ANESTHESIA FOR

MINIMALLY INVASIVE SURGERY

M.Dwi Satriyanto

1
Anesthesia Secret; Chapter 79
Definisi Laparoskopi

 Laparoskopi adalah suatu prosedur pembedahan minimally

invasive dengan memasukkan gas CO2 ke dalam rongga
peritoneum untuk membuat ruang antara dinding depan perut
dan organ viscera, sehingga memberikan akses endoskopi ke
dalam rongga peritoneum tersebut.

2
The Evolution of Standard
Practice

Past Present Future

O O

O
O O

Long Laparotomy Minimally Invasive Surgery Incisionless Surgery

80’s 90’s 00’s

3
MIP for Colon Surgery vs.
Conventional Colectomy

4
5
6
Breast Biopsy
Open Surgical
Biopsy

Minimally Invasive
Biopsy

7
What are the origins of modern
laparoscopic surgery?
 P. Bozzini developed the first self-contained endoscope in 1805,
utilizing candlelight for illumination.
 In 1901, G. Kelling examined the abdomen of a dog with a
cystoscope.
 The first clinical laparoscopic examination in humans was
performed by H. Jacobaeus in 1910.
 By the 1970s, following improvements in equipment safety and
technology, gynecologic laparoscopic surgery was being
routinely performed.
 Semm performed the first laparoscopic appendectomy in 1983,
and Muhe performed the first laparoscopic cholecystectomy in
1985.
 Since then, the concept of minimally invasive surgery has rapidly
evolved and expanded to include many different surgical
procedures in multiple surgical disciplines, and has become the
8
standard of care for certain procedures.
some currently practice
 Gynecologic procedures: Diagnostic procedures for chronic
pelvic pain, vaginal hysterectomy, tubal ligation, pelvic lymph
node dissection, hysteroscopy, myomectomy, oophorectomy,
tuboplasty, and laser ablation of endometriosis.
 Gastrointestinal procedures: Multiple procedures involving
the appendix, colon, small bowel, gallbladder and common
bile duct, stomach, esophagus, liver, spleen, pancreas, and
adrenals. In addition, hernia repairs, diagnostic laparoscopy,
adhesiolysis, and feeding-tube placement can be performed
laparoscopically.

9
some currently practice
 Thoracoscopic procedures/video-assisted thoracic
surgery (VATS): Lobectomy, pneumonectomy, wedge
resection, drainage of pleural effusions and pleurodesis,
evaluation of blunt or pulmonary trauma, resection of solitary
pulmonary nodules, tumor staging, repair of esophageal
perforations, pleural biopsy, excision of mediastinal masses,
transthoracic sympathectomy, splanchnicectomy,
pericardiocentesis, pericardiectomy, and esophagectomy.
 Cardiac surgery: Coronary artery bypass, valve repair.
 Orthopedics: Joint arthroscopy, including knee, ankle,
shoulder, wrist, and elbow.

10
some currently practice
 Otolaryngology: Endoscopic sinus surgery,
dacryocystorhinostomies.
 Urologic procedures: Laparoscopic nephrectomy/
nephroureterectomy, pyeloplasty, orchiopexy, cystoscopy/
ureteroscopy, and prostatectomy.
 Neurosurgery: Ventriculoscopy, microendoscopic
discectomy, interbody fusion, anterior spinal surgery, and
scoliosis/kyphosis correction.
 Plastic/reconstructive surgery: Breast augmentation,
browlifts.

11
Are there any contraindications for
laparoscopic procedures?
 Relative contraindications :
 increased intracranial pressure,
 patients with ventriculoperitoneal or peritoneojugular
shunts,
 hypovolemia,
 congestive heart failure or severe cardiopulmonary
disease, and
 coagulopathy.

