anesthesia for robotic surgery pdf dr vistal.pdf

Anesthesia for Laparoscopic and Robotic Surgery

1. Anesthesia for Laparoscopic
and Robotic Surgery
Dr. Godofredo S. Vistal MD

2. Objectives
•To understand the definition and scope of
laparoscopic surgery
•To know the anesthetic considerations for
laparoscopic and abdominal robotic surgery in
adults

3. Laparoscopic Surgery
•Account for >2 million
surgical procedures per
year
•Most common
procedures
–Cholecystectomy
–Appendectomy
–Sleeve gastrectomy
–Roux-en-Y Gastric bypass
–hysterectomy

4. Laparoscopy
•“Peritoneoscopy”
•Allow endoscopic access
to the peritoneal cavity
after insufflation of a gas
to create a space
between the anterior
abdominal wall and the
viscera

5. The Laparoscopic Approach
•Standard of care for
many abdominal
procedures
–Laparoscopic
Cholecystectomy: Gold
standard for
cholecystectomy

6. Advantages of Laparoscopic Surgery
•Smaller incisions
•Reduce periooperative
stress response
•Reduce postoperative
pain
•Shorter recovery time

7. Requirement:
INSUFFLATION OF
INTRAPERITONEAL OR
EXTRAPERITONEAL GAS TO
CREATE A SPACE FOR
VISUALIZATION AND
SURGICAL MANEUVERS

8. Abdominal Insufflation
(Pneumoperitoneum)
•Begins with intraabdominal
placement of the insufflation
needle or trochar
•Followed by carbon dioxide
insufflation of the abdominal
cavity to an intraabdominal
pressure (IAP) of 12-15
mmHg

9. WHY IS CO2 THE INSUFFLATING GAS
OF CHOICE?

10. Carbon Dioxide
•Nonflammable
•Does not support
combustion
•Readily diffuses across
membranes
•Rapidly removed in the
lungs
•Highly soluble
•Elimination can be
facilitated by increasing
ventilation

11. RISK OF CO2 GAS EMBOLISM
•0.0014 %- 0.6 %
•As much as 200 ml of
CO2 injected into a
peripheral vein may
not be lethal

12. Whereas….

13. Why Other Gases Are Not Used, Oxygen ,
and Nitrous Oxide
SUPPORT
COMBUSTION!
•Nitrous Oxide
•Air
•Oxygen

14. Why Other Gases Are Not Used, Oxygen ,
and Nitrous Oxide
Disastrous For
Gas Embolism
•Nitrogen
•Helium

15. 2 Main Components of CO2 Insufflation
Increased Intraabdominal
Pressure

16. PHYSIOLOGIC EFFECTS OF
LAPAROSCOPY

17. CARDIOVASCULAR CHANGES
DURING LAPAROSCOPIC SURGERY

18. Cardiovascular Changes During
Laparoscopy

19. Hemodynamic Events in Patients with
Significant Cardiopulmonary Disease
INCREASE
•MEAN ARTERIAL PRESSURE
•SYSTEMIC VASCULAR
RESISTANCE
•CENTRAL VENOUS PRESSURE
DECREASE
•CARDIAC OUTPUT
•STROKE VOLUME

20. EFFECTS OF PNEUMOPERITONEUM

21. Effects of
Pneumoperitoneum
NEUROENDOCRINE EFFECTS
1.Catecholamine release
2.Activation of Renin-Angiotensin
System
3.Vasopressin Release
4.Increased MAPà Increased
Systemic Vascular Resistance and
Pulmonary Vascular Resistance
5.Vagal Stimulation from insertion of
the Veress Needle or Peritoneal
Stretch with Gas Insufflation-à
Bradyarrythmias
> Bradycardia
> Atrioventricular Dissociation
> Nodal Rhythm
> Asystole

22. Effects of
Pneumoperitoneum
MECHANICAL EFFECTS
Compression of Arterial
Vasculature
1. Increased Systemic Vascular
Resistance
2. Increased Pulmonary Vascular
Resistance
3. Variable effects in Cardiac
Output and BP

23. EFFECTS OF POSITIONING

24. Positioning
•Allow intraabdominal
organs to fall away from
the surgical field
•Provide optimal
visualization of the
surgical field

25. Head Up/ Reverse Trendelenburg
•Produce favorable
ventilatory changes yet
unfavorable
cardiovascular changes
–Decreased venous return

