Anaesthesia for Laparoscopic surgeries and procedures

Anaesthesia for laparoscopy procedures and possible complications for such procedures. This also covers the Anaesthetic perioperative considerations, post operative care and possible perioperative complications.

1. ANAESTHESIA FOR
LAPAROSCOPIC SURGERY

2. Introduction
Most Endoscopic procedures are diagnostic,
few therapeutic, and are carried out by using
the natural orifices, with the use of fibreoptic
with camera.
Cut across all subspecialties with GIT
probably in the lead.
Are mostly done under moderate – Deep
sedation, GA
Laparoscopy – Most challenging

3. OBJECTIVES
To identify the anaesthetic challenges
associated with laparoscopic surgical
technique.
To be equipped with evidence based
knowledge to manage patients peri-
operatively for laparoscopic surgeries
and ensure their safety.

4. OUTLINE
1.History
2.What is laparoscopy and its applications
3.Advantages. and disadvantages.
4.Contraindications
5.Physiological changes
6.Choice of anaesthesia
7.Complications
8.Special considerations in Pregnant woman/Children
9.Conclusion.

5. HISTORY
•George Kelling used cystoscope to
observe abd organs of dogs—
CYSTOSCOPY
• 1910 – Swedish physician Hans Christian
Jacobaeus
used this procedure in man and coined the
term – LAPAROSCOPY

6. HX
 In 1924, Richard Zollikofer of
Switzerland promoted the use of CO2
as the insufflating gas.
Later Janos Veress of Hungary
developed a spring loaded insufflation
needle.
It was Raoul Palmer in Paris in 1944-
monitoring intra-abdominal pressure.

7. History
It was another 20 years, however,
before Kurt Semm in Kiel, Germany,
developed an automatic insufflation
device.
1986 that a computer chip TV camera
was developed and attached to the
scope.
1987 – Mourett in France succesfully removed
a diseased gall bladder.

8. Trend in Nigeria.
Dr Ojukwu in Lagos early 2000
In Ibadan – 2009, resuscitated
UCH Data- so far
>45 cholecystectomies,2 under CSE
30 Appendectomies, 10 under CSE.
18 OBG.
2 involving children.
Many diagnostic procedures.
Data @ at 2015.

10. Definition
•It is a minimally access procedure allowing
endoscopic access to peritoneal cavity after
insufflation of gas to create space between the
anterior abd. Wall & viscera for safe manipulation of
instruments & organs.
TYPES
1Intraperitoneal
2Extraperitoneal
3Abd wall retraction (gasless laproscopy)
4Hand assisted (Hassans tech.)
KEYHOLE SURG
PINHOLE SURG

11. ADVANTAGES
1 Minimal pain & illeus
2 Improved cosmesis
3 Shorter hospital stay , faster recovery & rapid
return to work, cost?
4 Non muscle splinting incision & less blood loss
5 Post op respiratory muscle function returns to
normal more quickly
6. Wound complications i.e. infection & dehiscence
are less, less retraction.
7 Lap surgery can be done as day care surgery

12. Disdvantages……
More expensive
More operating time
Difficult in complicated cases
Potential for major complications
in inexperienced hand

13. LAPROSCOPICS SURGERIES/ INDICATIONS
Early procedures were diagnostic

 Cholecystectomy, Appendectomy
 Vagotomy, Colectomy
 Hiatal, Inguinal & Diaphragmatic hernia repair
 Urological
Nephrectomy,Adrenelectomy&Prostatectomy
 OBG-Tubal surgeries,cystectomies,hystrectomies
various ablations (endometriosis)
 Thoracoscopies
 Neurosurgeries
 ENT.

14. CONTRAINDICATIONS
 -Inexperience surgeon
 -diaph hernia. CHD
 -severe cardio-pulmo dxs
 -adhesions
 -morbid obesity BMI>30
 -SCDx (sickle crisis pptd by acidosis
 -Raised ICP, IOP, Peritonitis

15. Causes of anaesthetic
challenges
Pneumoperitoneum
Mechanical effects relating to increased
intra-peritoneal pressure.
Chemical effect of CO
2 used for
insufflation.
Effect of Positioning.
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR

16. PHYSIOLOGICAL CHANGES/THE
CHALLENGE
Physiological
changes
p
o
s i t i o
n
c
o
2
pneumoperitoneum

17. INSUFFLATING GAS OF CHOICE FOR
LAPROSCOPY
Ideal insufflating gas of choice
Colorless, non toxic, nonflammable, easily available,
inexpensive, inert, readily soluble in blood and easily
ventilated out of lungs
Why CO2 is the gas of choice for laparoscopy ?
1 Nonflammable & does not support combustion
2 Highly soluble in blood because of rapid buffering
in blood so risk of embolisation is small
3 Rapidly diffusible through membranes so easily removed by
lungs
4 CO2 levels in blood & expired air can be easily measured & its
elimination is augmented by increasing ventilation
5 CO2 is readily available & is inexpensive

