anaesthesia for laparoscopic surgery.ppt

Drugs use in laparoscopy,doses, position, CVS change, Lee cardiac risk index

1. Anaesthesia for
laparoscopic surgery

2. Overview
Introduction
History
Indications for laparoscopic surgery
Contraindications
Procedure for pneumoperitoneum
Gases used for insufflation
Patient positioning
Pathophysiological changes d/t positioning &
pneumoperitoneum
Anaesthesia management for laparoscopy

3. Introduction
Laparoscopic surgery Also termed as as minimal access
surgery or key hole surgery has gained worldwide acceptance
d/t minimal trauma, shorter hospital stay & cost
effectiveness
Initially confined to gynecological procedures for diagnostic
& therapeutic purpose has now extended it uses to upper &
lower abdomen & thoracic surgery

4. History
In 1901 Dr.kelling was the 1
st
to inspect the viscera of a dog whose
abdomen had been insufflated with air
1910 , JACOBEUS applied this technique to humans & termed it as
laparoscopy
1968, SEMM ,discovered the co2 insufflator
1970 , laparoscopy was used for gynecological procedures
With the advance of time laparoscopy entered the general surgical
field
1989, Reddick & Olsen introduced laparoscopy for cholecystectomy

5. Indications
Intra abdominal
Cholecystectomy
vagotomy
Hiatus hernia repair
Appendicetomy
Colectomy
Inguinal hernia repair
Adrenalectomy

6. Gynecological
Diagnostic ( infertility)
Fallopian tube –TUBECTOMY
Ovarian cyst –Diagnostic & drilling
Hysterectomy.
Diagnosis of ectopic pregnancy

7. Advantages
Shorter hospital stay & early ambulatory
Smaller incisions & surgical scar
Minimal tissue trauma
Postop pain is relatively less
Minimal bowel handling

8. Contraindications
Absolute
Bleeding disorder
Severe obstructive lung disease
Recent MI
Advanced pregnancy
Diaphragmatic hernia
Increased ICP
Ventriculoperitoneal shunt
Peritoneojugular shunt

9. Relative
Massive ascites
Abdominal scar
Extensive organomegaly
Hypovolemia

10. Procedure for pneumoperitoneum
Laparoscopy is preceded by creation of pneumoperitoneum
Prerequisite before insufflation
STOMACH should be decompressed with NG tube
Bladder should be catheterised
Position –15 -20 degree TRENDELENBERG POSITION
Procedure
A small subumbilical incision is made & verses needle is introduced into
the abdominal cavity at 30 degree angle to the pelvis

11. Verses needle enters the peritoneal cavity with a click &
is connected to insufflator
Gad is insufflated at a rate of 1-2 l/min
Then quadrants of abdomen percussed for even
distribution of gas & prehepatic tympanism
Then gas flow is reduced 200-300 ml/min to maintain an
abdominal pressure of 14-15mmhg
Verses needle is removed ,trocar & cannula inserted
through same incision
Trocar is removed & laparoscope introduced

12. Gases used for insufflation
Ideal gas for insufflation should be
Colorless
Physiologically inert
Non explosive in the presence of cautery & laser
Easily eliminated

13. Carbondioxide
An odorless, non toxic ,non combustible, readily available gas
Blood gas solubility coefficient ir 0.8
20 times more soluble in blood than air
Readily buffered by bicarbonate in blood & easily eliminated by the
lungs
Lethal dose for co2 to embolise is 5 time that of air
S/E-shoulder tip pain , cardiac arrhythmias

14. Room Air
Room air was originally used d/t low blood gas solubility of
nitrogen (0.016)
It frequently migrated to neck, mediastinum ,pleural &
pericardial cavity & scrotum
S/E –Air embolism, delayed absorption-Prolonged post op
shoulder tip pain

15. Oxygen
Not used
It causes gas embolism & explosion with cautery

16. Nitrous oxide
Commonly used in mid 1970’s
Had lower potential for gas embolism than O2/air
Blood gas solubility coefficient 0.47
S/E –intraperitoneal explosion when nitrogen oxide &
methane ( from gut ) are ignited

17. Patient positioning
Depends on the type of surgery
Head down tilt –used foe pelvic & submesocolic surgery
Head up position-for supramesocolic surgery
Check the position of ETT after any change in position with
Head down tilt. Movement of ETT in to the right main
branches d/t Cephalad Movement of carina & diaphragm

18. The patient tilt should not exceed 15 degree
Tilting should be slow & progressive
To avoid sudden hemodynamic & respiratory
changes

