Lap surgery and anaesthesia

1. ANAESTHESIA FOR
LAPROSCOPIC SURGERY
Speaker Dr Archana
Moderator Dr Sukirti

2. HISTORY
Endoscopy first started in 1970 for various
OBG conditions.
It extended to lap cholecystectomy in late
1980 .
In 1987 PHILLIPE MOURETT described first
lap Cholecystectomy in france later on this
technique was introduced in USA in 1988 by
REDDICK & OSLEN.

3. OTHER LAPROSCOPIC INTRA
ABDOMINAL SURGERIES
1 Cholecystectomy, Appendectomy & Colectomy
2 Vagotomy
3 Hiatal, Inguinal & Diaphragmatic hernia repair
4 Urological- Nephrectomy, Adrenelectomy
& Prostatectomy.
5 OBG-Tubal surgeries,cystectomies,hystrectomies &
various ablations (endometriosis)
6 Thoracoscopies
7 Neurosuggeries
8 Lumbar discectomies

4. DEFINITION
It is a minimally access procedure allowing
endoscopic access to peritoneal cavity after
insufflation of gas to create space between
the anterior abd. Wall & viscera for safe
manipulation of instruments & organs.
TYPES
1 Intraperitoneal
2 Extraperitoneal
3 Abd wall retraction(gasless laproscopy)
4 Hand assisted (Hassans tech.)

5. ADVANTAGES
1 Minimal pain & illeus
2 Improved cosmesis
3 Shorter hospital stay,faster recovery &rapid return to
work
4 Non muscle splinting incision & less blood loss
5 Allow multiple assistants to see operative field from
same vantage point
6 Post op respiratory muscle function returns to normal
more quickly
7 Wound complications I.e infection & dehiscence are
less
8 Lap surgery can be done as day care surgery
DISADVANTAGES
1 Long learning curve for surgeons
2 Narrow 2D visual field
3 More cost & more intraop complications

6. FIG. DEMONSTARTING SURGICAL INCISION
SITES IN LC

7. POSITIONING
1 Lap cholecystectomy rTn & Tn
2 Urology Tn,supine & lateral
3 OBG Dorsolithotomy
4 Upper GIT & biliary Head up
5 Thoracoscopy lateral decubitus
Nephrectomy
Adrenalectomy

9. PHYSIOLOGICAL CHANGES
There are 3 forces that alters pts physiology
during laproscopy
1 Increase in IAP & volume
2 Extremes of pt positioning
3 CO2 insufflation & hypercarbia
1-PATIENT POSITION
Trendelenburg-
 Increase in CBV. CVP,PCWP,.SVR & HR are
unchanged
 Decrease in VC,FRC & thoracopul compliance by
30-50
 Change in distribution of V/Q due to increased
Paw
 Decreased diaphragmatic excursion

10.  rTrendelenburg –
 Improved pul dynamics
 decreased venous return & afterload
 decreased BP,CO & increased chances of DVT
2 RESP. SYSTEM
 Decrease in VC,FRC & thoracopul compliance by 30-50
 Change in distribution of V/Q due to increased Paw
 Decreased diaphragmatic excursion
3 CVS
 No change or decrease in CI,CVP,PAOP with
induction of GA & rT
 Increased venous return,IAP,intrathoracic pressure,SVR
& MABP with CO2 insufflation
 LV function remains same foll CO2 insufflation
 Increased LV end systolic wall stress with increase in
systemic arterial pressure

11. 4 CNS-
slight ↑ of Pco2-direct corticaldepression
& ↑ threshold for seizures.
Higher levels of Pco2-stimulates
subcortical centres- ↑ excitability &
seizures.
Increased CBF velocity
Increased ICP

12. 5 GIT
 LES tone more than intragastric pressure-so
more chances of regurgitation & aspiration
6 HYPERCARBIA/CO2 INSUFFLATION
 Decreased myocardial contractility
 Dysarrythmias
 Reflex increase in vagal tone
 Compression of IVC leading to decrease in
CO & venous gas embolism

