ANESTHESIA FOR LAPAROSCOPIC SURGERY.pptx

This ppt include most of anesthesia considerations and management for laparoscopic surgery

1. ANESTHESIA FOR LAPAROSCOPIC SURGERY PG; Dr. Michel TUYIZERE Consultant, Dr. Christian MUKWESI

2. Introduction It is minimally invasive & is becoming standard of care for abdominal & pelvic surgeries Benefits Shorter hospital stays, lower costs, and fewer infections and complications Smaller incisions, Reduces the perioperative stress response, Reduces postoperative pain, and Results in shorter recovery time

3. Introduction Presents unique challenges to the anaesthesia provider as Requires insufflation of intraperitoneal or extraperitoneal gas, usually CO 2 , -To create space for visualization and surgical maneuvers. Physiologic effects of the pneumoperitoneum, absorption of CO 2 , and positioning - Influence intraoperative care and outcomes Some take longer

4. Surgical Approach Requires creation of a pneumoperitoneum by insufflation of gas (CO 2 ), to open space in the abdomen for visualization and surgical manipulation Done blindly using Veress needle or by Hassan minilaparotomy incision The Veress needle is replaced by a port through which an endoscope is placed Laparoscope is inserted after insuflation. Under direct intraabdominal vision, further instrument ports are placed.

5. Physiologic effects of laparoscopy CVS Generally well tolerated if healthy Significant cardiac dysfxn can occur in elderly & comorbid pts (eg. COPD, CHF, pulm HTN, valve dz) ↑MAP, SVR, & CVP ↓CO & SV

6. CVS Changes are due to: Pneumoperitoneum/↑ IAP Release of catecholamines & RAS activation: release of vasopressin Vagal stimulation: bradyarrhythmias Dynamic mechanical effects Depend on volume status, insufflation pressure & position Arterial compression: ↑SVR & PVR CVS effects usually resolve rapidly as pneumoperitoneum is maintained within 15 minutes Position changes Head-up/Reverse Trendelenburg (ex cholecystectomy): venous pooling w/ ↓ venous return Head-down/Trendelenburg (ex pelvic surgery): ↑venous return & cardiac filling pressures Hypercarbia Direct effects: ↓ cardiac contractility, sensitization to arrhythmias, systemic vasodilation Indirect effects: sympathetic stimulation (tachycardia, vasoconstriction, ↑SVR/PVR

7. Physiologic effects of laparoscopy cont’d Respiratory Mechanical Cephalad displacement of diaphragm & mediastinal structures: ↓FRC & pulmonary compliance; atelectasis, ↑peak airway Pressure, V/Q mismatch Endobronchial migration of ETT Hypercarbia MV must ↑ to compensate Can lead to ↑intrathoracic P w/ ↑SVR & PVR

8. Physiologic effects of laparoscopy cont’d Other regional changes Splanchnic blood flow: no clinically significant effect ↓ by mechanical & neuroendocrine effects - ↓hepatic blood flow & bowel perfusion ↑ by hypercapnia (direct splanchnic vasodilatation) Renal blood flow: ↓renal perfusion & u/o renal parenchymal compression, ↓ renal vein flow, ↑vasopressin Cerebral blood flow: ↑CBF & ICP ↑IAP, hypercarbia, Trendelenburg May be significant if intracranial mass, signiificant cerebrovascular dz - important to maintain strict normocapnia Intraocular pressure: ↑

9. Anesthetic Management Induction & Maintainance Standard ASA monitors + NMB monitor, ensure & secure a good IV access GA with cuffed ETT , but neuraxial block T4-T6 NGT decompression( post induction) Empty the bladder Positioning + Adequate padding Critical step: Trochar insertion + CO 2 insuflation → Goal = intraabdominal pressure (IAP) ≤15 mmHg to minimize physiologic effects

10. Anesthetic Management cont’d Induction & Maintainance Ventilation Positive-pressure ventilation with neuromuscular blockade is recommended to provide optimal surgical exposure, PEEP: 4 to 5 cm H2O. FiO2 need not be set any higher than what is necessary

11. Anesthetic Management cont’d Induction & Maintainance Fluid Management: Fluid requirements usually decreased ( ↓fluid shifts, minimal third-space losses, and decreased evaporative losses) Adequate IV fluids are required to ensure optimal preload Transient oliguria or anuria is seen, interestingly do not last more than a few hours after desufflation Analgesia: Multimodal analgesia: Potent NSAIDs reduce opioid requirement Local anaesthetic infiltration at the port site (preincisional or at the time of closure)

12. Anesthetic Management cont’d Emergence Adequate reversal of neuromuscular blockade Ensure normocapnia prior to extubation. POSTOP CARE PONV Usually 5-HT3 receptor antagonist( e.g: ondansetron) or dexamethasone Anticipate risk factors : multimodal therapy can be considered Good teamwork between surgeons, anesthesiologists, anaesthetists, and perioperative staff is the key to good outcomes

13. Potential Complications Hemodynamic & pulmonary complications related to physiological changes of pneumoperitoneum Initial insufflation = higher risk time Occult hemorrhage - may not be visible due to small surgical field Vascular or solid organ injury Gas embolism Subclinical embolism very common; significant emboli rare Mechanisms: Direct venous injection of CO2 w/ Veress needle CO2 entrainment via severed/disrupted vein Subcutaneous emphysema ↑ CO2 absorption ➝ hypercarbia Potential airway compromise if crepitus/swelling in head, neck, or upper chest Risk factors: surgery >200 mins, ≥6 ports, age >65, Nissen fundoplication Capnothorax: suspect of unexplained ↑ airway P, hypoxemia, & hypercapnia Capnomediastinum & capnopericardium Complications related to positioning

14. Takehome message Procedure is advantageous for minimal tissue trauma, ↓ postoperative pain, quicker recovery, shortening the hospital stay. Laparoscopy induces intraoperative cardiorespiratory changes. Proper patient selection + preparation +adequate monitoring. GA + controlled ventilation with balanced anesthesia is commonly used Intraop complications arise due to physiologic changes w/t positioning & pneumoperitoneum PONV is most common after laparoscopic surgery. Multimodal analgesic regimen: opioids, NSAIDs, & local anesthetic infiltration=most effective regimen

15. References Bland PC. Anesthetic Implications of Laparoscopic Surgery. In: Freeman BS, Berger JS. eds. Anesthesiology Core Review: Part Two Advanced Exam. McGraw-Hill Education; 2016. Accessed March 24, 2024. https://accessanesthesiology.mhmedical.com/content.aspx?bookid=1750&sectionid=117323598 https://www.uptodate.com/contents/anesthesia-for-laparoscopic-and-abdominal-robotic-surgery-in-adults?csi=1fb6f08a-3286-441a-a47d-12eb53fc5c40&source=contentShare Amornyotin, Somchai. (2013). Anesthetic consideration for laparoscopic surgery. International Journal of Anesthesiology & Research. 1. 102. 10.19070/2332-2780-130002. Cunningham, A J. “Anesthetic implications of laparoscopic surgery.” The Yale journal of biology and medicine vol. 71,6 (1998): 551-78.