Anesthesia for

Laparoscopic Surgery
Garrett Peterson DNP, RN, CRNA
Association of Veterans Affairs
Nurse Anesthetists
Annual Education Meeting May 2012

Objectives
Discuss the technique used to create a
pneumoperitoneum
Describe the complications of laparoscopic
surgery
Recognize the physiologic effects of
pneumoperitoneum
Select the appropriate anesthetic management
techniques used for laparoscopic surgery
Identify the postoperative considerations for
laparoscopic surgery

Introduction
Laparoscopy
Greek words
Laparo- meaning flank
Skopein meaning to examine

Definition: process of examining the

contents of the abdominal cavity using a
specially designed endoscope
Use of laparoscopy has been expanded
by different surgical specialities over the
decades

Common surgical applications of laparoscopy

General Surgery
Diagnosis
Evaluation of abdominal
trauma
Lysis of adhesions
Cholecystectomy
Appendectomy
Inguinal hernia repair
Bowel resection
Esophageal reflux
surgery
Splenectomy
Adrenalectomy

Gynecologic Surgery

Diagnosis
Lysis of adhesions
Fallopian-tube surgery
Fulgration of
endometrrosis
Ovarian cyst surgery
Laparoscopic-assisted
hysterectomy

Urologic Surgery
Nephrectomy

Advantages of laparoscopic surgery

Incisions are small

Earlier postoperative
mobility
Shorter hospital stays

Creation of a Pneumoperitoneum
Pneumoperitoneum
Air within the peritoneal cavity
Essential to perform the surgery
Clears the view of the operative site allowing
room to move instruments
Causes physical stress to the body and has
residual effects that can increase morbidity
Highest risk to patient is during creation of the
pneumoperitoneum

Creation of a Pneumoperitoneum
Creation of
pneumoperitoneum
Two techniques
open or closed

Closed technique
(older of the two)
Spring loaded needle
(Veress needle) used to
pierce the abdominal
wall at the thinnest point
the infraumbilical region
Position confirmed by
injection of 10 ml of
saline

If unable to aspirate
saline, placement is
correct
Carbon dioxide (CO2) is
placed through the
needle to create a
space between
abdominal wall and
organs

Creation of a Pneumoperitoneum
The open or
Hasson technique
Small incision (1.5-3
cm) inferior to the
umbilicus
Peritoneum is
directly incised
Trocar (Hasson
cannula) is placed
Abdomen is
insufflated and the
catheter is sutured
in place

Creation of a Pneumoperitoneum
Research
Visceral injuries less frequent with open
technique (not statistically significant)
Major vascular injuries were less when
Hasson technique was used compared
to the Veress needle

Complications of Laparoscopic
Surgery
Potential for injury
Structures close to puncture site
IVC, aorta, iliac arteries and veins, bladder,
bowel, and uterus
Obesity, thin habitus, adhesions, masses (tumors)

Additional injuries
Trauma to major vascular structures
0.02-0.9% of cases

Gas embolism
Injury to abdominal or pelvic organs
Migration of gas to extraperitoneal spaces

Complications of Laparoscopic
Surgery
Gas embolism
Rare risk of cardiac arrest
Reported incidence 1 in 77,604 cases
Likely to occur during insufflation
Wrong placement of needle into vessel or organ

Gas bubbles enter circulation

Pulmonary hypertension
Right ventricular failure
Pulmonary edema
Large bubble can cause a gas lock phenomenon
which can obstruct right ventricular outflow

Complications of Laparoscopic
Surgery

Gas embolism

Signs/symptoms

Hypotension
Dysrhythmia
mill wheel murmur
(churning sound)
Cyanosis
Pulmonary edema

Complications of Laparoscopic
Surgery

Gas embolism
Management

Stop gas insufflation

Shut off nitrous if being used
100% O2 administration
Release pneumoperitoneum
Place patient in left lateral
decubitus position
Aspirate gas through a central
venous catheter

Complications of Laparoscopic
Surgery
Visceral Injuries
Occurring when closed technique is used
0.1 0.4%

Trocar insertion
Gastrointestinal tract perforation
Hepatic and spleen tears

Reduction of risk of trauma

Decompression with NG for stomach
Emptying of bladder with foley catheter

Complications of Laparoscopic
Surgery

Visceral lesions
Not recognized right away
Most in postoperative period when
symptoms arise
Sepsis
Fistulas
Peritonitis
Abscesses

Complications of Laparoscopic
Surgery
Pneumothorax (serious but rare)
A review of 968 cases revealed the incidence
of pneumothorax or pneumomediastinum in
1.9% of patients
Higher risk for those undergoing surgery for
esophageal reflux disease
Occurs by two mechanisms
Gas entering weak points in esophagus or aorta
Barotrauma secondary to increased airway
pressures and decreased pulmonary compliance
Ruptured bleb