13. 7 HAEMODYNAMICAL CHANGES

14. 8 RENAL SYSTEM
 Oliguria-hypovolemia.PPV & PEEP
 Decrease RPF & GFR
9 Hepatic system
 Air pneumoperitoneum- Decrease in hepatic blood flow
 CO2 pneumoperitoneum-no change
10 TEMP REGULATION
 50 litres of CO2 lead to decrease in temp by 0.3 degg cel.
11 NEUROENDOCRINOLOGICAL CHANGES
 Increased IAP & hypercarbia –activation of sympatho.adrenal
axis-increased plasma level of epinephrine,norep, aldosterone,
ADH,ANP&cortisol.in awake pts in trend position increase in
ANP occurs becoz of increase in venous return & atrial stretch.
during PPN ANP decreases suggesting interference with venous
return

15. 12 THROMBOEMBOLISM
increased IAP rT
increased intra abdominal venous pressure
decreased venous capccitance decreased venous outflow
dialation of femoral veins
endothelial microtears venous stasis hypercoaguability
thromboembolism

16. CONTRAINDICATIONS
1 Absolute-NA
2 Relative-
i. Coagulopathy
ii. Diaphragmatic hernia
iii Severe cardio pul disease
iv. Increased ICP/SOL
v. Renal shutdown
vi. H/o extensive surgery/adhesions
vii. Sickle cell disease
viii.Peritonitis,tumours of abd wall mass
ix. Pts with shunts,shunt obstruction
x. Pts with intracranial HT

17. INSUFFLATING GAS OF CHOICE FOR
LAPROSCOPY
Properties of ideal insufflating gas-
Nontoxic,colourless
noninflamable,cheap,easily available
readily soluble in blood & easily vented
through thru lungs
Main consideration in choosing a gas
is its solubility & its Support to
combustion

18. Gas Oswalds blood
gas solubility
coeffecient
complications
1 air 0.017 Supports combustion
Gas embolism
2 oxygen 0.036 do
3 nitrogen Gas embolism
4 nitrous
oxide
0.042 Supports combustion
Bowel distension
PONV
Explosion with cautery
5 CO2 0.49 Hypercarbia
Pain abdomen
Shoulder tip pain
Arrythmia
Promotion of port site
tumour growth
6 He 0.00098 Embolism
diffusible
7 argon Embolism

19. WHY CO2 IS THE GAS OF CHOICE
FOR LAPROSCOPY
1 Nonflamable & does not support combustion
2 Highly soluble in blood becoz of rapid buffering
in blood so risk of embolisation are small
3 Rapidly diffusable through membranes so easily
removed by lungs
4 CO2 levels in blood & expired air can be easily
measured & its elimination is augmented by
increasing ventilation
5 Medical grade CO2 is readily available & is
inexpensive

20. ANAESTHESIA
PAC
Done in usual manner with special attention to
cardiac & pul. Syetem
PREMEDICATION
Diet-clear liquid day before surgery & NPO
after midnight
Complete bowel preparation
Antibiotics as per surgical team
Awareness about post op shoulder tip pain
Consent for laprotomy
Anxiolytics/antiemetics/H2 receptor antagonist

21. INVESTIGATIONS
1. Complete haemogram
2. RBS
3. BUN,S Creatinine
4. S Na,K
5. Coagulation profile
6. Blood typing & screnning
7. CXR
8. ECG
SPECIAL INVESTIGATIONS
1. ECHO/stress ECHO
2. PFT

22. MONITORING
GENERAL
1. HR
2. NIBP
3. ECG
4. Pulse oxy
5. Capnography
6. Paw
7. I/O charting
8. Temp,PNS
IF REQURIED ABG/IBP/PCWP/Precordial doppler
VISUAL & TACTILE MONITORING
1. Skin colour,turgor & capillary refill

23. CHOICE OF ANAESTHESIA
1 GA
2 RA
3 LA
GA is the anaesthesia of choice becoz of
1 Long duration of surgrry
2 Pt anxiety
3 Trendelenburg position may cause resp compromise
&dyspnoea in awake spon breathing pts with abd contents
under pressure esp obese pts
4 Nasogastric tube is diiff to insert & also diff to tolerate by
awake pts
5 Good muscle relaxation & ventilation is needed to
compensate for resp acidosis & hypercarbia
adequate field for exposure decreasing risk of
embolism,pneumothorax & perforation by instruments

