Journal of Clinical Anesthesia (2006) 18, 67 – 78

Review article

Anesthesia for laparoscopy: a review

Frederic J. Gerges MD (Chief Resident), Ghassan E. Kanazi MD (Associate Professor),
Samar I. Jabbour-khoury MD (Associate Professor)*

Department of Anesthesiology, American University of Beirut-Medical Center, Beirut 1107-2020, Lebanon

Received 7 June 2004; accepted 27 January 2005

Keywords: Abstract Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbon
Laparoscopy; dioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several
Patophysiological pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient
changes; positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal
Anesthesia; anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most
General; common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia
Regional; for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be
Recovery; tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several
Complications intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and
cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe
alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory
depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for
limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This
article considers the pathophysiological changes during laparoscopy using carbon dioxide for intra-
abdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, and
discusses recovery and postoperative complications after laparoscopic abdominal surgery.
D 2006 Elsevier Inc. All rights reserved.

1. Introduction medical cost, less intraoperative bleeding, less postoperative

Laparoscopy started in the mid 1950s when gynecologists
declared this technique as a safe way to diagnose pelvic
pain while reducing hospital stay and postoperative pain.
Thereafter, laparoscopy for general surgery followed and
proved to be advantageous in reduction of postoperative pain,
better cosmetic results, quicker return to normal activities,
reduction in hospital stay resulting in overall reduction in
* Corresponding author. Tel.: +961 1 350 000x6380; fax: +961 1 744
464.
E-mail address: sj00@aub.edu.lb (S.I. Jabbour-khoury).
pulmonary complications, less postoperative wound infec-
tion, reduced metabolic derangement, and better postopera-
tive respiratory function [1].
In recent years, advanced laparoscopic surgery has
targeted older and sicker patients, rendering anesthesia during
laparoscopy more technically demanding. On one hand,
laparoscopy can compromise the cardiovascular and respira-
tory function of the patients, whereas on the other, it was
introduced as a safe and simple procedure that may be
performed on an outpatient basis hence demanding extreme
caution regarding the anesthetic technique. Furthermore, the
application of laparoscopy has expanded and is currently

0952-8180/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2005.01.013
68
used safely and effectively in children [2], in vascular cases
such as total laparoscopic aortomesenteric bypass [3], in
complicated urology cases such as laparoscopic nephrectomy
for large renal arteriovenous malformation [4], for radical
prostatectomy, in hand assisted laparoscopic radical cystec-
tomy [5], in advanced general surgery for distal pancreatec-
tomy [6], and in hepatic resection [7,8]. Consequently,
laparoscopic surgery presents several new challenges for
the anesthesiologist where an appraisal of the potential
problems is essential for optimal anesthetic care, allowing
early detection and reduction of complications.
2. The choice of insufflated gas
The ideal gas for insufflation would have the following
properties: minimal peritoneal absorption, minimal physio-
logical effects, rapid excretion of any absorbed gas, inability
to support combustion, minimal effects from intravascular
embolization, and high blood solubility [9].
Air and oxygen cannot be used for insufflations during
laparoscopy because they support combustion whenever
bipolar diathermy or lasers are used. Helium and nitrogen are
relatively insoluble, as compared with carbon dioxide, and
can result in more serious cardiovascular sequelae whenever
an intravascular gas embolization occurs. Furthermore,
concerns about helium cost effectiveness in laparoscopy
have been raised. Argon may have unwanted hemodynamic
effects, especially on hepatic blood flow. Although nitrous
oxide is advantageous for procedures requiring local/
regional anesthesia and, in some cases, of depressed
pulmonary function, it does not suppress combustion [9].
Carbon dioxide approaches the ideal insufflating gas and
maintains its role as the primary insufflation gas in
laparoscopy. Residual carbon dioxide pneumoperitoneum
is cleared more rapidly than that created with other gases,
minimizing the duration of postoperative discomfort [9].
However, the chief drawback of carbon dioxide is its
significant vascular absorption across the peritoneum,
leading to hypercapnia and intravascular embolization [10].
The gasless laparoscopic technique avoids using any gas
for insufflation, relying instead on an abdominal wall lift to
create an intra-abdominal space at atmospheric pressure,
consequently eliminating the problems attributed to increased
intra-abdominal pressure (IAP), hypercapnia, and carbon
dioxide embolization. Furthermore, it provides a better
cardiovascular condition with a resultant higher heart
performance and lower preload and afterload, as compared
with carbon dioxide laparoscopy [11]. Alijani et al [12] have
demonstrated that the abdominal wall lift approach avoids fall
in cardiac output associated with carbon dioxide pneumo-
peritoneum and is associated with a more rapid recovery of
postoperative cognitive function. Hence, abdominal wall-
lifting approach in laparoscopic cholecystectomy is a method
worthy of consideration for elderly patients or those with
cardiopulmonary problems [13]. However, in patients with
F.J. Gerges et al.
limited cardiac, pulmonary, or renal function, abdominal wall
lifting have no clinically relevant advantages compared with
low-pressure (5-7 mm Hg) pneumoperitoneum; furthermore,
abdominal wall lifting combined with low-pressure pneumo-
peritoneum might be a good alternative [14].
3. Pathophysiological changes during
laparoscopy
Laparoscopy induces particular pathophysiological
changes in response to pneumoperitoneum. Knowledge of
the pathophysiology of a carbon dioxide pneumoperitoneum
can help minimize complications and render laparoscopic
surgery a safer technique.
3.1. Effects of carbon dioxide absorption
Carbon dioxide diffuses to the body more during
extraperitoneal than intraperitoneal insufflation, and its
diffusion is not influenced by the duration of intraperitoneal
insufflation [15]. Furthermore, extraperitoneal carbon diox-
ide insufflation leads to higher Paco2 (tension of carbon
dioxide in arterial blood) values in the postoperative period
[16]. Intraperitoneally, carbon dioxide was shown to be
affected by raising the intraperitoneal pressure above the
venous vessels pressure, which prevents carbon dioxide
resorption leading to hypercapnia. Hypercapnia by itself
increases minute ventilation by as much as 60% to normalize
the end-tidal carbon dioxide (etco2) and activates the
sympathetic nervous system leading to an increase in blood
pressure, heart rate, myocardial contractility, and arrhyth-
mias. It also sensitizes the myocardium to catecholamines,
particularly when volatile anesthetic agents are used [10].