18. Pneumo Peritonium…

Insufflator Gas used
N2O /CO2 /Argon /He/ Air
Preferred gas : CO2
Working pressure : 12 to 14 mm Hg
Slow inflation of 1 liter / minute
(Air & O2 –risk of embolism high.
N
2
O –bowel distension,risk of explosion,PONV.
He & Argon not available here- embolism)

19. Hemodynamic Effects
Depends on the interaction of:
patient’s pre-existing cardiopulmonary
status
anesthetic technique
intra-abdominal pressure
carbon dioxide absorption
patient position
duration of surgery.

20. CVS
Early Hypercarbia stimulates symp-
adrenal axis with Adr & NAdr in bld
 Tachycardia, arrythmia
 BP - Elevated BP,CO,CVP
 when IAP > 20 – 30mmHg decrease
in BP,CO,CVP , same in late hypercarbia

21. RESPIRATORY
Respiratory
↓lung vol (TV,FRC), compliance





,VQmismatch
hypoxia, hypercarbia
(30-50%)
increased Paw

22. CNS
 2-4% in CBF with every 1mmHg
PCO2 (25-100mmHg)
 Raised ICP
 Increase in cranio-facial congestion,
worse with Trendeleburg position

23. RENAL
 Oliguria common during lap. surgery
 Hypovol, IPPV, PEEP
 Incr IAP eg > 15mmHg renal BF
decreased 60% & 50% u/o
 NO SUCH CHANGES- in Gasless
lap(abd wall lift)

24. METABOLIC
Temperature variation
continous flow of dry gases over peritoneal surface under P at
high flow rates + lavage with cold fluid
Neuro-hormonal stress response
- equal = open surgery (ACTH, cortisol, insulin, glucagon, bld
glucose)

hypothermia
(0.3˚C/50L co2)

25. Cont….
Thromboembolism
Pelvic surg
Long duration
Malignancy
obese
IAP
↓VR
Venous stasis
In rTr position
DVT

26. PATIENT POSITION
Produce gravitational displacement of viscera away
from surgical site.
Trendelenberg Rev Trendelenberg
15-20˚ head down 20-30˚ head up
Increased VR,CBV,CO ↓ VR,CBV,CO,MAP
↓VC,FRC,Compliance,
V/Q mismatch
Paw (atelectasis)
Improves diaph function
Endobronchial
intubation
Predisposition to DVT
due to raised femoral VP
cvs
Resp.
others

27. ANAESTHETIS TECHNIQUES
Lap Sx amenable to all but
individualize your pt
LA wt mild sedation(aim Ramsay 2-
3)eg in minor lap tubal sterilisation.
 GA- may be tech-of-choice with
cuffed ETT
 -RA – Spinal,Epidural or CSE

28. GA plus ETT

 Pros- less anxiety,amnesia possible
adeq muscle relaxation-very important
Flexibility(sx may be unusually long
Less risk of regurgitation/aspiration
Unanticipated resp compromise easily
managed

29. GA-
Cons – Unnecessary(short
procedure,experienced surgeon)
Delayed recovery
Others

30. REGIONAL ANAESTHESIA
Better post-op analgesia
Less PONV (Vs GA)- less emetogenic
agents use
 Less blood loss
 Faster recovery etc
 Less thromboembolic phenomena.

31. Cont---

 CONS- High level of block required
Sympathetic blockade – may worsen wt
hypercarbia of lap sx
NG Tube discomfort in consciuos pt
May delay discharge for day case.

32. ANAESTHESIA
Preop.
Done in usual manner with special attention to
cardiac & pulmonary system
Investigations
1.Complete hemogram
2.RBS
3.E/U, Creatinine
4.Coagulation profile
5.CXR, ECG
Special investigations
1. ECHO
2. PFT

33. PREMEDICATION
1. NPO
3. Antibiotics as per surgical team
4. Awareness about post op shoulder tip pain
5. Written informed consent for laparotomy
6. Anxiolytics/antiemetics/H2 receptor antagonist/analgesic
7. Antisialagogue (glyco-P) and vagolytic may be
administered at induction of anaes.
8. DVT prophylaxis (rTn, pelvic Sx, long duration,
malignancy, obesity) TED stocking.