26. Head Up/ Reverse Trendelenburg
•Venous pooling
•Reduce venous return to
the heart
•Hypotension

27. Head Down/ Trendelenburg
Diaphragm and abdominal
contents move cephalad
Reduced pulmonary
compliance and increase
peak airway pressureê

28. Head Down/ Trendelenburg
Decreased pulmonary
compliance
Increased Venous Return and
pulmonary capillary wedge
pressure

29. Neuroendocrine Response of
Trendelenburg Position
•Increased norepinephrine
levels
•Increased Plasma NT-
ProANP (N-terminal
proatrial natriuretic
peptide)
–Increased atrial stretch
caused by increase venous
return

30. Importance of Assessing Intravascular Fluid Volume
Status During Preop Evaluation
Recommendation to reduce the decrease in Cardiac Output
•Minimize duration of fasting
•Adequate preop hydration
•Use of intraabdominal
pressure < 15mmHg
Increased IAP
Initial Increase followed by Decreased Cardiac
Output
Decreased CO: accentuated by
hypovolemia and attenuated by
hypervolemia

31. Hemodynamic Effects of Patient Positioning and
Intravascular Fluid Volume Status

32. EFFECTS OF HYPERCARBIA

33. Hypercarbia
Direct
•Decreased cardiac
contractility
•Respiratory acidosis
•Sensitization to arrythmias
•Systemic vasodilation
Indirect
•Result of sympathetic
stimulation
•Tachycardia
•vasoconstriction

34. PULMONARY CHANGES

35. Pulmonary Changes During Laparoscopic
and Robotic Surgery

36. Special Patient Populations in Which
Hyperventilation may be Difficult
•COPD
• Asthma
•Morbidly Obese
•In this patients, end tidal
COP2 may not
accurately reflect
arterial partial pressure
of CO2
•ABGs may be required
to monitor ventilation

37. Anesthetic Considerations for Patients
with COPD
Hemodynamic
Change
Potential
Complication
Preop
Management
Periop
Management
Postop
Management
Hypercarbia,
Increased peak
and plateau
airway
pressures
Acidosis, bullae
rupture,
subcutaneous
emphysema,
pneumothorax
•Avoid Steep
Tredelendbur
g Position
•Higher
airway
pressures are
required to
ventilate
patients à
may lead to
bullae
rupture

38. Anesthetic Considerations for Patients
with Morbid Obesity
Hemodynamic
Change
Potential
Complication
Preop MgtPeriop
Management
Postop
Management
Diaphragmatic
displacement,
high baseline
intraabdominal
pressure,
increased
airway
pressures,
decrease
pulmonary
compliance
Acidosis, higher
ventilation
requirement
•Avoid Steep
Tredelendburg
•Sequential
compression
device
•Avoid early
extubation
•Extubate to
CPAP/BiPAP

39. CHANGES IN PULMONARY
MECHANICS

40. Changes in Pulmonary Mechanics
•Cephalad displacement
of diaphragm and
mediastinal structures
•Reduce Functional
Residual capacity and
pulmonary compliance
RESULT: ATELECTASIS AND PEAK
AIRWAY PRESSURE

41. CO2 ABSORPTION

43. Endotracheal Tube Position
•Pneumoperitoneum and
trendelenburg position may
cause cephalad movement
of the carina
CAN LEAD TO:
1.MAINSTEM ENDOBRONCHIAL INTUBATION
2.HYPOXIA
3.HIGH INSPIRATORY PRESSURE
4.INCREASED ET TUBE CUFF PRESSURE

44. REGIONAL CIRCULATORY CHANGES
DURING PNEUMOPERITONEUM

45. Splanchnic Blood Flow
•Decrease splanchnic
circulation
•Reduced total hepatic
blood flow
•Reduced bowel
perfusion

46. Renal Blood Flow
•Reduced renal perfusion
and urine output
•Renal parenchymal
compression
•Reduced renal vein flow
•Increased levels of
vasopressin

47. Cerebral Blood Flow
•Increased CBF and ICP
•At risk patients
–Intracranial mass lesions
–Carotid atherosclerosis
–Cerebral aneurysm

48. Intraocular Pressure
•Increased with
pneumoperitoneum
•Further increase with
trendelenburg
•Implaication
–May play a role in the
rarely reported
postoperative visual loss