3.2. Creation of the pneumoperitoneum
The creation of a pneumoperitoneum is ideally done with
2.5 to 5.0 L of insufflated carbon dioxide to permit adequate
visualization and manipulation of the abdominal viscera.
The pneumoperitoneum necessarily raises IAP, which
can have significant cardiovascular, respiratory, and neuro-
logic effects.
3.2.1. Cardiovascular effects
Major hemodynamic changes include alterations in
arterial blood pressure (ie, hypotension and hypertension),
arrhythmias, and cardiac arrest. The extent of the cardiovas-
cular changes associated with creation of pneumoperitoneum
will depend on the IAP attained, volume of carbon dioxide
absorbed, patient’s intravascular volume, ventilatory tech-
nique, surgical conditions, and anesthetic agents used.
However, the critical determinants of cardiovascular func-
tion during laparoscopy are the IAP and patient position.
At IAP levels below 15 mm Hg, venous return is aug-
mented as blood is bsqueezedQ out of the splanchnic venous
bed, producing an increase in cardiac output. Further increase
in cardiac output at lower IAP may result from increased
Anesthesia for laparoscopy
cardiac filling pressures due partly to mechanical factors and
partly to sympathetically mediated peripheral vasoconstric-
tion along with the effects of hypercapnia on cardiac efferent
sympathetic activity, which can increase systemic vascular
resistance and reduce cardiac index. At IAP levels greater
than 15 mm Hg, venous return decreases as the inferior vena
cava is compressed along with the surrounding collateral
vessels leading to decreased cardiac output and hypotension
[17]. Recent studies recommend a moderate to low IAP (b12
mm Hg) as it limits the alteration in splanchnic perfusion, and
consecutive organ dysfunctions will be minimal, transient,
and will not influence the outcome [10]. Zuckerman and
Heneghan [18] demonstrated that these changes are short
lived and lose their statistical significance at 10 minutes from
the time a patient undergoes pneumoperitoneum.
Bradyarrhythmias, including significant bradycardia,
atrioventricular dissociation, nodal rhythm, and asystole
have been reported. These are attributed to vagal stimulation
caused by insertion of the Veress needle or the trocar,
pneumoperitoneum-induced peritoneal stretch, stimulation
of the fallopian tube during bipolar electrocauterization, or
carbon dioxide embolization [19]. Tachyarrhythmias can
occur because of increased concentrations of carbon dioxide
and catecholamines. Paroxysmal tachycardia and hyperten-
sion, followed by ventricular fibrillation, have been reported
during laparoscopic adrenalectomy [20]. The induction of
pneumoperitoneum with the patient in the horizontal
position rather than in head-up or head-down position can
decrease the severity of these hemodynamic changes.
Patients with normal cardiovascular function are able to
well tolerate these variations in preload and afterload. Those
with cardiovascular disease, anemia, or hypovolemia require
meticulous attention to volume loading, positioning, and
insufflation pressures. However, many cases of cardiovas-
cular collapse during laparoscopy occurs in healthy patients,
because of, namely, vasovagal reflex response to peritoneal
stimulation from trocars or insufflation, myocardial sensiti-
zation by halothane, reduced venous return secondary to
reverse Trendelenburg position, inferior vena cava compres-
sion, high insufflation pressures, hypovolemia, hypercapnia
particularly in longer procedures, and venous gas embolism.
3.2.2. Respiratory effects
Changes in pulmonary function during laparoscopy
include reduction in lung volumes, increase in peak airway
pressures, and decrease in pulmonary compliance secondary
to increased IAP and patient positioning [21].
Creation of pneumoperitoneum at an IAP of 15 mm Hg
reduces respiratory system and compliance and increases
peak inspiratory and mean airway pressures, which quickly
return to normal values after deflation. Elevated IAP reduces
diaphragmatic excursion and shifts the diaphragm cephalad,
resulting in early closure of smaller airways leading to
intraoperative atelectasis with a decrease in functional
residual capacity. On one hand, upward displacement of the
diaphragm leads to preferential ventilation of nondependent
69
parts of the lung, which results in ventilation-perfusion (V/Q)
mismatch with a higher degree of intrapulmonary shunting,
whereas on the other, it leads to endobronchial intubation.
These pulmonary pathophysiological changes lead to hyper-
capnia and hypoxemia in case of noneffective ventilation
leading to pulmonary vasoconstriction [10]. Higher IAP
reduces more the thoracic compliance and can cause
pneumothorax and pneumomediastinum owing to the in-
crease in alveolar pressures, particularly in patients with
extensive pulmonary disease undergoing laparoscopic upper
abdominal surgeries [21].
In patients with significant pulmonary dysfunction, pre-
operative pulmonary function testing including arterial blood
gas analysis should be performed, and intraoperative radial
artery cannula should be placed. If refractory hypoxemia,
hypercapnia, or high airway pressures occur during the lapa-
roscopy, the pneumoperitoneum should be released followed
by slow reinsufflation using lower IAPs. If complications
recur, conversion to an open procedure is a must [21].
3.2.3. Neurologic effects
Increased intracranial pressure (ICP) along with a
decrease in cerebral perfusion pressure is encountered
whenever hypercapnia, increased systemic vascular resis-
tance, head-down positioning, and elevated IAP are present.
Because of this phenomenon, it is inadvisable to perform
laparoscopic surgery on patients with reduced intracranial
compliance unless absolutely necessary [22].
3.3. Patient positioning
Adverse patient positions can further compromise
cardiac and respiratory function, can increase the risk of
regurgitation, and can result in nerve injuries. These
complications were relatively rare when laparoscopy was
mainly confined to brief gynecologic procedures in healthy
patients but become more likely with longer and more
complex surgery performed in older and sicker patients.