 Morbid obesity, pregnancy, and prior abdominal surgery were

previously considered contraindications to laparoscopic
surgery; however, with improved surgical techniques and
technology, most patients with these conditions can safely
undergo laparoscopic surgery 12
What are the benefits of laparoscopy
when compared to open procedures
Intraoperative benefits:
 Decreased stress response with a reduction of acute phase
reactants (C-reactive protein and interleukin-6),
 decreased metabolic response with reduced hyperglycemia
and leukocytosis,
 decreased fluid shifts, better preserved systemic immune
function,
 avoidance of prolonged exposure and manipulation of
abdominal contents.

13
What are the benefits of laparoscopy
when compared to open procedures
Postoperative benefits:
 Less postoperative pain and analgesic requirements,

 improved pulmonary function (due to decreased pain,

decreased atelectasis, and earlier ambulation),
 improved cosmesis due to smaller incisions,

 fewer wound infections,

 decreased postoperative ileus,

 decreased length of hospitalization, and

 A quicker resumption of normal daily activities.

14
Why has carbon dioxide (CO2) become
the insufflation gas of choice during
laparoscopy?

 The choice of an insufflating gas for the creation of a

pneumoperitoneum is influenced by : the gas's blood
solubility, tissue permeability, combustibility, expense, and its
potential to cause side effects.
 The ideal gas would be physiologically inert, colorless, and
capable of pulmonary excretion.
 Although a number of gases have been used (Table), CO2
has become the gas of choice, as it offers the best
compromise between potential advantages and
disadvantages.

15
 Table 79-1
Comparison Of Gases For Insufflation
Advantages Disadvantages
CO2 Colorless Hypercarbia
Odorless Respiratory acidosis
Inexpensive Cardiac dysrhythmias, rarely resulting in sudden
Does not support combustion death
Decreased risk of air emboli compared with More postoperative neck and shoulder pain due to
other gases due to its high blood solubility diaphragmatic irritation (compared with other gases)
N2 O Decreased peritoneal irritation Supports combustion and may lead to intra-
abdominal explosions when hydrogen or methane is
present
Decreased cardiac dysrhythmias (compared Greater decline in blood pressure and cardiac index
with CO2) (compared with CO2)
Air Supports combustion
Higher risk of gas emboli (compared with CO2)
O2 Highly combustible
Helium Inert Greatest risk of embolization
Not absorbed from abdomen 16
How does CO2 insufflation affect PaCO2
 CO2 insufflation increases PaCO2.
 The degree of increase in PaCO2 depends on :
 The intra-abdominal pressure,
 The patient's age and
 The underlying medical conditions, patient positioning, and
 The mode of ventilation.

 In healthy patients, the primary mechanism of increased

PaCO2 is absorption via the peritoneum  increases in intra-
abdominal pressure result in diaphragmatic dysfunction and
increased alveolar dead space, leading to ventilatory
impairment and subsequent increases in PaCO2.

17
How does CO2 insufflation affect
PaCO2
 Spontaneous ventilation under local anesthesia does not
result in a rise in PaCO2; however, other anesthetic
techniques and ventilatory modes will result in hypercapnia
unless ventilation is adjusted.
 PaCO2 rises approximately 5-10 minutes after CO2
insufflation, and usually reaches a plateau after 20-25
minutes. The gradient between PaCO2 and end-tidal pressure
of CO2 (PETCO2) does not change significantly during
insufflation, but it does increase during pneumoperitoneum,
especially in more compromised patients.
 The final PaCO2 levels tend to be significantly higher in
patients with cardiopulmonary disease than in healthy patients
undergoing similar procedures

18
How does patient positioning affect
hemodynamics and pulmonary function during
laparoscopy?
 During laparoscopic surgery, the patient is positioned to utilize
gravitational displacement of the abdominal contents away
from the surgical site to facilitate optimal surgical exposure.
Trendelenburg position (head down):
 Reverse Trendelenburg (head up):

19
Trendelenburg position (head down):

 Cardiac output (CO) and central venous pressure (CVP)

increase and patients with intact baroreceptor reflexes will
typically experience vasodilatation and bradycardia.
 The Trendelenburg position decreases the transmural
pressure in the pelvic organs, possibly decreasing blood loss
but increasing the risk of gas emboli.
 Pulmonary effects include impaired diaphragmatic function
secondary to the cephalad displacement of abdominal
viscera, resulting in decreased functional residual capacity
(FRC), decreased total lung capacity, and decreased
pulmonary compliance, predisposing the patient to developing
atelectasis.
 Cephalad migration of lungs and carina may result in
mainstem intubation.
20
Reverse Trendelenburg (head up):

 Preload is decreased, resulting in decreased CO and mean

arterial pressure (MAP).
 Blood pooling in the lower extremities may increase the risk of
venous thrombosis and pulmonary emboli.
 Pulmonary function is improved.