19. Pathophysiological changes d/t
positioning & pneumoperitoneum
RESPIRATORY CHANGES :-
Increase in intra abdominal Pr. L/t
Decrease in VC, FRC, pulmonary compliance
INCREASE in paCO2, intra thoracic pressure, airway
pressure , normal or decrease paO2
Uneven distribution of ventilation
V/Q mismatch
Hyperbaric
Hypoxia
Increased risk of barotrauma during IPPV

20. These changes are more common in head down
tilt
In head up position, favorable to respiration
These respiratory changes are most marked in the
obese , elderly & debilitated patients
To restore normal lung volumes & respiratory
changes during laparoscopy, GA with controlled
ventilation Is preferred

21. CVS changes
With IAP of 10mmHg
Decrease in cardiac output
Increase in arterial pr.
Increase in SVR & pulmonary vascular resistance
When IAP is increased upto 20mmHg
increase in renal vascular resistance
Decrease in RBF & GFR by 25%
Decrease in urine output

22. An IAP of 20mmHg
Decreases mesenteric artery flow & also intestinal
mucosal blood flow
The relationship;/w hemodynamic depression &
the level of intra abdominal pr. Is influenced by
Rate of CO2 insufflation
Rate of co2 absorption
Rise of intraabdominal pr.
Steepness od tilt

23. The combined effect of anaesthesia, Patient
position & increase in IAP (14mmHg) , decreases
cardiac output by 50%
Mechanism of reduced CO is multifactorial

24. Causes of decrease in CO during
pneumoperitoneum

25. Reflex increases vagal tone
D/t sudden stretching of peritoneal
Vagal stimulation increases lighter planes of
anaesthesia
Rx –discontinue insufflation , administer atropine,
deepen anaesthesia after Stabilization of HR

26. Arrhythmia:-
D/t to increase in PaCO2 during halothane on
spontaneous ventilation
Also result from gas embolism

29. Anaesthesia for laparoscopic surgery
Ideal –GA with controlled ventilation
Because it counters hypercarbia d/t
Mechanical impairment of ventilation
Depression of ventilation by anesthetic drugs
Absorption of CO2 from peritoneal
Provides good muscle relaxation
Cuffed ETT prevents aspiration

30. GA used in
Long laparoscopic procedure
Patients with preexisting Rs / cardiac disease
In obese pt with impaired Vc,FRC & compliance

31. Pre-op evaluation
History with emphasis on extent & severity of RS & CVS
disease
In a patient with poor pulmonary reserve pre operatively like
COPD –PFT is advisable
PFT identify the patient who are Likely to experience
hyperbaric & acidosis
Lee cardiac risk index Can be used for quantification of
cardiac risk
Check cardiopulmonary reserve –Breath holding test (N-
25sec)

32. LEE CARDIAC RISK INDEX

33. Cardiac complications
MI
PULMONARY EDEMA
VF
Complete block

34. Pre medication
Anxiolytics –Inj.Midazolam 1-2 mg iv
Anti-emetics –inj. Odansetron 4mg/ inj.Promethazine 12.5 –
25 mg im/
Antacid –inj. Ranitidine 50 mg iv/ inj.Pantaprazole 40mg iv
Pro-kinetic-inj. Metaclopramide 10 mg iv ( pregnancy, Dm)
Analgesics-inj. Fetanyl ( 1-2 mcg/kg) / inj.pentazocine 0.5
mg/kg or NSAIDS
Anticholinergic-inj. Atropine 0.02mg/kg –to counter the
increase in vagal tone (Brady arrhythmia) during laparoscopy

35. Bag & mask ventilation should be minimized to avoid
gastric distinction
Insertion of nasogastric tube maybe required to deflate
the stomach
It will improve surgical View & avoid gastric injury during
trocar insertion

36. Induction
 Propofol 2-2.5 mg/kg ,
 Thiopentone sodium 4-6mg/kg
 Midazolam 0.1 -0.2 mg/kg
-Safe & effective for induction even in patient
with severe Aortic stenosis
Etomidate 0.35 -0.45 mg/kg
-Good choice in cardiac pt , as there is no
change in HR,MAP,PCWP,CVP, SVR, CVR

37. Muscle relaxants
Prevent high intra abdominal & intra thoracic pressure
d/t pneumoperitoneum
PIP decreases , there by reduces the effect on
hemodynamic, risk of pneumothorax & respiratory dead
space
Muscle paralysis reduces IAP ,same level required for
abdominal distention