3.3.1. Cardiovascular changes and patient positioning
Cardiovascular changes are complicated by the patient’s
position during laparoscopic surgery. The head-up position
reduces venous return and cardiac output, with a decrease in
mean arterial pressure and cardiac index, as well as an
increase in peripheral and pulmonary vascular resistance
[10,17,23]. These effects may be mistaken as the side effects
of anesthetic agents. Furthermore, a study done by Cunning-
ham et al [24] using transesophageal echocardiography has
showed an increase in left ventricular end-systolic wall
stress, along with a decrease in left ventricular end-diastolic
area, with left ventricular ejection fraction being the same.
Conversely, head-down position increases venous return
and normalizes blood pressure [17].
3.3.2. Respiratory changes and patient positioning
Blood gas changes and respiratory mechanics are
affected by the duration of pneumoperitoneum and patient
positioning. The deterioration in respiratory function is
70
reduced when the patient is in the reverse Trendelenburg
position and worse when the patient is in the Trendelenburg
position [25].
4. Patient monitoring
Appropriate anesthetic techniques with proper monitor-
ing to detect and reduce complications must be used to
ensure optimal anesthesia care during laparoscopy. Hence,
electrocardiogram, noninvasive arterial pressure monitor,
airway pressure monitor, pulse oximeter, etco2 concentra-
tion monitor, peripheral nerve stimulation and body
temperature probe are routinely used. For hemodynamically
unstable patients or those with compromised cardiopulmo-
nary function, careful monitoring of cardiovascular and
blood gases by an arterial cannulation is indicated along
with urine output measurement. These measures also apply
for obese patients [14].
End-tidal carbon dioxide is most commonly used as a
noninvasive substitute for Paco2 in evaluating the adequacy
of ventilation during laparoscopic surgery. However, a careful
consideration should be taken for the gradient between Paco2
and PEco2 (tension of carbon dioxide in expired air) because
the etco2 may differ considerably from Paco2 because of
V/Q mismatching. In patients with compromised cardiopul-
monary function, the gradient between Paco2 and PEco2
increases to become unpredictable so that direct estimation of
Paco2 by arterial blood gas analysis may be necessary to
detect hypercarbia. Therefore, a radial artery cannulation for
continuous blood pressure recording and frequent arterial
blood gas analysis should be considered in patients with
preoperative cardiopulmonary disease and in situations
where intraoperative hypoxemia, high airway pressures, or
elevated etco2 are encountered [14].
An airway pressure monitor is routinely used during inter-
mittent positive pressure ventilation. A high airway pressure
alarm can aid detection of excessive elevation in IAP [14].
Nerve stimulation ensures adequate muscle paralysis,
which reduces the IAP necessary for abdominal distension
and prevents sudden patient movement that can lead to
accidental injuries of intra-abdominal structures by laparo-
scopic instruments [14].
Inadequate anesthesia may occur in the presence of
neuromuscular block, resulting in awareness. The use of a
Bispectral Index, a possible monitor of depth of hypnosis,
can help to reduce the occurrence of awareness. Some
anesthesiologists have used this monitor to titrate intrave-
nous and inhaled anesthetic drugs to fasten emergence and
improve recovery [26-28].
5. Anesthetic techniques
Because more laparoscopic procedures are done on an
outpatient basis, general and regional anesthesia have been
F.J. Gerges et al.
successfully and safely used with great emphasis on short
duration drugs, cardiovascular stability, rapid recovery and
fast-tracking, mobility, and freedom from postoperative
nausea and vomiting and pain.
5.1. General anesthesia for laparoscopy
General anesthesia using balanced anesthesia technique
including inhalational agents such as nitrous oxide, sevo-
flurane, isoflurane, and desflurane; intravenous induction
agents such as thiopentone, propofol, and etomidate; and a
variety of muscle relaxants including succinylcholine, miva-
curium, atracurium, and vecuronium have been reported.
Shorter-acting drugs such as sevoflurane, desflurane, and con-
tinuous infusions of propofol represent the maintenance
agents of choice. In fact, comparative studies have demon-
strated an early recovery, which is similar with any of these
drugs. Propofol, however, does have the advantage of produc-
ing less postoperative nausea and vomiting (PONV) [29,30].
The use of more rapid and shorter-acting volatile
anesthetics such as desflurane and sevoflurane and
bultrashort-actingQ opioid analgesics such as remifentanil
has allowed anesthesiologist to more consistently achieve a
recovery profile that facilitates fast tracking after the
administration of general anesthesia. Fast tracking in the
ambulatory setting implies taking a patient from the
operating room directly to the less extensively monitored
phase II step-down unit bypassing the postanesthesia care
unit. It is applied in multiple laparoscopic procedures
including cholecystectomy, gastric fundoplication, splenec-
tomy, adrenalectomy, and donor nephrectomy [31]. Nowa-
days, fast-track anesthesia is gaining more and more practice
in laparoscopic surgery to include the pediatric age group
where laparoscopic appendectomy is demonstrated to be
safely performed as fast-track or same-day surgery with a
postoperative stay of 24 hours or less [32]. Furthermore,
endoscopic thoracic sympathectomy is currently performed
safely on an outpatient basis [33].
Compared with standard monitoring practices, the use of
an auditory evoked potential or Bispectral Index monitor to
titrate the volatile anesthetic leads to a significant reduction
in the anesthetic requirement, resulting in a shorter
postanesthesia care unit stay and an improved quality of
recovery from the patient’s perspective [34]. Song et al [35]
demonstrated that the electroencephalographic Bispectral
Index values at the end of anesthesia is useful in predicting
fast-track eligibility after laparoscopic tubal ligation with
either a desflurane or propofol-based anesthetic technique.
Total intravenous anesthesia using the following agents:
propofol, midazolam and ketamine, and alfentanil and
vecuronium have been reported for outpatient laparoscopy.