Complications of Laparoscopic
Surgery

Subcutaneous emphysema
(minor complication)
Trocar or Veress needle
misplacement in subcutaneous
tissue
Manifested by crepitus

Complications of Laparoscopic
Surgery
Gas used
Most common is CO2
Readily available and inexpensive
Does not support combustion
Rapidly absorbed from the vascular space
Easily excreted
Can cause hypercarbia
Peritoneal and diaphragmatic irritation
Leading to shoulder pain

Physiologic Effects of
Pneumoperitoneum
Degree of intraabdominal pressure
(impede diaphragmatic expansion)
Presence of preexisting cardiac
disease
(increased catecholamine release)
Intravascular volume depletion
(decrease cardiac output)
Duration of the surgery (hypercarbia)

Physiologic Effects of
Pneumoperitoneum
Three mechanisms of how pneumoperitoneum
affects the body
Direct mechanical effect
Presence of neurohumoral responses
Effects of absorbed CO2

Pneumoperitoneum-induced physiological
changes
Ventilatory techniques
Intraoperative positioning
Surgical conditions (presence of retractors and packing
in)

Physiologic Effects of
Pneumoperitoneum
Hemodynamic Changes Associated
with Pneumoperitoneum
Hemodynamic Parameter

Result

CVP

Increased or decreased

Mean Arterial Pressure

Increased

Stroke Volume

Decreased

Cardiac output

Increased/decreased or
same

Systemic Vascular
Resistance

Increased

Heart rate

Increased

Physiologic Effects of
Pneumoperitoneum
SVR increased
Documented in laparoscopy patients
At intraabdominal pressures of 14 mmHg
Increases in SVR as high as 65%

Mechanism
Increased compression of abdominal arteries
and humoral factor release (vasopressin,
renin) have caused increased afterload

Physiologic Effects of
Pneumoperitoneum
CVP filling pressures
Mixed opinions
Patients with increased intrabdominal
pressures in range of 14 to 20 mmHg had
increased CVP
Patients with increased intraabdominal
pressures > 20 mmHg had a decrease in
CVP

Mechanisms
Vasodilation actions of anesthetics
Intraoperative positioning

Physiologic Effects of
Pneumoperitoneum
Stroke Volume
Reduction
Decreases seen when intraabdominal
pressure was in range of 14 to 15 mmHg

Interventions to attenuate the decrease

in SV
Trendelenburg position
Adequate hydration
Compression of the lower extremities

Physiologic Effects of
Pneumoperitoneum
Cardiac Output/Cardiac Index
Typically decreased
Up to 50% reduction in CO has been seen
Noticed with intraabdominal pressures of 8 to 12
mmHg, with significant reduction at 16 mmHg
5 to 10 minutes after initial decrease, it will partially
reverse and increase back to baseline
Increase in heart rate occurs in laparoscopy patients

Interventions
Wrapping of legs
Optimize intravascular volume

Physiologic Effects of
Pneumoperitoneum
Arterial Blood Pressure
Increased
At intraabdominal pressures as low as 14
mmHg
Up to 35% increase in MAP

Mechanism
Increased afterload caused from
pneumoperitoneum

Physiologic Effects of
Pneumoperitoneum
Humoral factors
Increased afterload in patients with CO2
pneumoperitoneum
Increased dopamine, vasopressin,
epinephrine, norepinephrine, renin, and
cortisol
Vasopressin is the most significant mediator
Catecholamine level increase secondary to
stress response

Physiologic Effects of
Pneumoperitoneum
Cardiovascular effect of
pneumoperitoneum
Distention of the vagus nerve during
insufflation
Bradycardia is sometimes observed

Increased intraabdominal pressure

can reduce lower extremity blood
flow velocity

Physiologic Effects of
Pneumoperitoneum

Patients who are ASA Class III or IV

are significantly more prone to the
effects of pneumoperitoneum
especially if they suffer from altered
hemodynamics

Physiologic Effects of
Pneumoperitoneum
CO2 pneumoperitoneum
Increases in partial pressure of arterial CO2
(PaCO2) and end-tidal CO2 with or without
acidosis

Caused by absorption of gas on peritoneal

surface
No increase in O2 consumption during
insufflation
Maximum absorption rate of CO2 is noted
with intraabdominal pressure of 10 mmHg
PaCO2 levels reach a plateau

Physiologic Effects of
Pneumoperitoneum
Mild hypercapnia (45 to 50 mmHg)
not clinically significant
Hypercapnia (50 to 70 mmHg) can
cause increased physiologic effects
Increased CBF
Peripheral vasodilation
Pulmonary vasoconstriction
Increase risk of cardiac dysrhythmias

