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Anesthesia
th i ffor
Laparoscopic Surgery
Ricky S. Harika
8/28/09
History and Benefits
¾ 1910 – Hans Christian Jacobaeus (Sweden)
performed first laparoscopic procedure on a
human
¾ Benefits
z Smaller incision
z Reduced post-
post-op pain
z Decreased
ec eased post
post--op ileus
eus
z Earlier ambulation and shorter hospital stay
Insufflation with Carbon Dioxide
¾ Insufflation of the abdominal cavityy with CO2 via
a small infra/supra-umbilical trocar
z 12-15mm Hg, tolerable in healthy patients
reduce
d risk
i k off ttrauma with
ith ttrocar iinsertion
ti
z CO2 is readily absorbed, non-combustible and
non-toxic
Why Not Nitrous Oxide?
¾ Concerns due to its ability to diffuse into the bowel
l di tto di
leading distention
t ti and d expand d iin closed
l d spaces, which
hi h
may interfere with surgical field
z Nitrous oxide can leave blood and enter air filled cavity 34x more
rapidly then nitrogen can leave the cavity to enter blood
¾ Combustible
¾ Egar & Saidman (1965) – noted an increase of >200% in
the intestinal lumen after 4 hours of breathing nitrous
oxide
¾ Taylor, et. al (1992) – no difference in surgical conditions
during lap chole lasting 80-
80-90 minutes with/without NO2.
Bowel distention did not increase with time.
¾ Tramer, et. al (1996) - emetic effect of NO2 is not
significant
Hemodynamic Effects
¾ D
Depends
d on th
the iinteraction
t ti of:
f
z patient’s pre
pre--existing cardiopulmonary status
z anesthetic
th ti technique
t h i
z intra--abdominal pressure
intra
z carbon
b dioxide
di id absorption
b ti
z patient position
z duration of surgery
surgery.
Cardiovascular
¾ ↑ in MAP, SVR and variable/↓ CO
z ↑ SVR secondary
d tto PaCO2
P CO2 iincrease d
due tto carbon
b didioxide
id
absorption from the peritoneal cavity.
• Hypercarbia Æ initial reduction of HR (~28% @ 15mm Hg)
and contractilityy ÆSympathetic/catecholamine
y p
release/vasopressin Æ mild increase in HR and BP
• ↓ CO due to ↓ pre-load (VC compression), ↓ LV-EDV and ↑
afterload
z Prevent by giving adequate fluids to keep CO increased
d tto pneumoperitoneum
due it and
d patient
ti t positions
iti
z Controlled ventilation necessary to prevent
hypercarbia
z Muscle paralysis to avoid further increase in intra-
intra-
thoracic pressure
z Large
Large--bore peripheral IV – especially if arms are to be
tucked during case
z Orogastric tube to aspirate gas from stomach before
trocars placed
Post--Op Care
Post
¾ Pain control – opiods, NSAIDs
¾ Unrecognized intra-
intra-abdominal visceral and/or
vascular injury
j y
z Progressive hypotension, increased abdominal size,
decreased Hct
¾ Increased N/V
z Zofran, Reglan, Decadron, Scopolamine patch
¾ PE due to venous stasis
z Risk of 0.016% vs. open surgery 0.8%
Works Cited
¾ Dunn, P. (2007). Clinical anesthesia procedures of the
Massachusetts
M h it l. Philadelphia:
tt generall hospital.
hospital
h Phil d l hi LiLippincott
i tt
Williams & Wilkins.
¾ Egar, E., Saidman, I. (1965). Hazards of nitrous oxide
anesthesia
th i iin b
bowell obstruction
b t ti and d pneumothorax.
th
Anesthesiology,, 26, 61-
Anesthesiology 61-66.
¾ Joshi, G. (2002) Anesthesia for laparoscopic surgery.
Anesthesia,, 49,
Canadian Journal of Anesthesia 49 45
45--49
¾ Kaba, A. & Joris, J. (2001) Anesthesia for laparoscopic
surgery. Current Anesthesia and Critical Care,
Care, 12(3),
159--165.
159 165 Retrieved August 22 22, 2009 from
http://www.currentanaesthesia.com/article/S0953--
http://www.currentanaesthesia.com/article/S0953
7112%2800%2990309--0/abstract.
7112%2800%2990309
¾ Mullet, C., Viale J., Sagnard, P., et al. (1993). Pulmonary
CO2 elimination
li i ti d during
i surgical
i l procedures
d using
i iintra-
intra
t -
or extraperitoneal CO2 insufflation. Anesthesia &
Analgesia, 76, 622
622--6.
¾ St lti
Stoelting, R
R., & Mill
Miller, R
R. (2007)
(2007). Basics th i .
B i off anesthesia.
anesthesia
Philadelphia: Churchill Livingstone
¾ Taylor, E., Feinstein, R., White, P., & Soper, N. (1992).
Anesthesia for laparoscopic cholecystectomy: is nitrous
oxide contraindicated? Anesthesiology
Anesthesiology,, 76, 541-
541-3
¾ Tramer, M., Moore, A., & McQuay, H. (1996). Omitting
nitrous oxide in general anesthesia: meta
meta--analysis of
interoperative awareness and postoperative emesis in
randomized controlled trials. British Journal of
Anesthesiology, 76, 186-
186-93.