Anesthesia For Laparoscopic Surgeries

Prepared & Presented By: Hem Raj Paneru MD 2nd Year, Anesthesiology Moderator: Prof. Dr. B B Singh NAMS
16th Magh, 2067

Aims
To review the history of laparoscopic surgeries.

To discuss, briefly, the basic principles of laparoscopic surgeries.

To discuss the physiological consequences of laparoscopic surgeries. To discuss the complications (management) of laparoscopic surgeries. To discuss the anesthetic management of laparoscopic surgery.

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.

Historical notes (contd.)

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.

Advantages of laparoscopic surgery

Less postoperative pain Less postoperative pulmonary impairment Less incidence of postoperative ileus Shorter hospital stay Earlier ambulation Smaller surgical scars

Laparoscopic Procedures (general)

Cholecystectomy Vagotomy Appendectomy Colectomy Inguinal hernia repair Adrenalectomy Nephrectomy Prostatectomy Pancreatectomy Bariatric surgery Nissen fundoplication Para-esophageal hernia repair Splenectomy Liver resection Cystectomy with ileal conduit

Laparoscopic Procedures (gynecologic)

Ectopic pregnancy Ovarian cystectomy Reversal of ovarian torsion Salpingooophorectomy Hysterectomy Myomectomy Sacrocolpopexy Lymphadenectomy Lymphadenectomy, staging Ablation of endometriosis

Surgical Steps
Introduction of Veress Needle

Creation of pneumoperitoneum
Electrocautery dissection

 Helium Argon

Gases used to create pneumoperitoneum: Why is CO2 preferred??

Insoluble, gas embolism

N2O: Supports combustion, diffuses into the bowel, PONV N2 Air

CO2:
Safe during electrocautery Can be easily eliminated through the lungs Rapidly absorbed into the bloodstream

Properties Of Ideal Gas For Insufflation

Colorless Limited systemic absorption across the peritoneum Limited systemic effects when absorbed. Rapid excretion if absorbed Incapable of supporting combustion.

High solubility in blood.

Limited physiological effects with intravascular systemic embolism

Physiological Effects Of Laparoscopy

Minimally invasive surgery is not minimally stressful!

Major factors responsible for alteration in physiology

Pneumoperitoneum Positioning
Systemic absorption of Carbon dioxide

Effect of Pneumoperitoneum (mechanical effects)

Respiratory & Ventilatory Changes

Increased Intra-abdominal pressure Upward displacement of diaphragm/Impaired diaphragmatic excursion Reduced lung compliance, FRC Increased airway pressure & barotrauma V/Q mismatch with hypoxemia & hypercarbia Compression of basilar lung segments & atelectasis

Hemodynamic Changes
IAP

Venous return & SVR

Cardiac Output & Cardiac Index

CNS
1) Intrathoracic pressure 2) PaCO2 & CBF 3) Compression of IVC, lumbar spinal pressure & CSF drainage

ICP

Hepatoportal
? Splanchnic blood flow
Mechanical compression ADH Superior mesenteric artery constriction

? Maintained Splanchnic blood flow

Hypercarbia Vasodilation

Renal
Decrease in renal blood flow when IAP >15 mmHg
Decrease 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) Femoral venous blood flow
2) Pooling of blood (Reverse Trendelenberg position)

DVT

Effect of Pneumoperitoneum On Pharmacokinetics

Prolonged T1/2 of drugs eliminated by liver (reduction of hepatic perfusion)
Reduced Clearance of drugs eliminated through kidneys (reduced creatinine clearance and urine flow)

Neurohumoral Responses
RAA system activation ( renin, angiotensin, and aldosterone)
Sympathetic system activation ( catecholamines)

Effect of Positioning

Friedrich Trendelenburg 1844-1924

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 and inframesocolic procedures

Reverse Trendelenberg position

Supremesocolic procedures (e.g., Cholecystectomy)

tilt Patients age Intravascular volume status Associated cardiac disease Ventilation techniques Anesthetic drugs

Effects Of Trendelenberg Position

Cardiovascular System
CVP & CO
Baroreceptor reflex vasodilation and bradycardia Usually insignificant in healthy patients

Patients with coronary heart disease with poor left ventricular function - central blood volume, and pressure changes maybe deleterious

Effects of Trendelenberg Position

Respiratory System
Facilitates the development of atelectasis FRC, total lung volume, and pulmonary compliance is reduced.

CNS
CBF

ICP
Venous return

Effects Of Reverse Trendelenberg Position

Cardiovascular System
Venous return thus reducing CO and MAP (compounded by the pneumoperitoneum) Venous stasis occurs in the legs

Respiratory System
Increased FRC

Effects of CO2 Insufflation

Direct Effects:
Hypercarbia, Acidosis Decrease in HR, contractility, and SVR.