34. MONITORING
1.HR
2.NIBP
3.Continous ECG
4.Pulse oximetry
5.Capnography
6.Temperature
7.Airway pressure
8.IAP
If required, ABG, precordial sthet.,

35. CONDUCTION OF LAP. SURGERY UNDER GA
1.Preloading- 5-10 ml/kg to prevent hemodynamic
changes during pneumoperitoneum
2.Induction- propofol, thiopentone Na, TIVA
(propofol+fentanyl)
3. Msl relaxation – Scoline (RSI) for antireflux surg.
NDMR
4.Maintainence – O2 +? N2O + iso/sevo, halo

36. Cont…..
4. Folleys catheter and NG tube insertion to avoid
bladder/bowel injury (↓PONV, improve surgical view)
5.Ventilatory settings- To maintain normocarbia
(ETco2 34-38 mm Hg)- RR rather than TV as the
lung compliance is low.
6. Positioning – gradually, tilt < 15-20˚, check ETT
position, padding at pressure points.
7. Gas insufflation – slow (1-1.5 →1-2.5 L/min)
IAP<15 mm Hg (10-12)
check ETT position

37. Cont….
8. Prevent hypothermia
9. Analgesic / antiemetic
10. Postop recovery- monitor vitals
O2 supplementation

38. Nitrous ?
potential undesirable effects during
lap sx
 may cause bowel distension
 will worsen pneumothorax if dev.
 May be a potential ignition hazards
 worsen PONV highly emetogenic

39. COMPLICATIONS
Intraop. events from:-
1.Pneumoperitoneum viz cvs, resp.
2.Gas Extravasation, pneumothorax,
Mediasternum, s/c emphysema
3.Positioning, nerve injury,
endobronchal intubation from
Tradelenburg/Abd. distention

40. GASLESS LAPAROSCOPY
Peritoneal cavity is expanded using
abdominal wall lifter.
This avoids haemodynamic &
respiratory repercussions of increased
IAP
It increases technical difficulty

41. POSTOP.COMPLICATIONS
1.PONV
2.Respiratory – O2
3. Pain – Shoulder tip

42. CO2 embolism (rare but potentially fatal)
Risk factors - previous abd surg, needle/Trocar in vessel
Consequences- GAS LOCK in vena cava ,RA → ↓ VR →© collapse


Diagnosis
HR, ↓BP, CVP, hypoxia, cyanosis,
ET CO2 biphasic change, Δa ETco2
ECG- Rt heart strain, TEE, pulm art.
aspiration of gas/ foamy bld from CVP line
Mill will murmur.

43. Cont…..
Treatment
1. Release source (stop co2 + release pneumoperit)
2. position – steep head low
3. stop N
2
O
4. Hyperventilation
5.
CVP/PA catheter to aspirate CO2
6. Cardiac massage may break embolus- rapid
absorption

44. Laparoscopy in children
1 Physiological changes = adults
2 Paco2/ ETco2 increase but ETco2 overestimates
Paco2
3 Co2 abs more rapid and intense due to larger
peritoneal SA / body wt.
4 More chances of trauma to liver during trocar
insertion
5 More chances of bradycardia , maintain IAP to as low
as possible

45. Laparoscopy in pregnancy
Indications- appendicectomy
cholecystectomy
Risk – preterm labour, miscarriage, fetal acidosis
Timing – II trimester (< 23 wk)
Lap technique – HASSANS tech
Special considerations
1.prophylactic- antithrombolytic measures + tocolytics
2.operating time to be minimised
3.IAP as low as possible
4.Continous fetal monitoring .

46. Cont….
8. Prevent hypothermia
9. Analgesic / antiemetic
10. Postop recovery- monitor vitals
O2 supplementation

47. CONCLUSION
 An improved knowledge of intraoperative
repercussions of laparoscopy permits safe
management of patients who may subsequently
benefit from the multiple postop advantages
offered by this technique

48. REFERENCES
Joshi, G. Anesthesia for
laparoscopic surgery. Canadian
Journal of Anesthesia 2002; 49:
45-49
Kaba, A. Joris, J. Anesthesia for
laparoscopic surgery. Current
Anesthesia and Critical Care 2001;
12(3): 159-165.

49. Mullet, C., Viale J., Sagnard, P., et al.
Pulmonary CO2 elimination during
surgical procedures using intra- or
extraperitoneal CO2 insufflation.
Anesth-Analg 1993; 76: 622-6.
Taylor, E., Feinstein, R., White, P., &
Soper, N. Anesthesia for laparoscopic
cholecystectomy: is nitrous oxide
contraindicated? Anesthesiology
1992; 76: 541-3