21
What is considered a safe increase in
intra-abdominal pressure (IAP)?
 The current recommendation for IAP during laparoscopy is less
than 15 mmHg, and most laparoscopic procedures are
performed with IAPs in the 12-15 mmHg range.
 In general, IAPs less than 10 mmHg have minimal physiologic
effects.
 Insufflation pressures above 16 mmHg result in undesirable
physiologic changes, namely decreased CO, increased systemic
vascular resistance (SVR), and increased mechanical impedance
of the lung and chest wall.
 At pressures greater than 20 mmHg, renal blood flow, glomerular
filtration rate, and urine output also decline.
 Insufflation pressures of 30-40 mmHg have significant negative
hemodynamic effects and should be avoided.
 Low-pressure pneumoperitoneum (7 mmHg) and gasless
laparoscopy have been advocated as means of decreasing the
magnitude of hemodynamic derangement associated with higher22
IAP
 Summarize the hemodynamic
effects of pneumoperitoneum
• The observed changes in CO are biphasic:
• CO initially decreases with induction of anesthesia and onset of CO2
insufflation; within 5-10 minutes, CO begins to increase, approaching
preinsufflation values.
• At IAPs greater than 10 mmHg, venous return decreases, but
cardiac filling pressures increase with CO2 insufflation, most likely
due to increased intrathoracic pressure.
• SVR and MAP also significantly increase during the initial stages of
insufflation.

23
 Summarize the hemodynamic
effects of pneumoperitoneum
• Though these changes partially resolve approximately 10-15
minutes after insufflation, the changes in cardiac filling pressures
and SVR increase left ventricular wall stress.
• In healthy patients, left ventricular function appears to be
preserved; however, in patients with underlying cardiovascular
disease, the changes could be deleterious (Table 79-2)

24
Table 79-2. Hemodynamic Changes
During Laparoscopy

Increased Decreased No Change

SVR CO (initially, then increases) Heart rate (may increase due to
MAP Venous return (at IAP > 10) hypercapnia or catecholamine
CVP release)
PAOP
Left ventricular wall stress
Venous return (at IAP < 10)

SVR = systemic vascular resistance, MAP = mean arterial pressure, CVP = central venous pressure,
PAOP = pulmonary artery occlusion pressure, IAP = intra-abdominal pressure

25
Describe pulmonary changes associated
with pneumoperitoneum
 CO2 insufflation and the resultant increase in intra-abdominal
pressure result in cephalad displacement of the diaphragm,
reducing FRC and compliance.
 Trendelenburg position further aggravates these changes.
 When the FRC is reduced relative to the patient's closing
capacity, hypoxemia may result from atelectasis and
intrapulmonary shunting.
 Hypoxemia is uncommon in healthy patients but becomes a
concern in obese patients or those with underlying
cardiopulmonary disease (Table 79-3).

26
Table 79-3. Pulmonary Changes Associated
With Laparoscopy

No Significant
Increased Decreased
Change
PaO2 (in healthy
Peak inspiratory pressure Vital capacity
patients)
Functional residual
Intrathoracic pressure
capacity
Respiratory compliance
Respiratory resistance
pH
PaCO2

27
What are the neurohumoral responses
associated with laparoscopy
 Plasma concentrations of dopamine, vasopressin, epinephrine,
norepinephrine, renin, angiotensin, and cortisol all significantly
increase.
 The increases correspond to the onset of abdominal insufflation.
 Serum levels of vasopressin and norepinephrine most closely
parallel the changes noted in CO, MAP, and SVR.
 Hypercarbia, the mechanical effects of the pneumoperitoneum,
and stimulation of the autonomic nervous system have all been
implicated as potential causes of these observed changes.
 Preoperative alpha2 agonists (clonidine/dexmedetomidine) have
been shown to decrease the stress response.

