrathoracic pressure,
mediastinal shift, decreased venous return and right ventricular
compression.
• Early signs – palpable subcutaneous emphysema
high peak airway pressure
hypoxia and hypotension
• Treatment – immediate peritoneal insufflation
hyperventilation
addition of PEEP

17. 3. VENOUS GAS EMBOLISM –
• Venous carbon dioxide gas embolism is a potentially fatal complication of
laparoscopy that occurs when large gas bubbles enter the venous system
that circulate to heart and result in right ventricular chamber gas lock and
venous outflow obstruction.
• Signs – acute tachycardia , cardiac arrhythmia,
QRS complex widening
hypotension, hypoxemia, low end tidal CO2
cyanosis , mill wheel murmur
• Investigation – TEE is most sensitive
• Treatment – peritoneal deinsufflation, hyperventilation, 100%oxygen
rapid intravenous fluid and advanced cardiac life
support for cardiac arrrest

18. REGIONAL PERFUSION EFFECTS –
1. Renal effects – decrease in renal blood flow and glomerular
filtration rate due to reduction in cardiac output.
2. Splanchnic and hepatic blood flow – splanchnic blood flow
decreases due to external compression and systemic
vasoconstriction. IAP produced during pneumoperitoneum reduces
hepatic vein flow.
3. Gastrointestinal effect – regurgitation and aspiration
4. Neurological effects- increase in intracranial tension with resultant
decrease in cerebral perfusion pressure.
5. Ocular effect – intraocular pressure increases.
6. Neuroendocrine effect – increased levels of stress hormones.
increase in ADH and aldosterone effects.

19. INTRAOPERATIVE MANAGEMENT
• General anesthesia with endotracheal intubation (GETA), muscle
relaxation, controlled mechanical ventilation remains preferred
anesthetic technique for laparoscopic surgery.

20. Monitoring
• Electrocardiogram, noninvasive arterial pressure monitor , airway
pressure monitor , pulse oximeter , ETCO2 concentration monitor ,
core body temperature monitoring is used.
• For patients with compromised cardiopulmonary function continuous
arterial pressure, cardiac filling pressure and blood gases monitoring
is indicated

21. Anesthetic maintenance
• Inhaled anesthetics and propofol-
The induction agent of choice is propofol and anesthesia maintenance
with inhaled volatile anesthetics
• Nitrous oxide –
It is avoided for two reasons –
- It diffuses into abdominal cavity sufficient to support combustion
- It will diffuse into air bubbles / CO2 causing obstruction of pulmonary
circulation.

22. • Pharmacological adjuncts-
Lower postoperative pain is a benefit of laparoscopic surgery .
- Wound infiltration or intraperitoneal instillation with a local
anesthetic .
- Lidocaine infusion administration.
- Remifentanil suppresses sympathetic stimulation.
- Dexmedetomidine infusion.
• Neuromuscular blockade –
They are routinely used to improve surgical exposure during
pneumoperitoneum.

23. Mechanical ventilation
• volume control(VC) and pressure control(PC) ventilation with positive
end expiratory pressure are conventional mode of ventilation during
GETA.
• During VC – tidal volume remain constant , peak airway pressure
increases
• During PC – peak airway pressure constant , tidal volume decreases
• Though switching from VC to PC during trendelenburg may result in
significant static lung changes, oxygenation improvements.

24. Body temperature –
• Carbon dioxide gas insufflation causes heat loss during laparoscopic
surgery , so to correct hypothermia warming of patient and
humidifying insufflated gas with an inline heating device.

25. POSITIONING :
• Patient positioning is determined by the view that the surgeon is
trying to optimize.
• Prolonged steep trendelenburg position increases risk of –
- Cerebral oedema
- Upper airway oedema
- Well leg compartment syndrome
• In reverse trendelenburg position –
-reduced venous return
-hypotension
-myocardial and cerebral ischaemia

26. COMPLICATIONS RELATED TO SURGERY
INTRAOPERATIVE POSTOPERATIVE
-intra-abdominal injuries -Respiratory dysfunction
-cardiopulmonary complication -Venous thrombosis
-carbon dioxide extravasation
-ocular injuries
-peripheral nerve and brachial plexus injury
-airway edema

27. POSTOPERATIVE MANAGEMENT
ACUTE PAIN MANAGEMENT
• Parenteral anesthetics and regional anesthesia are common options
for postoperative pain management.
• Preemptive multimodal strategy is used that includes NSAIDS, COX 2
inhibitor and acetaminophen.
• Transverse abdominis block can be used for pain management in
laparoscopic surgery.

28. POSTOPERATIVE NAUSEA AND VOMITING
• Risk factors –
-inhaled volatile anesthetics
-perioperative opioid administration
-young age
-females gender
• Optimal antiemetic prophylaxis is key for minimizing prolonged
postanesthesia recovery.

29. Is laparoscopy safe during pregnancy ?
• Laparoscopy can be performed during pregnancy in second trimester
because - organogenesis is complete
- uterine size is not large enough to interfere
with operative field

30. PHYSIOLOGICAL CHANGES IN PREGNANCY AFTER
PNEUMOPERITONEUM
• Pregnancy is associated with respiratory and cardiovascular changes.
-There is cephalad shift of diaphragm – decreased FRC
-compression of inferior venacava
• Laparoscopy exacerbates these changes making patient more
susceptible to hypoxemia and hypotension .
• Head low position – worsen ventilation
• Head high position – decrease venous return and cardiac output.

31. SPECIFIC MEASURES TO BE FOLLOWED IN PREGNANT PATIENTS
• Preoperative discussion with obsetrecian
• Pneumatic compression stocking
• Rapid sequence induction
• Position with uterine displacement
• Fetal heart rate monitoring if more than 16 weeks
• Orogastric tubes to deflate stomach
• Limit IAP to 12-15 mm Hg

32. Laparoscopic surgery in children-
• It has been used safely in procedures-
-fundoplication
-hernia repair
-orchidopexy
• Insufflation pressure should be limited upto 5-10 mmHg in neonates
and 10-12 mm Hg in older children.

33. CONTRAINDICATIONS FOR LAPAROSCOPY
• Absolute contraindication
1. Shock
2. Significantly raised ICT
3. Retinal detachment
4. Right to left cardiac shunts
• Patient specific contraindication
1. Bullous emphysema
2. Congestive heart failure
3. Significant renal dysfunction