50. ANESTHETIC MANAGEMENT

51. Choice of Anesthetic
•General Anesthesia
•Spinal anesthesia or
epidural anesthesia for
short procedures
–Sensory level T4-T6

52. Monitoring and IV Access
•Standard ASA Monitors
–BP
–ECG
–O2 Saturation
–Capnography
–Temperature
–Intraarterial pressure as
required by the patient’s
medical condition
•IV Access:
–At least one venous
catheter
–Need for additional
access: dictated by the
expected blood loss

53. Induction of Anesthesia
•Chosen based on patient
factors
–Intravenous Induction
–Inhalation Induction
–Rapid Sequence
Induction

54. Induction of Anesthesia
Close and Cover EyesDecompress stomach to minimize stomach injury

55. Choice of Airway Device
•Endotracheal Tube
–Optimal control for
ventilation
–Protect against aspiration
–Cuffed tube allow for the
use of PEEP and high peak airway pressure
required during
pneumoperitoneum
•Supraglottic Airway
Device
–Controversial
–Do not fully protect from
aspiration of stomach
contents
–Second Generation
SGAà allow use of
higher airway pressure
without leak and have esophageal vents to
minimize aspiration

56. Second Generation Supraglottic Airway
device
•LMA Proseal
•i-gel
•LMA Supreme
•Laryngeal tube suction II
•Streamlined liner of the
pharynx airawy

58. Positioning
•GOAL:
–Prevent injuries to
peripheral nerves and
bony prominences
–Pad pressure points
–Arms are often tucked at
patient’s sides

59. Positioning Devices
Nonslip Padding

60. Positioning Devices
Shoulder
Support

61. Positioning Devices
•Cross body taping
•Tape attached to
the OR table from
over the shoulder

62. Positioning Devices
Foot Support
(For Reverse
Trendelenburg)

63. MAINTENANCE OF ANESTHESIA

64. Maintenance of Anesthesia
•Various inhalation and IV anesthetics

65. Concern with Nitrous Oxide
•Controversial
•Associated with a
modestly higher
incidence of Post
operative nausea and
vomiting
•Bowel distention
–Impair surgical exposure
and dissetion

66. Neuromuscular Blockade
•Facilitate endotracheal
intubation
•Improve surgical
conditions

69. Mechanical Ventilation
•Adjust settings to
maintain ETCO2 at
approximately 40 mmHg
•Lung Protective Strategy
•Volume controlled/
pressure controlled
ventilation with volume
guarantee
•FiO2 of 0.5
•Tidal volume of 6-8
ml/kg ideal body weigh
•PEEP of 5-10 cmH20

70. How to Modify Ventilation in Different
Situations
PROBLEM
•Peak Pressures >50 mmHg
SOLUTION
•Set I:E ratio at 1:1

71. How to Modify Ventilation in Different
Situations
PROBLEM
•Hypoxia (ie SaO2 < 90
percent)
SOLUTION
•Ausculate breath sounds
bilaterally to rule out
bronchospasm and
endobronchial intubation
•Increase FiO2
•Recruitment maneuver
every 30 minutes (maintain
peak airway pressures at 30
cmH20 for 20-30 seconds if
arterial BP permit)

72. How to Modify Ventilation in Different
Situations
PROBLEM
•Persistent hypoxemia and or
peak airway pressures for
patients in trendelenburg
position
SOLUTION
•Reduce the degree of tilt
•Reduce insufflation pressure
(eg from 15 to 12 mmHg or
less)

73. How to Modify Ventilation in Different
Situations
PROBLEM
•How to increase
minute ventilation
SOLUTION
•Increase the RR rather than tidal volume
to compensate for CO2 absorption while
avoiding barotrauma
•Accept mild hypercapnia (ETCO2 of
approx. 40 mmHg if necessary) to
maintain peak airway pressures under 50
cmH20

74. How to Modify Ventilation in Different
Situations
PROBLEM
•Hypercarbia (ie ETCO2 > 50
mmHg) despite
hyperventilation
SOLUTION
•Examine for signs of
subcutaneous emphysema
•Discuss conversion to open
surgery

78. Fluid Management
•Restrictive or goal
directed fluid therapy
•Excessive fluid
administration during
robotic surgery:
–Facial, pharyngeal,
laryngeal edema

