AIMS
HITORICAL NOTES
1980: Patrick Steptoe (UK): started laparoscopic procedures. 1983: Semm (German gynecologist): performed the first laporoscopic appendectomy. 1985: Erich Muhe (Germany): 1st reported lapaorscopic cholecystectomy. 1987: Ger: lap repair of inguinal hernia.
1987: Phillipe Mouret (France): 1st Laparoscopic Cholecystectomy using video technique 1988: Harry Reich: laparoscopic lymphadenectomy for t/t of ovarian cancer. 1989: Harry Reich: first laparoscopic hysterectomy using bipolar dissection. 1990: Bailey and Zucker (USA): laparoscopic anterior highly selective vagotomy with posterior truncal vagotomy.
Less postoperative pain Less postoperative pulmonary impairment Less incidence of postoperative ileus Shorter hospital stay Earlier ambulation Smaller surgical scars
Pancreatectomy Bariatric surgery Nissen fundoplication Para-esophageal hernia repair Splenectomy Liver resection Cystectomy with ileal conduit
SURGICAL STEPS
Introduction of Veress Needle
Creation
of pneumoperitoneum
Electrocautery dissection
Helium Insoluble, gas embolism Argon N2O: Supports combustion, diffuses into the bowel, PONV CO2:
Soluble in blood, Risk of gas embolus is reduced. Safe during electrocautery (Non-flammable) Can be easily eliminated through the lungs Rapidly absorbed into the bloodstream Inexpensive
Colorless Limited systemic absorption across the peritoneum Limited systemic effects when absorbed.
Pneumoperitoneum
Positioning Systemic absorption of Carbon dioxide
HEMODYNAMIC CHANGES
Intra-abdominal Pressure
CNS
Intrathoracic pressure 2) PaCO2 & CBF Compression of IVC, lumbar spinal pressure & CSF drainage
1)
3)
ICP
HEPATOPORTAL
? Gastrointestinal (Splanchnic) blood flow
Mechanical
Vasodilation
RENAL
in GFR Decrease in urine output Decrease in creatinine clearance Decrease in sodium excretion Potential for volume overload in the face of excessive fluid administration.
LOWER LIMB
1)
2)
DVT
NEUROHUMORAL RESPONSES
RAA system activation ( renin, angiotensin, and aldosterone)
Sympathetic system activation ( catecholamines)
EFFECT OF POSITIONING
Friedrich Trendelenbur g
EFFECTS OF POSITIONING
Position varies according Associated changes are to the anatomical site of related to: operation Degree of head-down/up
Trendelenberg position
Pelvic procedures
tilt Patients age Intravascular volume status Associated cardiac disease Ventilation techniques Anesthetic drugs
Cardiovascular System
CVP & CO
Patients with coronary heart disease with poor left ventricular function - central blood volume, and pressure changes maybe harmful.
Respiratory System
Facilitates
the development of atelectasis FRC, total lung volume, and pulmonary compliance is reduced.
CNS
CBF
ICP
Venous return
Cardiovascular System
Venous
return thus reducing CO and MAP (compounded by the pneumoperitoneum) Venous stasis occurs in the legs
Respiratory System
Increased
FRC
Direct Effects:
Cardiovascular:
Hypotension, hypertension, tachycardia, bradycardia, dysrhythmias, asystole Hypercapnia, hypoxemia, atelectasis, barotrauma Subcutaneous emphysema, gas embolism, pneumothorax, pneumomediastinum, pneumopericardium, extreme CO2 absorption Hemorrhage, damage to hollow viscera, damage to nerves Damage to nerves or eyes (positioning and draping), dislodgement of ET tube with endobronchial intubation Hypothermia, nausea and vomiting, hyperkalemia, renal failure, increased risk of regurgitation
Pulmonary:
Surgical
Mechanical
Miscellaneous:
DYSRHYTHMIAS
ENDOBRONCHIAL INTUBATION
HYPOXEMIA
Hypoventilation: positioning, pneumoperitoneum, ET tube obstruction, bronchospasm, inadequate ventilation, gas embolism.
Intrapulmonary shunting: decreased FRC, endobronchial intubation, pneumothorax, atelectasis. Decreased Cardiac Output: hemorrhage, dysrhythmias, myocardial depression. Technical equipment failure: circuit disconnection, delivery of hypoxic gas mixture.
HYPERCARBIA
Excessive absorption of CO2 Hypoventilation Increased dead space CO2 embolism Pneumothorax, pneumomediastinum, pneumopericardium Subcutaneous emphysema Exhausted CO2 absorber Malignant hyperthermia
ABSOLUTE CONTRAINDICATIONS
CONDUCT OF ANESTHESIA
Premedication:
CONDUCT OF ANESTHESIA
Goals:
IAP: 12 15 mmHg (dont allow to rise >20 mmHg) Airway pressure <40 cmH2O (20 30) EtCO2 ~ 35 mmHg Maintain BP and HR.
Give attention to
Prevent Acid Aspiration ET tube displacement Rhythm changes esp. at the time of gas insufflation PONV prophylaxis Post-operative pain management
Patient may be anxious Duration may be long Trendelenburg position (with pneumoperitoneum) may cause respiratory compromise and dyspnea in the awake patient Muscle relaxation is invariably needed. LMA, & spontaneous breathing not recommended.
Induction: Injection Pethidine 0.5 1 mg/kg; then inj Propofol (1.5 2 mg/kg) or STP (5 mg/kg); Succinylcholine (vecuronium, rocuronium, cisatracurium) + Inj Dexamethasone 4 mg iv for PONV prophylaxis
Intubation: appropriate size cuffed ET tube (LMA not recommended). NG or OG tube insertion and aspiration of stomach content (air) Maintenance: Isoflurane (or TCI of TIVA) + O2 + Muscle relaxant ; Ventilation: O2 + IPPV (spontaneous ventilation not recommended) adjusted to eliminate CO2 End of the Sx: Give inj ondansetron 4 mg; stop isoflurane when instruments are removed; slightly reduce ventilation, allow the patient to breathe spontaneously (but avoid hypoventilation); Reversal agent Halothane (+ fentanyl) not recommended.
Extubation
Watch
Watch
Inspect
POSTOPERATIVE MANAGEMENT
Issues:
Pain:
PONV
PONV
Incidence as high as 42%. Inj Dexamethasone 4 mg iv at the time of induction. Inj Ondansetron 4 mg iv at the end of surgery. Third anti-emetic for rescue therapy. Adequate pain control.
Recent Advances
GASLESS LAPAROSCOPY
Less postoperative pain, less blood loss, faster recovery time, and better cosmetic results Drawbacks - increased operative time
Thank You