Physiologic Effects of
Pneumoperitoneum
Pulmonary Function Changes
Associated with Pneumoperitoneum
Pulmonary Change

Result

Positive inspiratory pressure Increased

(PIP)
Pulmonary compliance

Decreased

Vital capacity

Decreased

Functional residual capacity

Decreased

Intrathroacic pressure

Increased

Physiologic Effects of
Pneumoperitoneum
Controlled ventilation
Increase of 20 to 30 % in minute
ventilation will help to decrease the
hypercapnia that occurs during
pneumoperitoneum
Careful with respiratory compromised
patients
May have CO2 retention leading to
decreases in arterial pH
With very high ETCO2, a direct measurement
of PaCO2 may be warranted because ETCO2
may underestimate PaCO2

Physiologic Effects of
Pneumoperitoneum

Endobronchial intubation
Cephalad displacement of the
diaphragm from the increased
intraabdominal pressure
One study 50 patients with IAP
15 mmHg
Patients in reverse Trendelenburg
position
6% had right mainstem intubation

Physiologic Effects of
Pneumoperitoneum
Kidneys
Oliguria
Compression of kidneys
Compression of inferior vena cava
Increase in levels of antidiuretic hormone
Significant reduction in renal blood flow
Intraabdominal pressure around 24 mmHg
Humoral factors
Vasopressin, renin, aldosterone

Physiologic Effects of
Pneumoperitoneum
Hepatic/Spleen
One study, Intraabdominal pressure around 16
mmHg and elevated head of bed caused a 68%
decrease in hepatic blood flow
Another study, IAP of 12 mmHg increased
hepatic perfusion
Splanchnic blood flow not disrupted with IAP of
11 to 13 mmHg

Anesthetic Management
General, regional and local have
been used
Local
Minor GYN procedures
Diagnostic laparoscopy or sterilization
Only one hole is created and scope is very
small
Shorter hospital stay and reduction in
anesthetic costs
5.5% converted to general
Surgical exposure was limited

Anesthetic Management
General, regional and local have
been used
Regional
Limited to minor GYN surgical
procedures
Shoulder and chest discomfort result
from pneumoperitoneum is not well
managed with the regional technique

Anesthetic Management
General, regional and local have
been used
General
Most practical
Manages patient discomfort
Controlled ventilation
Use of muscle relaxation

Anesthetic Management
Use of LMA
Controversial
Increased intraabdominal and intrathoracic
pressures
Increase risk of gastroesophageal reflux and
pulmonary aspiration

Study with 1469 GYN laps concluded that use

of an LMA appears safe
Study using fiberoptic examination of the
laryngopharynx of 91 pts with an LMA failed to
show any regurgitation

Anesthetic Management
Guidelines for Use of the Laryngeal Mask Airway
During Laparoscopy

Ensure clinician is an experienced LMA user

Select patients carefully (e.g., fasted, not obese)
Use correct size of LMA
Make surgeon aware of the use of the LMA
Use total IV anesthetic technique or volatile agent
Adhere to 15 rule: <15 degrees tilt; < 15 cm H2O
intraabdominal pressure; <15 min duration
Avoid inadequate anesthesia during surgery
Avoid disturbance of the patient during emergence

Maltby JR et al. LMA-Classic and LMA-ProSeal are effective alternatives to endotracheal

intubation for gynecological laparoscopy. Can J Anaesth. 2003; 50:71-77.

Postoperative
Considerations
N&V
Common after laparoscopy surgery
Some research shows 50-62% incidence

Pain
Usually visceral quality on day of surgery
Abdominal distension
Traction on the nerves and trauma to blood vessels

Shoulder pain on first day post-op

CO2 induced intraperitoneal acidosis irritates
the phrenic nerve, leading to the shoulder pain

Postoperative
Considerations
Post-op pain
Managed with multimodal approach
NSAIDS, local anesthetics, and opioids

Research shows the use of NSAIDS in

combination with opioids result in a
synergism leading to decreased opioid
consumption
Research on port-site infiltration showed
value but short lived

Future of Laparoscopic
Surgery
Overcomes some of the limitations
imposed by standard laparoscope
technology
Robotic surgery
Robotic-assisted surgery
daVinci surgical system
Surgeon can be 100s of miles away
3-d imaging

Robot assisted radical prostatectomy requires

steep Trendelenburg tile (30 to 45 degrees)
which increases laryngeal edema and brachial
plexus injury

References
Nagelhout, John J. & Plaus, Karen L. Nurse
Anesthesia, W.B. Saunders Company, 4th
ed., 2010;32:771-779.
Sandhu, T., Yamada, S, et al. (2008).
Surgical Endoscopy