Indirect Effects (stimulation of SNS)

Increase in HR, contractility, and SVR.

Premature ventricular contractions Bradydysrhythmias Asystole

Complications of laparoscopy with relevance to anesthesia

Cardiovascular:
Hypotension, hypertension, tachycardia, bradycardia, dysrhythmias, asystole

Pulmonary:
Hypercapnia, hypoxemia, atelectasis, barotrauma

Related to gas insufflation

Subcutaneous emphysema, gas embolism, pneumothorax, pneumomediastinum, pneumopericardium, extreme CO2 absorption

Surgical
Hemorrhage, damage to hollow viscera, damage to nerves

Mechanical
Damage to nerves or eyes (positioning and draping), dislodgement of ET tube with endobronchial intubation

Miscellaneous:
Hypothermia, nausea and vomiting, hyperkalemia, renal failure, increased risk of regurgitation

Foramen Bochdalek Paraesophageal hiatus Foramen of Morgagni

Subcutaneous Emphysema Subcutaneious

Emphysema

Gas Embolism: Detection

Fall in ETCO2 Dysrhythmias (bradycardia, tachycardia, VPCs, asystole) Hypotension (decreased left ventricular filling) Fall in arterial oxygen saturation Increased CVP and venous congestion ECG evidence of acute right heart strain Mill-wheel murmur Precordial Doppler, TEE, Transthoracic echocardiography

Gas Embolism: Treatment

Stop gas insufflations immediately Increase inspiratory O2 concentration to 100% and hyperventilate Position patient head down, left lateral decubitus Attempt intracardial gas aspiration if CVP present Give inotropes to support right ventricle Treat severe hypotension with vasopressors CPR for asystole

Dysrhythmias
Tachycardia, bradycardia, VPCs, asystole
Identify the cause Stop gas insufflation Consider Atropine (may need to give undiluted atropine) Dont delay CPR

Endobronchial Intubation
Carina shifts upwards with creation of pneumoperitoneum
Exaggerated by positioning (head down)

Check tube position frequently

Hypoxemia
Pre-existing conditions: morbid obesity, COPD

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 Unidirectional valve dysfunction Malignant hyperthermia

Anesthesiological Contraindications Of Laparoscopy

Congestive heart disease (NYHA II-IV) Ischemic heart disease Obstructive and restrictive pulmonary diseases Morbid obesity Pregnancy Patent foramen ovale Huge organomegaly Moderate to severe ascites Right-to-left shunt

Absolute Contraindications
Acute or recent MI Blood dyscrasias

Late 2nd trimester of pregnancy

Uncompensated COPD Hiatus hernia

Conduct Of Anesthesia
Pre-anesthetic check-up & Pre-op advice
History, physical examination, risk assessment. Premedication: H2-blocker, Anxiolytic (midazolam/diazepam)

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.
Prevent Acid Aspiration ET tube displacement Rhythm changes esp. at the time of gas insufflation PONV prophylaxis Post-operative pain management

Give attention to

GETA with IPPV The Gold Standard

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: 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 for facial edema Watch for subcutaneous emphysema Inspect oropharynx

Do we need ABG??? When To Perform ABG?

After 30 minutes of pneumoperitoneum???
During laparoscopy an unsteady sate of CO2 level exists between body compartments. Rate of rise of PCO2 is greatest during the first 20 30 minutes.

After 20 30 minutes, new equilibrium levels are reached between the different compartments, and the rate of PCO2 rise is slower.

Postoperative management
Issues:
Pain: wound/ right shoulder PONV

Protocol For Postoperative Pain Relief

Preoperative administration of a non-opioid analgesic (e.g. NSAID, Paracetamol) Pre-incisional infiltration of trocar insertion sites with local anesthetics (e.g. 40 ml bupivacaine 0.25%, lidocaine 0.5%) Rescue medication with small doses of an opioid (e.g. morphine) Treat postoperative shivering with clonidine or pethidine.

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

ABDOLIFT

Gasless Laparoscopy

Laparoscopic Cholecystectomy Under Regional Anesthesia

12 patients, ASA I & II 4 ml 0.5% hyperbaric bupivacaine + 150g Morphine Minimal operating table tilt CO2 pneumoperitoneum IAP <10 mmHg

Ambulatory Laparoscopic Cholecystectomy

ASA I & II patients Appropriate social conditions

Uncomplicated surgery
Minimal post-operative analgesia requirements No PONV

Thank You