28
 Should nitrous oxide (N2O) be used as
an anesthetic during laparoscopy
 There are no clinically significant differences in bowel
distention and postoperative nausea and vomiting when N2O-
oxygen was compared to air-oxygen and no conclusive
evidence suggesting N2O cannot be used during
laparoscopy.

29
What anesthetic techniques can be
used for laparoscopy
 Local anesthesia with IV sedation, regional techniques, and
general anesthesia have all been used with favorable results.
 The unexpected conversion from a laparoscopic to an open
procedure must be considered when choosing an anesthetic
technique.

30
Can laparoscopy be performed on
children or pregnant women
 Laparoscopic surgery is now commonly performed in pediatric
populations.
 Children undergo similar physiologic changes and experience
similar benefits of laparoscopic procedures as adults.
 Carbon dioxide absorption in infants may be faster and more
intense than adults due to a greater peritoneal surface area-
to-body weight ratio.

31
Can laparoscopy be performed on
children or pregnant women
 Pregnancy was initially considered a contraindication to
laparoscopic surgery due to concerns regarding decreased
uterine blood flow, increased intrauterine pressure, and
resultant fetal hypoxia and acidosis.
 Multiple reports have since determined that laparoscopic
surgery is safe in pregnancy and does not result in increased
rates of fetal morbidity or mortality.
 Since fetal acidosis is typically more severe than maternal
acidosis, the end-tidal CO2 concentration (ETCO2) should be
maintained between 25 and 33 mmHg

32
What complications are associated with
laparoscopic surgery and CO2
pneumoperitoneum?

 Complications are most likely to occur during placement of the trocar

through the abdominal wall and during CO2 insufflation.
 Intraoperative complications: Major vessel injury, hemorrhage,
organ perforation, bladder/ureter injury, burns, cardiac arrhythmias
(atrioventricular dissociation, nodal rhythms, bradycardia, and
asystole), hypercapnia, hypoxemia, CO2 subcutaneous
emphysema, pneumothorax, gas embolism, endobronchial
intubation, increased intracranial pressure, aspiration, and
peripheral nerve injury. Other complications are possible depending
on the specific procedure performed.
 Postoperative complications: Postoperative nausea and vomiting,
pain, shoulder and neck irritation, deep venous thrombosis, delayed
hemorrhage, peritonitis, wound infection, pulmonary dysfunction,
incisional hernia, and port site metastasis of neoplasms.
33

Key points
PaCO2 increases during CO2 pneumoperitoneum in
laparoscopy because of CO2 absorption and ventilation-
perfusion mismatch; if the patient is spontaneously
breathing, ventilatory depression may also contribute to
hypercapnia.
 Hemodynamic changes during laparoscopy include
increased systemic vascular resistance, mean arterial
pressure, and left ventricular wall stress; cardiac output
decreases initially, then gradually increases back to
baseline.
 Pulmonary changes during laparoscopy include increases in
peak inspiratory pressure, intrathoracic pressure, and
respiratory resistance and decreases in vital capacity,
functional residual capacity, and pulmonary compliance
34
 Terimakasih
Experience has shown us that minimally invasive
procedures can have an influence over the
quality of the patient experience when
compared to traditional open surgical options.

35
Benefit :
 Less Recovery Time - Since MIP requires smaller incisions
than conventional surgery (usually about the size of a dime),
the human body can heal much faster.
 Less Time in Hospital - MIP helps get patients out of the
hospital and back to life quicker than conventional surgery.
 Less Scarring – MIP patients have smaller incisions
eliminating large scars.
 Less Pain - Since MIP is less invasive than conventional
surgery, there is typically less pain.

36