Propofol-based anesthesia provided inferior perioperative
conditions compared with isoflurane caused by more frequent
movement in spontaneously breathing patients. Furthermore,
sevoflurane and desflurane were still superior to propofol,
even when PONV was considered, and resulted in a higher
percentage of patients being judged fast-track eligible [36].
Anesthesia for laparoscopy
Patients are more liable to develop perioperative aware-
ness and PONV whenever opioid-based techniques are used
for laparoscopy. Therefore, opioid supplementation of
intravenous or inhalation-based anesthesia is more appro-
priate. The ultrashort-acting opioid remifentanil, which is
rapidly hydrolyzed by circulating and tissue nonspecific
esterases, has been shown to provide better control of
perioperative hemodynamic responses, compared with
alfentanil [37]. A major advantage of remifentanil is that
doses sufficient to attenuate cardiovascular responses can be
used without the risk of postoperative respiratory depression
and delayed recovery. However, postoperative analgesia
should be considered. Song and White [38] demonstrated
that the adjunctive use of a remifentanil infusion during
desflurane–nitrous oxide anesthesia facilitates early recov-
ery without increasing PONV, pain, or the need for rescue
medication after laparoscopic surgery. Yang et al [39] did
not find any difference in PONV, pain, or anesthetic/
recovery times or costs between sevoflurane-remifentanil
induction and propofol-fentanyl-rocuronium induction in
the first 24 hours after laparoscopic surgery.
Preemptive analgesic techniques using nonopioids such
as acetaminophen, non steroidal anti-inflammatory drugs,
a 2-agonists, and N-methyl D-aspartate antagonists proved to
be of benefit in multimodal analgesia and ambulatory
surgery where rapid recovery is the aim. Non-opioids are
increasingly used during laparoscopy to decrease opioid
requirements and avoid delayed recovery [40].
Nitrous oxide is commonly used to provide perioperative
analgesia and to reduce the requirements for inhaled or
intravenous anesthetics. The contribution of nitrous oxide to
nausea and vomiting is still controversial. There is
apparently no clinical advantage to omitting nitrous oxide,
and any benefit from its elimination must be balanced
against a greater risk of awareness [41]. Earlier anesthetic
techniques described for laparoscopic cholecystectomy
avoided nitrous oxide. Further studies have confirmed
similar surgical conditions and view regardless of whether
nitrous oxide was used, questioning its contraindication
during laparoscopic cholecystectomy. However, omission of
nitrous oxide improves surgical conditions for intestinal and
colonic surgery by avoiding the possible nitrous oxide
diffusion into the bowel lumen. Diemunsch et al [42] have
demonstrated that nitrous oxide diffuses into a carbon
dioxide pneumoperitoneum up to a level that can support
combustion in a 2-hour interval. Whether nitrous oxide
diffusion represents a real clinical risk of fire and explosion
during prolonged laparoscopy remains unclear, however. In
practice, some gas usually leaks from the abdomen and is
replaced by fresh carbon dioxide, which would somewhat
compensate for the ingress of nitrous oxide.
Succinylcholine was once commonly used as the muscle
relaxant of choice for short laparoscopic procedures, but it
was associated with a high incidence of postoperative
muscle pains. Currently, there is a considerable choice in
nondepolarizing neuromuscular blocking drugs rendering
71
their use more frequent, although none of them are quite as
short acting as succinylcholine. When they are used in place
of succinylcholine, the amount of muscle pain especially in
the neck is reduced [43,44]. Shoulder pain is still common,
however, being largely a consequence of the pneumo-
peritoneum. The lack of a very-brief-duration nondepolariz-
ing neuromuscular blocking drug is no longer a significant
problem because laparoscopic surgery has become more
complex and takes more time. However, it is desirable to use
repeated doses of short-acting agents rather than occasional
doses of longer-acting drugs. Using short-acting drugs
makes it feasible to reverse residual neuromuscular block
even if the last increment of a short-duration drug were
given within the previous 5 to 10 minutes. Some anesthesi-
ologists avoid the use of reversal drugs because it has been
suggested that they increase the incidence of PONV [43].
However, others have not found an increase in PONV
associated with the use of neostigmine and glycopyrrolate to
reverse residual neuromuscular block [45]. More impor-
tantly, even minor degrees of residual neuromuscular block
can produce distressing symptoms, such as visual distur-
bances, facial and generalized weakness, and the inability to
sit without assistance [46]. These symptoms can be present
despite signs of clinical recovery from neuromuscular block
and can prolong the recovery process. These findings should
present an incentive to minimize the use of neuromuscular
blocking drugs in ambulatory anesthesia. When they are
used, however, reversal drugs should be administered in
appropriate doses without hesitation.
General anesthesia without intubation can be performed
safely and effectively with a ProSeal laryngeal mask airway
(LMA) in nonobese patients [47]. Moreover, a correctly
placed classic LMA or a ProSeal (ProSeal LMA, San Diego,
CA, USA) LMA is as effective as an endotracheal tube for
positive pressure ventilation without clinically important gas-
tric distension in nonobese and obese patients [48]. However,
it should be restricted to short procedures performed using
low IAP and small degrees of tilt. It results in less sore throat
and might be proposed as a safe alternative to endotracheal
intubation [49]. Furthermore, it allows controlled ventilation
and accurate monitoring of etco2. However, decreased thor-
acopulmonary compliance during pneumoperitoneum fre-
quently results in airway pressures exceeding 20 cm H2O.
Because the LMA cannot guarantee an airway seal above this
pressure, its use for controlled ventilation should be limited to
healthy, thin patients. If tracheal intubation is still required, it
can be performed under deep intravenous [50] or inhalation
anesthesia [51], eliminating the potential problem of exces-
sively prolonged paralysis. Lu et al compared the ProSeal
LMA with the classic LMA for positive pressure ventilation
during laparoscopic cholecystectomy and found the ProSeal
LMA to be a more effective ventilatory device than the classic
LMA. Hence, he did not recommend the use of classic LMA
for laparoscopic cholecystectomy [52].