38. Succinyl choline 1-2mg/kg
NDMR –Vecuronium 0.04-0.05 Mg / kg, Atracurium 0.5 mg
/kg, Rocuronium 0.6 –1 Mg /kg

39. Inhalation agent
Maintaining deep level of anaesthesia with Sevoflurane ,
Isoflurane ,halothane but the hemodynamic response to
pneumoperitoneum
Ideally ISOFLURANE 1-1.5% used
Nitrous oxide causing nausea & vomiting is controversial,
but it may distend the bowel in patients with intestinal
obstruction
Once the depth of hypnosis achieved, use of vasoactive drug
like esmolol & labetalol can be used to control hypertension

40. During induction-pneumoperitoneum ,controlled
ventilation adjusted to maintain ETCo2 –
35mmHg
In COPD / BULLOUS EMPHYSEMA -increase RR
rather than TV ,preferred to avoid alveolar
inflation & decrease the risk of pneumothorax

41. Reversal
Should be done after a smooth & complete desufflation
of pneumoperitoneum
Neostigmine 0.5mg/kg + glycopyrolate 0.01mg/ kg
After signs od adequate reversal pt is extubated & shifted
to post op recovery room

42. GA with spontaneous ventilation
It is restricted for Short laparoscopic procedure (
diagnostic)
In healthy young pts
Procedures performed by using low intra abdominal
pressure

43. Regional Anaesthesia
Epidural with head down tilt –pelvic diagnostic
laparoscopy
It is limited
Required extensive block
Should tip pain persists
Take time for onset of action ,position should be given after
fixation of drug

44. Local anaesthesia
Used in laparoscopic Tubal ligation
Requires LA with mild sedation
IAP should be low
It is contraindicated in laparoscopy with multiple puncture
site, organ manipulation, steep tilt & large
pneumoperitoneum
It makes spontaneous ventilation difficult

45. Intra op complication
Injury From surgical instruments
Complications associated with pneumoperitoneum
Arrhythmia
Congestive cardia failure & Cardiac arrest
Gas embolism
Pneumothorax & pneumopericardium
Subcutaneous emphysema
Aspiration

46. Post op monitoring
Requires hemodynamics monitoring & oxygen
administration
Hypertension –short duration in recovery indicates the
release of pneumoperitoneum
There will be increased oxygen demand following
laparoscopy
Compared to laparotomy ,there is less post op pulmonary
dysfunction

47. Following laparoscopy, FRC & VC decreases L/t Atelectasis
& hypoxemia
Post op nause & vomiting is decreased by nasogastric
drainage & anti emetics
Shoulder tip pain occur d/t irritation of diaphragm with
residual gas
Visceral pain common in lap. Cholecystectomy

48. Mechanism of pain in lap sx
Rapid distention of peritoneal
Tearing of blood vessels & traction of nerves –Release of
inflammatory mediators
Shoulder pain ( Last for 3 days )
d/t excitation of phrenic nerve & irritation d/t gas under
diaphragm
Upper abdominal pain
d/t pneumoperitoneum & peritoneal inflammation

49. Management
NSAIDS –decreases shoulder tip pain & inflammatory pain
Abdominal drain for 6hrs releases the residual gas
LOCAL ANESTHESTICS
B/l rectus sheath block. 15ml of 0.25% Bupivacaine b/l
above the umbilicus in diagnostic laparoscopy
Intraperitoneal administration of 0.25% Bupivacaine 20ml
into gall bladder bed
Interpleural 30ml of 0.25% Bupivacaine-decreases
shoulder tip pain & visceral pain after laparoscopic
cholecystectomy

50. LA infiltration of fallopian tube & injection into
mesosalphinx in Tubal ligation
LA gel to fallopian tube while clipping
Thoracic epidural analgesia

51. Alternatives to Co2 pneumoperitoneum
Inert gases
Gasless laproscopy

52. Use of inert gases
Helium & Argon can be used instead of co2
Inert gas avoids increase in PaCo2 & hyperventilation
Has low blood gas solubility, -increases the risk of gas
embolism

53. Gasless laproscopy
Laparoscopy without pneumoperitoneum
Mechanical abdominal wall retraction is done by FAN
retractor to expose peritoneal contents
ADVANTAGES
It is useful in pts with anatomical defects in diaphragm &
in pts with increased intracranial pressure
Recommended for pts With poor cardio-pulmonary reserve
No complications of increased intra abdominal pr,
hypercarbia, arrhythmia & gas Embolism

54. Disadvantages
Requires a steep headlow foe longer time
Intervention of vision d/t Distented bowel loops is a major
hindrance
GA & epidural allows early ambulation & decreased
thromboembolism episodes

55. Points to remember
Thorough pre-op evaluation of cardio-pulmonary status
Slow insufflation With IAP 12-14 mmHg
Positioning –slow & gradual progressive
Should be aware of intra op complications & its
management
Proper intra op & post op monitoring should be done