Anesthesia For Laparoscopic Surgeries
Prepared & Presented By: Hem Raj Paneru MD 2nd Year, Anesthesiology Moderator: Prof. Dr. B B Singh NAMS
16th Magh, 2067
• 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.
• 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
• 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
– 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
↓Venous return & ↑SVR
↓ Cardiac Output & Cardiac Index
1) ↑ Intrathoracic pressure 2) ↑ PaCO2 & ↑CBF 3) Compression of IVC, ↑ lumbar spinal pressure &↓ CSF drainage
• ? ↓ Splanchnic blood flow
– Mechanical compression – ADH Superior mesenteric artery constriction
• ? Maintained Splanchnic blood flow
– Hypercarbia Vasodilation
• 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.
1) ↓ Femoral venous blood flow
2) Pooling of blood (Reverse Trendelenberg position)
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)
• 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 Patient’s 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.
– ↑ CBF
– ↓ 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
– Hypotension, hypertension, tachycardia, bradycardia, dysrhythmias, asystole
– Hypercapnia, hypoxemia, atelectasis, barotrauma
• Related to gas insufflation
– Subcutaneous emphysema, gas embolism, pneumothorax, pneumomediastinum, pneumopericardium, extreme CO2 absorption
– Hemorrhage, damage to hollow viscera, damage to nerves
– Damage to nerves or eyes (positioning and draping), dislodgement of ET tube with endobronchial intubation
– Hypothermia, nausea and vomiting, hyperkalemia, renal failure, increased risk of regurgitation
Foramen Bochdalek Paraesophageal hiatus Foramen of Morgagni
Subcutaneous Emphysema Subcutaneious
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
• Tachycardia, bradycardia, VPCs, asystole
– Identify the cause – Stop gas insufflation – Consider Atropine (may need to give undiluted atropine) – Don’t delay CPR
• Carina shifts upwards with creation of pneumoperitoneum
– Exaggerated by positioning (head down)
• Check tube position frequently
• 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.
• • • • • • • • • 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
• 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
– – – –
– – – – –
IAP: 12 – 15 mmHg (don’t 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.
– 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.
– 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.
• 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.
Laparoscopic Cholecystectomy Under Regional Anesthesia
• • • • •
12 patients, ASA I & II 4 ml 0.5% hyperbaric bupivacaine + 150µg 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