Because general anesthesia with endotracheal intubation
and controlled ventilation is certainly the safest technique, it
72
is recommended for inpatients and for long laparoscopic
procedures. During pneumoperitoneum, controlled ventila-
tion must be adjusted to maintain etco2 at approximately
35 mm Hg, requiring no more than a 15% to 25% increase in
minute ventilation.
In patients with chronic obstructive pulmonary disease
(COPD) and in patients with a history of spontaneous
pneumothorax or bullous emphysema, an increase in
respiratory rate rather than tidal volume is preferable to
avoid increased alveolar inflation and reduce the risk of
pneumothorax [53,54].
Anesthetic agents that directly depress the heart should be
avoided in patients with compromised cardiac function in
favor of anesthetics with vasodilating properties such as iso-
flurane. Infusion of vasodilating agents, such as nicardipine,
reduces the hemodynamic repercussions of pneumoperito-
neum and might facilitate management of cardiac patients.
Because of the potential for reflex increases of vagal tone
during laparoscopy, atropine should be administered before
the induction of anesthesia or should be available for
injection if necessary.
5.2. Regional anesthesia for laparoscopy
Regional anesthesia offers several advantages: quicker
recovery, decreased PONV, less postoperative pain, shorter
postoperative stay, cost effectiveness, improved patient
satisfaction, and overall safety, early diagnosis of complica-
tions, and fewer hemodynamic changes [55,56]. Sequelae of
general anesthesia such as sore throat, muscle pain, and
airway trauma can be avoided. However, this anesthetic
approach requires a relaxed and cooperative patient, low IAP
to reduce pain and ventilatory disturbances, reduced tilt, a
precise and gentle surgical technique, and a supportive
operating room staff. Any compromise may result in
increased patient anxiety, pain, and discomfort, necessitating
supplementation with intravenous sedation. The combined
effect of pneumoperitoneum and sedation can lead to
hypoventilation and arterial oxygen desaturation [57].
Laparoscopic tubal ligation might be a good indication for
regional anesthesia. However, any other laparoscopic proce-
dure that requires multiple puncture sites, considerable organ
manipulation, steep tilt, and voluminous pneumoperitoneum
makes spontaneous breathing difficult for the patient and,
consequently, must not be managed with regional anesthesia.
Regional anesthetic techniques are subdivided into 3
main categories: peripheral nerve blocks, neuraxial blocks,
and local anesthetic infiltration.
5.2.1. Peripheral nerve blocks
Five techniques have been described for laparoscopy:
rectus sheath block, rectus sheath block combined with
mesoplanix block, inguinal block, pouch of Douglas block,
and paravertebral block. They represent either the principal
method of anesthesia or an adjunct to general anesthesia.
5.2.1.1. Rectus sheath block. The rectus sheath block,
with successful blockade of the relevant intercostal nerves
F.J. Gerges et al.
within the rectus sheath, provides anesthesia of the anterior
abdominal wall. When administered in conjunction with
general anesthesia, rectus sheath block resulted in improved
postoperative analgesia and a faster discharge [56].
5.2.1.2. Rectus sheath block and mesosalpinx block.
When administered with general anesthesia, rectus sheath
and mesosalpinx blocks resulted in less postoperative pain
and analgesic requirement and earlier hospital discharge, as
compared with general anesthesia with rectus sheath block
alone [58].
5.2.1.3. Inguinal block. Inguinal block is a useful adjunct
to general anesthesia for laparoscopic hernia repair [56].
5.2.1.4. Pouch of Douglas block. A catheter can be placed
in the pouch of Douglas under direct vision using an epidural
needle inserted through the abdominal wall. Local anesthetic
placed into the pouch of Douglas provides effective pain
relief after tubal ligation, whereas the use of a catheter tech-
nique permits repetition of the dose to prolong analgesia [59].
5.2.1.5. Paravertebral block. Bilateral paravertebral block-
ade at T5-6 level combined with general anesthesia for
patients undergoing laparoscopic cholecystectomy im-
proved postoperative pain relief and resulted in less PONV,
as compared with general anesthesia alone [60].
5.2.2. Neuraxial blocks
Regional anesthesia, including epidural and spinal
techniques, combined with the head-down position, can be
used for gynecologic laparoscopy without major impairment
of ventilation. In fact, the respiratory changes are less
evident when laparoscopy is performed in awake patients
under regional anesthesia, and arterial blood gases are
maintained within normal limits [61]. Globally, epidural and
local anesthesia share the same benefits and disadvantages;
however, neuraxial anesthesia alone has the advantages of
reducing the need for sedatives and narcotics, produces
better muscle relaxation, and can be proposed for laparo-
scopic procedures other than sterilization.
5.2.2.1. Epidural anesthesia. Epidural anesthesia was
considered as a safe alternative to general anesthesia for
outpatient laparoscopy without associated respiratory de-
pression because the respiratory control mechanism remains
intact, allowing the patients to adjust their minute ventila-
tion and, therefore, maintaining an unchanged etco2 [61].
Moreover, despite the increase in respiratory work and V/Q
mismatch, alveolar ventilation was not compromised even
in the Trendelenburg position, and the time to discharge was
significantly reduced using epidural compared with general
anesthesia. Shoulder pain, which is secondary to diaphrag-
matic irritation that results from abdominal distension, is
incompletely alleviated using epidural anesthesia alone.
Extensive sensory block (T4 through L5) is necessary for
surgical laparoscopy and may also lead to discomfort. The
epidural administration of opiates and/or clonidine might
help to provide adequate analgesia [56].
In case of gasless laparoscopy for gynecologic surgery,
epidural anesthesia can provide comfort and more adequate
Anesthesia for laparoscopy
pain relief while avoiding most of the side effects of carbon
dioxide pneumoperitoneum. Furthermore, no significant
difference in cardiorespiratory function is present in gasless
gynecologic laparoscopy whenever general or epidural
anesthesia is performed [62].
