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Anesthesia

and
Laparoscopic
Surgery
Waldemar P. Siahaan, MD
Anesthesia Department
MAMC

OBJECTIVES

Advantages compared to open surgery


Relationship with pulmonary function
Relationship with patient position
Relationship with heart function
Advantages and Disadvantages of several type
of Anesthesia
Special Monitoring in Laparoscopic surgery
Complications

What are the advantages of


laparoscopic cholecystectomy compared
with open cholecystectomy?

Much smaller incission.


Decreased Post-op pain.
Shorter hospital stay
Earlier ambulation
Smaller surgical scars
Medical and economic advantages.

How does laparoscopic surgery affect


intraoperative pulmonary function?
Hallmark =
creation of a pneumoperitoneum with
pressurized CO2

How does laparoscopic surgery affect


intraoperative pulmonary function?
Laparoscopy

Pressurized CO2

Pneumoperitoneum
Increase Intra Abdominal Pressure (IAP)
Displaced diaphragm cephalad
Decrease in lung compliance

ncrease in peak inspiratory Pressure


Smaller
Tidal
Volume

High solubility of CO2


Increase systemic absorption by the
vasculatur of peritoneum
Increase arterial CO2 levels
Decrease pH
Hypoxemia

Why does patient position affect


oxygenation?
Tredelenburg
Cephalad shift in abdominal viscera
and diaphragm.
Decreased FRC, Decreased Total Lung
Volume, Decreased Pulmonary Compliance
TOLERATED
Presumed preexisting lung disease
Obesity
ASA III, IV
Hypoxemia

Shift trachea upward


+
insufflation of the abdomen

Migration of ET Tube to Right


Main-stem bronchus

Does laparoscopic surgery affect


cardiac function?
Moderate Insufflation
Pressures

Higher insufflation Pressures


(>25cm H2O, or 18mmHg)

Blood tends to be forced out of the


abdomen and into the chest

Collapse the major abdominal


veins (IVC)

Increased effective cardiac filling


Slightly elevated (or normal) Heart Rate,
Central venous pressure, and cardiac
output.

Decreased Venous Return


Drop of Cardiac Output

Insufflation presure of 15mmHg will decrease cardiac output 28%


Insufflation presure of 7mmHg will be maintained
Recommended pressure = 12mmHg

Does laparoscopic surgery affect


cardiac function?
HYPERCARBIA
Sympathetic Nervous system stimulation
Increase BP, Increase HR, Risk of
dysrhytmias

Compensate attemption
Ex:Increasing the tidal volume
or Respiratory Rate
Increase Mean Intrathoracic
pressure
Hindering venous return
Increase the mean Pulmonary
artery pressure.

Describe the advantages and


disadvantages of Alternative anesthetic
techniques.
Local Anesthesia:
gynecologic procedures in young healthy and
motivated patients
Laparoscopic tubal sterilization
Intrafallopian transfers.

Continuous Epidural or Spinal Anesthesia


High level is required
Complete Muscle relaxant
Prevent diaphragmatic irritation

Shoulder pain (referred pain) from


diaphragmatic irritation

Describe the advantages and


disadvantages of Alternative anesthetic
techniques.
ET tube:
Decrease the risk of regurgitation from increased
intra abdomial pressure
Controlled ventilation to prevent hypercapnia
The need for muscle paralysis during surgery to
allow lower insufflation pressures
Provide better visualization

GENERAL ANESTHESIA

What special monitoring should be


considered?
Monitoring end tidal CO2= provides adequate guide for determining
the minute ventilation required to maintain normocarbia

reverse Trendelenburg, High Inflation


Pressures, and CO2 embolism
Decrease Cardiac Output
Reduction in lung perfusion
Increase Alveolar dead space
Dilute expired CO2
Lessens ETCO2 measurement

What are some possible


complications of laparoscopic surgery?
Trocar Introduction

Perforated Viscus

HEMORRHAGE

Lacerated Major Abdominal


Vessels

-Inadvertent intravenous
placement of veress needle
-Open vessels on the liver
surface during GB dissection

Passage of CO2 into abdominal wall and peritoneal vessels, open vessels
VENOUS CO2 EMBOLISM

What are some possible


complications of laparoscopic surgery?
Insufflation of Gas into an open vein
-Hypoxemia
-Pulmonary Hypertension
-Pulmonary Edema
-Cardiovascular collapse

TREATMENT!!!
-Immediate release of the pneumoperitoneum
-Insertion of a central venous catheter
-Placement of patient. Head down and LLDP

What are some possible


complications of laparoscopic surgery?
-Trocar Insertion

Nausea and Vomiting

-Peritoneal insufflation
-Manipulation of Viscera
Emptying of the stomach with NGT
Vagal Stimulation

Bradychardia/
Arrhythmias
Sinus Arrest

Metoclopromide / Plasil

Postoperative Considerations
-Increased IAP during penumoperitoneum

Venous stasis

Deep vein thrombosis


Pulmonary embolism
Nausea and Vomiting

Emptying of the stomach with NGT


Metoclopromide / Plasil