79. Nausea and Vomiting Prophylaxis
•Multimodal antiemetic
therapy
•Dexamethasone 4 to 8 mg
IV after induction
•5-HT3 antagonist (eg
ondansetron 4 mg IV at the
end of surgical procedure
•Transdermal scopolamine
1.5 mg
•Promethazine 6.25 mg IV
•Laparoscopy is a risk factor
for PONV

80. POSTOPERATIVE PAIN
MANAGEMENT

81. Origin of Pain
•Somatic
–Port site incisions
•Visceral
–From peritoneal stretch
and manipulation of
abdominal tissues

82. Degree of Pain
•Usually Low to Moderate
•Less compared with open procedures
•Depends on the specific surgery

83. Multimodal Approach to Pain
Management
•Start prior to and continuing in the OR•Acetaminophen
•NSAIDS or COX2 speficic inhibitors
•Dexamethasone
•Infiltrate incisions with local anesthetic at the time of wound closure
•Opioids
–Low to moderate intensity pain: Tramadol
–Moderate to high intensity pain: Oxycodone or hydrocodone

84. Multimodal Approach to Pain
Management
•Start prior to and
continuing in the OR
•Interfascial plane blocks
such as transversus
abdominis plane block
•Intraperitoneal
instillation of local
anesthetics

86. INTRAOPERATIVE COMPLICATIONS

87. Subcutaneous Emphysema
•occur when CO2 is
insufflated to
subcutaneous tissue
•CAUSE: improperly
placed trocar or Veress
Needle during
intraperitoneal or
extraperitoneal
insufflation

88. Risk Factors of Subcutaneous
Emphysema during Laparoscopy
•Surgery lasting > 200 minutes
•Use of 6 or more surgical ports
•Patient age > 65
•Nissen fundoplication surgery

89. Clinical Manifestations
•Hypercarbia despite hyperventilation
•Crepitus or swelling in patient’s abdomen, chest and neck

90. When subcutaneous emphysema
happens..
•Notify Surgeon
–Readjustment of ports
–Reduction of insufflation
pressure
–Conversion to open

91. Treatment for Subcutaneous
Emphysema
•Usually resolves after
abdomen is deflated
•No specific intervention
required
•Usually superficial

92. If there is crepitus in the head, neck or
upper chest
•Potential for airway
compromise
–Laryngoscopy to assess
airway edema while patient
is anesthetized
–Extubation over a tube
changer
–Delayed extubation for
several hours with the
paitent positioned Head-up
to allow resorption of CO2
–Postop Chest X ray to rule
out Capnothorax

93. Capnothorax
•Rare
•Life threatening

94. •Inadvertent peritoneal breach
•Retroperitoneal insufflation
•Misdirected veress needle or peritoneal port
•Gas tracked through fascial planes from neck and thorax into the
mediastinum and pleural space
•Dissection aroun the diaphragm (during Nissen fundoplication ,
gastric bypass)
•Passage of gas through the pleuroperitoneal hiatus (Foramen of
Bochdalek)
Passage of Gas through congenital defects (Foramen of Morgagni)
Causes of Capnothorax and
Capnomediastinum

95. Treatment of Capnothorax
•Depend on patient’s
hemodynamic and
respiratory status
•Reduction of insufflation
pressure
•Hyperventilation
•Increase in PEEP
•Placement of Chest Tube/
Intrathoracic Needle
•Convert to open surgery

96. Capnomediastinum and Capnopericarium
•Rare
•Diagnosis: Chest X Ray
•Treatment
–Deflation of
pneumoperitoneum
–Depend on degree of
hymodynamic
compromise
–supportive

97. Gas Embolism
MECHANISM
•Direct venous injection of
CO2 with the trocar or
Veress Needle at the time of
abdominal insufflation
•CO2 entrainment via a
severed vein during surgery
MANIFESTATIONS
•Unexplained hypotension
•Abrupt reduction in ETCO2
•Hypoxemia
•Arrhythmias
•ECG: Right heart strain with
widened QRS
•Parodoxical embolism
through a patent foramen
ovale and atrial septal defect

98. Treatment of Gas Embolism
•Supportive
•Deflate abdomen
•Increase ventilation to reduce the size of CO2
bubbles
•Convert to open

99. •END
•Thank you for listening

100. References
•https://www.ahajournals.org/doi/pdf/10.1161
/CIRCULATIONAHA.116.023262