In patients with COPD, epidural anesthesia could be
safely and effectively used for laparoscopic cholecystecto-
my, therefore avoiding general anesthesia in patients with
chronic respiratory disease [63,64].
Laparoscopic extraperitoneal herniorrhaphy can be per-
formed effectively under epidural anesthesia, obviating the
need for general anesthesia [65].
5.2.2.2. Spinal anesthesia. Spinal anesthesia is the
simplest and most reliable of the regional anesthesia
techniques. It has become more common in ambulatory
practice with the introduction of fine-gauge pencil-point
needles. Spinal anesthesia, as the primary technique for
laparoscopy, offers many benefits over general anesthesia;
however, conventional dose hyperbaric spinal anesthesia
might not be ideal for laparoscopy. In fact, the Trendelen-
burg position predisposes to cephalad spread of the spinal
block, a greater sympathetic block, bradycardia, and
hypotension [66]. Administration of reduced doses of the
local anesthetics or hypobaric solutions minimizes side
effects such as hypotension, bladder distension, and
prolonged sensory and motor block traditionally associated
with conventional doses [67]. For short-duration laparosco-
py, a spinal hypobaric solution of 10 mg lidocaine with
10 lg of sufentanil provides adequate analgesia [68].
In ambulatory gynecologic laparoscopy, small-dose
spinal anesthesia is an effective alternative to a desflurane
general anesthetic. It results in less postoperative pain, cost,
and faster recovery [69]. As compared with propofol-based
anesthesia, small-dose selective spinal anesthesia has
significantly shorter recovery period [70].
Laparoscopic extraperitoneal inguinal hernia repair under
spinal anesthesia and extraperitoneal nitrous oxide insuffla-
tion has been performed safely and effectively [71].
Laparoscopic cholecystectomy under spinal anesthesia
with nitrous oxide pneumoperitoneum has been performed
successfully [72].
In patients with severe COPD undergoing laparoscopic
intraperitoneal inguinal hernia repair, spinal anesthesia
using hyperbaric bupivacaine is an effective alternative to
general anesthesia [73].
With the advent of gasless laparoscopy and micro-
laparoscopy, the role of spinal anesthesia will probably
increase in the future.
5.2.2.3. Combined spinal-epidural anesthesia. One
disadvantage of epidural anesthesia is the relatively slow
onset of anesthesia. Recently, there has been increasing
interest in combining spinal and epidural anesthesia.
Potential advantages of combined spinal-epidural (CSE)
anesthesia include rapid onset of anesthesia and the
ability to administer minimally effective doses of intrathecal
agents initially.
73
In a prospective randomized study, Hirschberg et al [74]
studied the clinical impact of CSE anesthesia in patients
undergoing total extraperitoneal laparoscopic hernia repair
vs balanced general anesthesia with controlled ventilation.
The respiratory compensation of extraperitoneal gas insuf-
flation was not decreased by CSE anesthesia; however, most
of the patients with CSE anesthesia showed severe agitation
often accompanied by chest pain. Hence, the author did not
recommend this technique.
5.2.2.4. Caudal epidural block. Caudal epidural blocks are
an effective modality for providing postoperative analgesia
after laparoscopic hernia surgery in children. Children
receiving caudal anesthesia as an adjunct to general
anesthesia have lower pain scores and do not require
supplemental analgesia in the postoperative period [75].
When combined with general anesthesia, caudal epidural
block is more effective than ilioinguinal/iliohypogastric
block in controlling pain after laparoscopic herniorrhaphy in
children, thereby resulting in earlier hospital discharge [76].
5.2.3. Local anesthetic infiltration
The advances in optical fiber technology have now
produced laparoscopes with external diameters of as little
as 1.2 to 2.2 mm. These instruments allow ‘‘micro-
laparoscopyQ to be performed with local anesthesia alone or
supplemented by sedation. Therefore, local anesthesia could
be used as a reliable and affordable alternative to general
anesthesia. It is safe, effective, and less costly and has been
primarily used for patients with infertility, chronic pelvic
pain, and tubal ligation [77,78].
Office microlaparoscopy for female sterilization under
local anesthesia is cost-effective and safe [79], with less post-
operative analgesic requirement as compared with conven-
tional laparoscopic sterilization [80]. In the therapy for
polycystic ovarian syndrome, ovarian drilling in minilaparo-
scopy under local anesthesia has similar therapeutic results to
those achieved by traditional laparoscopy. It offers a less-
invasive technique with an early hospital discharge that can be
carried out in an outpatient service without the need for
general anesthesia and postoperative additional analgesia [81].
Obese patients are unsuitable for microlaparoscopy; the
short instrument is likely to end up in the extraperitoneal
space, and the low insufflation pressures can be insuffi-
cient to lift the weight of the abdomen and provide a good
view. Patients with multiple adhesions from previous
surgery are also less suitable. Further developments in
optics and small instruments could increase the indications
for microlaparoscopy.
In laparoscopic cholecystectomy under general anesthe-
sia, preinsertion of local anesthesia at the trocar site
significantly reduces postoperative pain and decreases
medication usage costs [82]. Moreover, intraperitoneal spray
of local anesthetic significantly decreases postoperative pain
[83]. The extraperitoneal laparoscopic repair of inguinal
hernia is feasible under local anesthesia alone. This
technique adds a new treatment option in the management
74
of bilateral inguinal hernias, particularly in the population
where general anesthesia is contraindicated [84].
6. Recovery after laparoscopy
During the early postoperative period, respiratory rate
and etco2 of patients breathing spontaneously are higher
after laparoscopy as compared with open surgery. The
additional carbon dioxide load can lead to hypercapnia even
in the postoperative period. This causes an increased
ventilatory requirement, when the ability to increase
ventilation is impaired by residual anesthetic drugs and
diaphragmatic dysfunction. Patients with respiratory disease
can have problems excreting excessive carbon dioxide load,
which results in more hypercapnia and eventually respira-
tory failure. Patients with cardiac disease are more prone to
hemodynamic changes and instability caused by the hyper-
dynamic state developing after laparoscopy.
