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Anaesthesia for Laparoscopic surgery

In 1902 - the first laparoscopic procedure in dogs


In 1910 - the first laparoscopic operation in humans
In 1975 - First organ resection, Salpingectomy
In 1981 - the first laparoscopic appendicectomy.
Prior to 1990, mostly used for diagnostic laparoscopy or tubal
ligation.
The introduction of clip applier in 1990 made more
comfortable with laparoscopic cholecystectomies.

A major benefit of laparoscopic surgery is

The shortened recovery time after major surgery

Shorter in-hospital stay Reduced morbidity

Importance to the anaesthetist ?

Reasons - multi-factorial:
1. Reduced manipulation of the bowel and peritoneum

decreased incidence of postoperative ileus,


enteral intake can be resumed more rapidly
Limits requirements for i.v. fluid regimes (tissue
oedema, poor wound repair, prolonged postop
recover
2.

Small access points


- Minimized incision size, trauma
- Minimizing complications associated with
postoperative pain and wound healing
- Reduced incidence of both wound and systemic
infections

Special patient groups


Obese pts - open surgery technically very
challenging susceptible to wound infection
Severe respiratory disease - large incisions with
suboptimal analgesia post op deterioration of
pulmonary functions

1.

GI sx- Cholecystectomy, Bowel resectionsick/elderly


Adrenalectomy, Nephrectomy, Fundoplication,
Hernia repair
Gynaecological procedures-young & fit
Emergency op sick/elderly

The peritoneal cavity is usually insufflated with a gas pneumoperitoneum

Rate-4-6 L/min
10-20 mmHg
Constant gas flow 200-400 ml/m

Carbondioxide

Rapid stretching of the peritonium vagal


stimulation
Arrhythmias- nodal rhythm, sinus bradycardia,
asystole

Complications-more insidious

Range of surgery - Increasing in complexity;


-

It is common to the human body


Can be absorbed by the tissues and removed by the
respiratory system.
Also non-flammable, is important as electrosurgical
devices are commonly used in laparoscopic
procedures
Colourless
Higher blood solubility, greatest margin of safety in
the event of a venous embolism (effects less than
with air)
This elevates the abdominal wall above the internal
organs like a dome to create a working and viewing
space.

2.

Procedure related
Positional-Complications
Pneumoperitonium
Patient specific

Procedure related-Surgical/Associated with


laparoscopic technique
Trochar insertion without direct vision

Potential to damage to solid viscera, bowel,


bladder, blood vessals

Incorrect positioning of
needle/trochar/anatomical anomalies/gas
dissecting across weak tissue planes Subcut
emphysema, pneumomediastinum,
pneumothorax

Retroperitonial hematomas

Venous gas embolism circulatory


collapse - Rare,fatal.
Directly into a blood vs/gas can be drawn into
open vs by venturi effect, Desaturation,
hypotension, a mill wheel murmur may result
Positional-Complications associated with extremes of
positioning, well leg compartment syndrome
Physiological effects of positioning depends on the
operation

Trendelenburg (head down) Gyn surgery


Reduction in FRC

V/Q mismatch
Greater risk of atelectasis
Cephalad movement of lungs & carina in relation to
the fixed ET tube endobronchial intubation
Initially VRCOcompensatory vasodilatation

-minimal effects on CVS in a pt with no CV illness


-may not be tolerated in pts with compromised myo
compliance (hypertrophy/ischemia)
Prolonged steep T position

risk of cerebral oedema + upper airway oedema


well leg compartment syndrome

Well leg compartment syndrome


Rare but devastating complication of prolonged
steep Trendelenburg position
Impaired arterial perfusion to raised lower limbs
Compression of venous vessels by lower limbs
supports
Reduced femoral venous drainage by
pneumoperitoneum.
Presentation during post operative period

ii. Physiological effects of gas absorption


Absorbed readily from the peritoneum
Increase in Paco2
Direct/ Indirect- cat levels
Effects on CVS
Tachycardia,cardiac contractility,reduction in
diastolic filling myo:o2 supply demand
ratiogreater risk of MYO ischeamia
iii. IAP
CVS
Res
Renal
GI
Neurological
CARDIOVASCULAR EFFECTS

Disproportionate Lower Limb Pain


Rhabdomyolysis
Myoglobin-associated Acute Renal Failure
significantly increased morbidity and mortality.
Risk factors
Surgery >4 h duration

Muscular lower limbs

Obesity

Peripheral vascular disease

Hypotension

Steep Trendelenburg positioning


Reverse Trendelenburg (head up) upper abdominal
surgery
Few RS effects
More marked CVS effects
InitiallyVRCOBP myocardial ,cerebral
ischemia
More marked;elderly/ hypovoleamic/compromised
cvs cerebrovascular disease
3. Pneumoperitonium
direct effect of gas insufflation
IAP
effects of CO absorption
i. Effects of gas insufflation

Stretching of the peritonium vagal stimulation


Arrhythmias- nodal rhythm, sinus brady, asystole

Increased IAP increased VR, SVR, myocardial


function
IAP < 10mm Hg

increased VR (autotransfusion of pooled


blood from splanchnic circulation due to
mechanical compression of AA) increased
CO

compression of AA increased vasopressin


and R-A-A axis
IAP 10-20mm Hg

reduced VR (compression of IVC)


reduced CO
increased SVR (direct effect,

catecholamines -E, NA) >>>>CO


/BP
increased SVR, SBP, DBP, HR

myocardial workload myocardial ischeamia


IAP > 20mm Hg

Reduced VR CO
SVR CO, BP

Effects more pronounced in; hypovoleamia, cardiovascular


disease.
Cephalad displacement of the diaphragm which raises ITP
with further reduction in blood flow through the IVC, and
compression of pulmonary parenchyma which increases
pulmonary vascular resistance, further reducing cardiac
output.

