Anaesthesia for Laparoscopy

David Green MB FRCA MBA

Consultant Anaesthetist
King’s College Hospital
 Aims

• to underline the principles of anaesthesia

for laparoscopic surgery
• to point out the dangers of peritoneal
insufflation of CO2 and look at alternatives
• to examine claims that laparoscopic
procedures are less stressful than open
procedures
 Objectives

• to increase awareness of the risks and

benefits of laparoscopic surgery from the
anaesthetist’s (and patient’s) point of view
• to stimulate further interest and research in
newer techniques which may reduce the
risks
 Introduction

• Gynaecological laparoscopy
• Dangers of peritoneal insufflation of CO2
“Though laparoscopy offers advantages to both patients and
surgeon it involves considerable alteration in respiratory
and cardiovascular homeostasis and should not be
regarded as yet another minor investigation”
Hodgson, McClelland and Newton 1970
 Anaesthetic techniques

• The role of endotracheal intubation

• The role of mechanical ventilation
• The role of muscle paralysis
• The role of nitrous oxide
 Anaesthetic techniques
• Capnography
– CO2 absorption through peritoneum, venous channels,
retroperitoneal and subcutaneous tissues
• Invasive monitoring
• Insufflating gas
– air, nitrous oxide, carbon dioxide
• Helium
– Haemodynamic stability (Fleming et al., Junghans et al.
1997)
– Inhibition of tumour growth (Neuhauss et al. 1999)
 Pathophysiological effects

Haemodynamic
• head up versus head down position
• bradycardia
• blood loss
• visceral traction
• gas embolus: early versus late
 Pathophysiological effects

Respiratory: Hypercapnoea
• Head down, spontaneous respiration
• CO2 absorption
• Compromised diaphragm function with raised
IAP
• Pneumothorax
 Pathophysiological effects
CO2 pneumoperitoneum (Safran and Orlando AJS 1994)

• Hypertension, tachycardia leading to increased myocardial oxygen demand

• Increased noradrenaline levels leads to increased SVR (and decreased Q)
• Hypercarbia and acidosis
• Decrease in urine output and increased plasma renin activity (PRA)
– due to increased intra-abdominal pressure (IAP) and the local compression of renal
vessels
• Intra-abdominal distension leads to a decrease in pulmonary dynamic compliance .
• Low compliance, together with an increased minute volume of ventilation, is
accompanied by high peak airway pressures .
• head-up positioning and fluid deficit accounts for many of the adverse effects in
haemodynamics during laparoscopic cholecystectomy (Hirvonen et al 2000).
 Pathophysiological effects
Gasless/abdominal wall lift techniques

• abdominal wall lift permits the conduct of

laparoscopic procedures at an intra-
abdominal pressure of only 6-8 mm Hg
• benefits patients with pre-existing cardiac
disease and chronic bronchitis, especially
for liver surgery (Banting et al. 1993).
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

• .. gasless technique provided inferior exposure and the operation took longer,
… value in high-risk patients with cardiorespiratory disease? (Vezakis et al.
1999, Johnson and Sibert 1997)
• .. using thoracic epidural: no clinically important differences in cardiovascular
and systemic response were observed between patients undergoing CO2 or
gasless laparoscopy for colonic disease (Schulze et al. 1999).
• .. compromised surgical exposure and thus increased technical difficulty.
Patients realised no benefits from its use in terms of postoperative discomfort
or return to activity (Goldberg and Maurer 1997)
• .. gasless laparoscopic cholecystectomy resulted in more uneventful and faster
immediate and late postoperative recovery than conventional carbon dioxide
pneumoperitoneum (Koivusalo et al 1996, 1997).
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

Conclusion
• Most studies have shown decreased surgical
access and increased conversion rates
• Cardiorespiratory benefits are limited in most
studies
• Side effects are similar overall
• Need a meta-analysis/more studies
 Studies of laparoscopic vs open procedures

• endocrine and metabolic changes during acute emergency

abdominal surgery performed using either laparoscopy or
laparotomy in children. Prolactin, cortisol,
interleukin-6, glucose, insulin, lactic acid and epinephrine
levels .. No differences were elicited (Bozkurt et al. 2000)
• stress responses after sigmoid colectomy, in patients
undergoing lap. assisted colectomy, are comparable with
open operation (Fukushima et al. 1996)
• LC produces significant increases in stress hormone levels
.
… “not physiologically minimally invasive” (Naude et al.
1997)
 Studies of laparoscopic vs open procedures

• significant lower values of intraoperatively and

postoperatively measured epinephrine, norepinephrine,
interleukin-1 beta, and interleukin-6 in patients with
laparoscopic vs open cholecystectomy (Glaser et al. 1995)
• neuroendocrine stress response and inflammatory
response following laparoscopic cholecystectomy were
significantly reduced compared with those after open
cholecystectomy (Karayiannakis et al. 1997)
• activation of stress-related factors during gynaecologic
laparoscopy seems to be less intense and of shorter
duration (Muzii et al. 1996)
Studies of laparoscopic vs open procedures

Conclusion

More studies and larger patient groups are

needed to be certain that laparoscopic
procedures produce less stress response
than open procedures … especially if the
duration of the operation is longer
 Conclusion

• Laparoscopic procedures are not minimally

invasive physiologically
• The benefits of gasless techniques are yet to
be established