As compared with other outpatient procedures, laparo-
scopic surgery still produces substantial morbidity. Tele-
phone follow-up revealed incisional pain in about 50% of
laparoscopic patients, double the overall incidence of pain in
outpatients. Drowsiness (36%) and dizziness (24%) were also
more common after laparoscopic surgery than after any other
ambulatory procedure [85]. A high incidence of minor morbi-
dities is noticed: abdominal pain (71%), shoulder pain (45%),
sore throat (26%), headache (12%), and nausea (3%), and
only 8% of the patients would have preferred an overnight stay
[86]. Although morbidity is considerable, most symptoms re-
solve within a week [87]. The anesthesiologist must deal with
these postoperative problems and address them adequately.
6.1. Postoperative pain
Although laparoscopic surgery results in substantially
less severe and prolonged discomfort compared with the
corresponding open procedure, postoperative pain still can
be considerable. Prevention and treatment of pain relies on
local anesthesia, nonsteroidal anti-inflammatory drugs, and
opioid analgesics, often used in combination.
6.1.1. Local anesthesia
All the regional anesthesia techniques previously de-
scribed reduce postoperative pain and delay the requirement
for rescue analgesics.
6.1.2. Nonsteroidal anti-inflammatory drugs
Because nonsteroidal anti-inflammatory drugs (NSAIDs)
have analgesic properties comparable with opioid com-
pounds without opioid-related side effects, these drugs are
often administered as adjuvant during and after surgery.
There is no significant difference between the various
NSAIDs in their efficacy, provided that an adequate dose is
used and sufficient time is allowed for the onset of effect.
There could be minor differences between drugs in the pattern
of side effects, but most patients tolerate short-term admin-
istration of NSAIDs remarkably well [88].
F.J. Gerges et al.
6.1.3. Opioids
Opioid analgesics are obviously effective in treating pain
after laparoscopic procedures; however, these drugs are
associated with numerous side effects, including nausea,
respiratory depression, and sedation, which are especially
undesirable in outpatients.
6.1.4. Multimodal analgesia techniques
The most effective pain relief can be obtained by
combining opioids, local anesthetics, and NSAIDs into
balanced analgesia. This approach at least allows the opioid
dose to be reduced by the use of other modalities, thereby
limiting side effects, reducing postoperative pain and
analgesic requirements, and facilitating an earlier return to
normal activities [89,90].
6.1.5. Other analgesic techniques
A variety of other therapeutic modalities have been used to
try to reduce pain after laparoscopy, including anticholinergic
drugs, tramadol, acetaminophen, and dexmedetomidine.
6.1.5.1. Anticholinergic drugs. Anticholinergic smooth
muscle relaxants have been used to treat pain induced by
spasm in the smooth muscle of the fallopian tube after
laparoscopic sterilization. Glycopyrrolate reduced patient
pain scores on patients’ awakening and reduced require-
ments for morphine [91], but buscopan failed to achieve the
same results [92].
6.1.5.2. Tramadol. Tramadol is a weak opioid that also has
analgesic effects through inhibition of neurotransmitter
uptake. It is effective in reducing pain scores and opioid
analgesic requirements [93].
6.1.5.3. Acetaminophen. Combinations of acetamino-
phen with either dextropropoxyphene or codeine are as
effective as tramadol administration in treating postopera-
tive pain [94].
6.1.5.4. a 2 Agonist. Dexmedetomidine has sedative,
hypnotic, and analgesic properties. It diminishes the need
for other anesthetics and sympathicolytics, and it reduces
catecholamine release. Furthermore, it lowers the need both
for other sedatives and for analgesic morphine, although
spontaneous breathing is not affected [95].
6.2. Postoperative nausea and vomiting
Postoperative nausea and vomiting is extremely common
after laparoscopic surgery and can delay discharge after
outpatient surgery. Some aspects of the anesthetic technique
as well as the use of antiemetic medications could decrease
the incidence of PONV.
6.2.1. Anesthetic technique
Because propofol has the lowest incidence of PONV,
maintenance of anesthesia for laparoscopic surgery with
propofol results in a lower incidence of PONV, compared
with inhalation anesthetics [29,30]. Nitrous oxide is known to
increase the incidence of PONV; however, its omission failed
to reduce the occurrence of PONV after laparoscopies [41].
Because opioids are a potent cause of PONV, the concomitant
Anesthesia for laparoscopy
use of NSAIDs and opioids helps to better control postop-
erative pain, while decreasing opioid-related side effects. The
routine use of neostigmine to reverse residual neuromuscular
block has been reported to increase the incidence of PONV
compared with spontaneous recovery from mivacurium [43];
however, others have failed to confirm an adverse effect of
neostigmine in a similar study [96].
6.2.2. Antiemetic medications
Although ondansetron (an antagonist of the 5-HT3
receptor), is as effective as older antiemetics such as droper-
idol [97] or cyclizine [98], it avoids most of their adverse
effects. Ondansetron given at the end of surgery results in a
significantly greater antiemetic effect, compared with
preinduction dosing [99]. Dolasetron and granisetron, other
5-HT3 antagonists, are effective as well [100,101].
Dexamethasone reduced PONV in the first 24 hours after
laparoscopic sterilization and reduced the requirement for
rescue antiemetics with no adverse effects noted from this
single dose of steroid [102].
7. Contraindications for laparoscopy
Laparoscopy brings the highest benefits to the highest
risk group of patients notably in intensive care unit patients,
patients with cardiac and/or respiratory compromise, renal
failure, obese, children, and the elderly. However, extreme
care to anesthetic management and surgical performance
must be considered. Absolute contraindications for lapa-
roscopy include shock, markedly increased ICP, severe
myopia and/or retinal detachment, inadequate surgical
equipments, and inadequate monitoring devices. Relative
contraindications include bullous emphysema, history of
spontaneous pneumothorax, pregnancy, life-threatening
emergencies, prolonged laparoscopy more than 6 hours
associated with acidosis and hypothermia, and new
laparoscopic procedures. Special care must be taken in
patients with increased ICP resulting from brain tumors,
hydrocephalus, or head trauma. Patients having ventricular
peritoneal shunt must have the shunt clamped before
peritoneal insufflation.