RESPIRATORY EFFECTS

Reduced FRC - supine position


- due to GA
- due to cephalad movement of diaphragm as a
result of pneumoperitoneum, trendelenburg position
- FRC<<< CV airway collapse, atelectasis,
V/Q mismatch, potential hypoxaemia/hypercarbia
Increased airway resistance
Reduced pulmonary compliance
Limited diaphragmatic excursion result in raised
ITP barotrauma with IPPV
which in turn leads to pulmonary atelectasis, altered V/Q
relationships, and hypoxaemia.
SPLANCHNIC EFFECTS

Blood flow to the kidney and liver is significantly


compromised - important consideration in patients
with existing disease
Persistent IAPs > 20 mmHg reduced mesenteric and
gastrointestinal mucosal blood flow up to 40%with
progressive tissue acidosis
Raised IAP is recognized as an independent cause of
AKI. An IAP of 20 mm Hg will reduce GFR by
25%.
The mechanism for this is an impaired renal
perfusion gradient secondary to the combined effect
of reduced renal afferent flow due to impaired
cardiac output and reduced efferent flow due to
raised renal venous pressure.

How may these effects be minimised?

Regurgitation of gastric contents risk of


pulmonary aspiration
Significant in obese patients

NEUROLOGICAL EFFECTS

An elevated IAP causes an increase in ICP by


limiting cerebral venous drainage as a consequence
of raised ICP and reduced CPP, Especially if CO

CPP is maintained by the increase in MAP lead to


cerebral oedema.

4.

This contributes to the temporary neurological


dysfunction that patients often experience on
emergence from prolonged laparoscopic procedures,
in steep Trendelenburg positioning.

Patient specific - Affects significantly if

Both pneumoperitoneum and steep Trendelenburg


positioning inhibit effective ventilation
Traditional volume control modalities- increased risk
of barotrauma particularly in obese patients.
pressure controlled modalities - minimize peak
pressures, and provide improved alveolar
recruitment and oxygenation for obese patients.
titrated levels of PEEP can be used to minimize
alveolar de-recruitment but must be used cautious as
increasing PEEP may further compromise cardiac
output

Analgesia

elderly/associated morbidity
Contraindications
severe IHD
valvular disease

All patients for laparoscopic surgery should be fully


assessed before operation-pt selection
Some are at elevated risk of AE from
pneumoperitoneum
A probability of conversion to an open procedure
should be considered when choosing the anaesthetic
technique
AIRWAY-protect against gastric aspiration
The most common technique for airway
management involves placement of a cuffed oral
tracheal tube (COTT), neuromuscular relaxation, and
positive pressure ventilation.
This also allows optimal control of CO2, and
facilitates surgical access.
Bag and mask ventilation before intubation should
be minimized to avoid gastric distension
Insertion of a nasogastric tube may be required to
deflate the stomach, also improve surgical view and
avoid gastric injury on trochar insertion.

Ventilation

GI

significant renal dysfunction


end stage respiratory disease
raised ICP
severe uncorrected hypovoleamia
RL cardiac shunts , PFO

high-quality analgesia is essential to prevent delayed


hospital discharge.
pain is often short, yet intense
up to 80% of patients will require opioid analgesia
at some stage perioperatively.
regional techniques such as subdural, epidural, and
more recently transversus abdominis plane block
Wound infiltration with local anaesthetic
intraperitoneal levobupivacaine reduces
postoperative pain and opiate requirements

Antiemetics

high incidence of postoperative nausea and vomiting


very distressing, worsen pain, extend the period of
hospital stay
prophylaxis is important
multi-modal regimes such as ondansetron, cyclizine,
and dexamethasone seem most effective
Dexamethasone- before induction - reduce
subsequent opiate analgesia requirements in the first
2 h anti-emetic effects.
general measures
- deflate the stomach
- avoid known emetogenic drugs (opiates)
- ensure good quality postoperative analgesia.

Monitoring

significant physiological disturbances to the patient

limited access once surgery has commenced

Venous tamponade mask apparent bleeding

The effects of pneumoperitoneum on the respiratory


system
-

assessed by capnography, pulse oximetry


supported by peak and plateau airway pressures,
delivered tidal volumes, observing dynamic flowvolume loops

optimizing preload with fluid

judicious use of vasoactive drugs

inotropic drugs such as ephedrine are often more


effective than vasopressors such as metaraminolsince SVR is normally raised

Well leg compartment syndrome


Prevention
avoid intermittent compression stockings
move the patients legs at regular intervals during
surgery
use heel/ankle supports instead of calf/knee supports
(LloydDavies stirrups)
return to the horizontal position at least every 2 h /
limbs are massaged for 510 min before returning to
the Trendelenburg position.
A pulse oximeter is placed on the great toe
throughout surgery to assess the adequacy of
pulsatile flow to distal areas of the lower limbs.
Postoperative management

invasive arterial monitoring during prolonged


surgery and patients with cardiovascular comorbidities

Haemodynamic instability is best treated by

Accurate assessment of preload is challenging


- pressure-based indices of preload (CVP) may be
misleading- due to the effects of raised IAP and
subsequently ITP on cardiac filling pressures
- minimally invasive devices- oesophageal Doppler
monitor, LiDCO may provide more accurate assessments

Maximal Pain during the first 2 h post-procedure


Postoperative shoulder-tip pain after laparoscopic
surgery is common - may be reduced if the surgeon
expels as much gas from the peritoneal cavity as
possible
All should receive supplemental oxygen while in
recovery
Patients with existing respiratory disease or those
having prolonged surgery -Alveolar recruitment
techniques, using short-term continuous positive
airway pressure