24. GA
1. Preloading
2. atropinisation
3. iv fentanyl & lidocaine –blunt pressor response to
laryngoscopy & analgesia
4. Induction with TP,Propofol & TIVA
5. Muscle relaxation with scoline/ve,rocuronium or atracurium
6. Intubation with cuffed ETT & CMV to maintain normocapnia
(RR by 12-14 %)
7. Anaesthesia mtd with O2+N2O+ISO
8. Intra op pain releif with iv fentanyl &NSAIDS
9 Urinary catheterisation,oro/nasogastric tube
10. Positioning
11 Flow rates(1-2,2-8,6-8)
12. Insufflation &exsufflation should be gradual

25. FLUID MANAGEMENT
4ml/Kg/Hr of Ringer lactate solution
depending on paitent”s preoperative
haemodynamic status & the volume of
Intra peritoneal irrigation fluid used by
surgeon. In laproscopy third space loss
Is less. So volume of retained
intraperitoneal fluid should be added to
final total volume of fluid infused.
( no fluid loss by evaporation &
insufflated dry CO2 results in negligible
insensible loss )

26. REGIONAL ANAESTHESIA
1 SAB
2 EPIDURAL BLOCK
3 CSE
DRAWBACKS
1 REQURIES A HIGH LEVEL OF SENSORY BLOCK POSSIBLY
causing dyspnoea in trendelenburg position
2 NG/OG tube may not be well tolerated
3 Hyperventilation in response to hypercarbia may cause too
movement in surgical field
4 Hyperventilation may not be adequate to compensate for
hypercarbia in trendelenburg position
5 i.v analgesics or propofol –resp depression/obstruction
esp in trendelenburg position.hypoxia in presence of
hypercarbia has serious consequences
6 In laproscopy there is sympathetic nervous system stimulation.
in RA there is sympathetic denervation-hypotension &
decreased CO

27. LOCAL ANAESTHESIA
1 LA with sedation
2 LA with N2O +O2
Under LA CO2 causes pain intraperitoneally which is
refferrd to shoulder so nitrous oxide which is non irritating
to Peritoneum has been the insufflating gas of choice for
brief OBG procedures I.e diagnostic lap & tubal ligation
without cautery

28. COMPLICATIONS
INTRAOP-
1 anaesthesia related
2 laproscopy related
 introduction of pneumoperitoneum
CVS-Arrythmia(vasovagal,brady &tacchy)
hypotension-cardiac arrest
hypertension
RESP-hypercarbia
gas embolism
 Due to extravasation of gas-S.C emphysema
pneumothorax
pneumomediastenums
 Insertion of trocars
similar to above
injury to organs-stomach,liver,spleen & urinary bladder

29.  Positioning of patients
Nerve injuries
Endobronchial intubation
Thermal injuries
POST OP-
1 Pain
2 Nausea & vomiting
3 DVT
4 Infections
5 Spread of malignancy
SPECIFIC-Due to surgery involved

30. DIAGNOSIS OF RESP. COMPLICATIONS

32. LAPROSCOPIC SURGERY
IN SOME SPECIAL
SITUATIONS

34. LAPROSCOPY IN INFANTS & CHILDREN
1 Physiological changes are same
2 Both PaCO2 & ETCO2 increase during laproscopy but
ETCO2 may overestimate PaCO2
3 CO2 absorption is more intense & rapid in infasnts than
adults becozperitoneal SA reffered to body wt is greater
4 For brief duration laproscopy Paw & ETCO2 rise only
slightly so no increase in ventilation is requried
5 More chances of trauma to trauma to liver by trocar &
needle
6 More chances of bradycardia
7 Restrict IAP & use slow insufflation rates.in infants up to
1 year of age use 6 mmof hg after that use up to 12
12 mm hg

35. LAPROSCOPY IN PREGNANCY
Indications-non OBG surgeries I.e appendicectomy
cholecystectomy
1 Operation should be done during 2nd trimester ideally b/w
4-23 weeks to minimise risk of miscarriage & preterm labour
2 Maintain LUD
3 Use open laproscopic tech for trocar insertion(HASSANS)
4 Maintain IAP as low as possible
5 Machenical ventilation should be adjusted to maintain a
state of maternal alkalosis& normocapnia
6 Use of avtive antithromboembolic measures
7 Continous fetal monitoring using trans vaginal scan
8 Tocolytics should not be used prophylactically
9 Minimise operating time
10 If intraop cholangiography is to be performed-protect the
fetous with lead shield