8. Complications of laparoscopy
The incidence of complications associated with laparo-
scopic procedures varies significantly, depending on the
type of procedure and the training and experience of the
surgeon. The anesthesiologist has to be aware and deal with
these potential problems to avoid any undesirable outcome.
8.1. Inadvertent extraperitoneal insufflation
Misplacement of the Veress needle can lead to intravas-
cular, subcutaneous tissue, preperitoneal space, viscus,
omentum, mesentery, or retroperitoneum insufflation of
carbon dioxide.
75
Direct intravascular gas insufflation, a tear in an abdom-
inal wall or peritoneum vessel, can lead to gas embolism. It is
a rare but potentially lethal complication of laparoscopic
surgery where profound hypotension, cyanosis, dysrhyth-
mias, and asystole may occur after intravascular embolization
of carbon dioxide. Initially, there is a sudden increase in
etco2 concentration, which then can decrease owing to
cardiovascular collapse and reduction of pulmonary blood
flow. A mill-wheel murmur can be auscultated. By using a
precordial Doppler probe or transesophageal echocardiogra-
phy, embolized carbon dioxide is detected earlier and
confirmed. Rapid absorption of the carbon dioxide embolus
facilitates dissolution of the resulting intracardiac or intra-
vascular foam and leads to rapid reversal of hemodynamic
impairment whenever the volume of carbon dioxide embolus
is low [10]. If gas embolism is suspected, carbon dioxide
insufflation should be discontinued and the abdomen
deflated. The patient should be turned to the left lateral
decubitus with a head-down position to allow the gas to rise
into the apex of the right ventricle and prevent entry into the
pulmonary artery. Hyperventilation with 100% O2 for rapid
carbon dioxide elimination, central venous catheter place-
ment for aspiration of gas, and aggressive cardiopulmonary
resuscitation should be done [103].
Pulmonary air embolism after inadvertent vascular
puncture by an air-cooled laser has been reported during
laparoscopic cholecystectomy. Because carbon dioxide is
more soluble in blood than air or nitrous oxide, a greater
volume of carbon dioxide embolism can be tolerated when
compared with air or nitrous oxide embolism [103].
Subcutaneous insufflation of carbon dioxide leads to
subcutaneous emphysema. It is identified by the development
of crepitus over the abdominal and chest wall, associated with
an increase in airway pressures and etco2 concentrations,
leading to significant hypercapnia and respiratory acidosis. In
most cases, no specific intervention is necessary, and the
subcutaneous emphysema resolves soon after the abdomen is
deflated and nitrous oxide is discontinued to avoid expansion
of carbon dioxide–filled space [103,104].
8.2. Pneumothorax
Pneumothorax can occur with the gas traversing into
the thorax either through a tear in the visceral peritoneum,
breach of the parietal pleura during dissection around
the esophagus, a congenital defect in the diaphragm
(patent pleuroperitoneal canal), and spontaneous rupture of
preexisting emphysematous bulla. Subcutaneous emphyse-
ma in the neck and face can result in gas tracking to the
thorax and mediastinum, thereby resulting in pneumothorax
or pneumomediastinum. Pneumothorax can be asymptom-
atic or can increase peak airway pressures, decrease
oxygen saturation and, in severe cases, can lead to
significant hypotension and cardiac arrest. The treatment
is according to the severity of cardiopulmonary compromise
from conservative treatment with close observation to chest
tube placement [103].
76
8.3. Pneumomediastinum and pneumopericardium
Extension of subcutaneous emphysema from the cervical
region into thorax and mediastinum can lead to pneumo-
mediastinum. Although, pneumopericardium can occur
when the carbon dioxide is forced through the inferior vena
cava into the mediastinum and pericardium or when carbon
dioxide tracks through the defect in the membranous portion
of the diaphragm, which can have embryonic communica-
tion between the pericardial and peritoneal cavities. The
management of pneumomediastinum and pneumopericar-
dium depends on the severity of associated cardiopulmonary
dysfunction. Release of the pneumoperitoneum is adequate
in many patients [103].
8.4. Vascular injuries
Accidental insertion of the Veress needle or trocar into
major vessels such as the aorta, common iliac vessels,
inferior vena cava, or cystic or hepatic artery can lead to
serious and even fatal complications requiring conversion to
laparotomy for control of bleed. Other minor vascular
injuries involve the abdominal wall vessels and can be
managed during laparoscopy [103].
8.5. Gastrointestinal injuries
Gastrointestinal injuries frequently involve the small
intestine, colon, duodenum, and stomach. Lacerations of
the liver, spleen, and colonic mesentery also have been
reported. Gastric decompression before placement of the
Veress needle should minimize stomach injuries. In patients
undergoing laparoscopic Nissen fundoplication, the anesthe-
siologist should carefully insert the esophageal bougies to
avoid esophageal or gastric perforation especially in patients
with Barrett’s esophagus, ulcers, or strictures [103].
8.6. Urinary tract injuries
Although injuries to the bladder and ureters are rare,
decompression of the bladder by placement of a urinary
catheter before laparoscopy is advisable [103].
9. Summary
Laparoscopy is most commonly performed with the
patient under general anesthesia. For prolonged and upper
abdominal procedures, this remains the only realistic option
at present, but regional techniques involving peripheral and
neuraxial blocks and local anesthetic infiltrations could be
used with precautions for pelvic laparoscopy. Rectus sheath,
mesosalpinx, inguinal, pouch of Douglas, paravertebral and
caudal blocks are useful adjuncts to general anesthesia
and facilitate postoperative analgesia. Other techniques
such as spinal and epidural anesthesia and combination
of the two are suitable as a sole anesthetic technique for
pelvic laparoscopy.
F.J. Gerges et al.
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