Anesthesia For Laparoscopic

Surgeries

Introduction
Laparoscopic techniques offer shorter
in-patient stay and reduced
perioperative morbidity.
risks associated with individual
laparoscopic techniques or due to the
physiological changes associated with
the creation of a pneumoperitoneum.
anesthetic techniques for laparoscopic
surgery must be refined to anticipate
these differences from open surgery.

History
traced back to the tenth century A.D
Arabian physician Abulkasim(936 1013)
used reflected light to inspect cervix.
The term laparoscopy was coined by a
Swedish physician Hans Christian
Jacobaeus
Richard Zollikofer of Switzerland
promoted the use of Carbon dioxide for
insufflating peritoneum.

Introduction

Laparoscopy introduced in 20 th Century

1975 : first laparoscopic salpingectomy

1970 -- 80 : used for gyne procedures

1981: Semm, from Germany,1st lap

appendectomy

1989: laparoscopic cholecystectomy

DEFINITION
Laparoscopy is a minimally invasive
procedure allowing endoscopic access
to the peritoneal cavity after
insufflation of a gas to create space
between the anterior abdominal wall
and the viscera.
The space is necessary for safe
manipulation of instruments and
organs.

What all gases can be used?

Air, oxygen, carbon dioxide, argon and
helium
ideal gas for insufflation should be
nontoxic, colourless, readily soluble in
blood, easily ventilated through lungs,
nonflammable and inexpensive
most widely used gas for insufflationCO2

Intra-abdominal
pressure(IAP)
IAP is the steady pressure within the
closed abdominal cavity.
normal values of IAP are 0-5 mmHg.
values more than 12-14 mmHg
compromises venous return.
Initial flow : 4-6 L/min.
Maintenance : 200-400 ml/min.

What are the benefits of

laparoscopy?
shortened recovery time and reduced
morbidity.
reduced manipulation of the bowel and
peritoneum, decreased incidence of
postoperative ileus, early enteral intake
and decreased requirements for iv
fluids.

Benefits contd.
laparoscopic wounds are smaller when
compared to open techniques.
complications associated with
postoperative pain and wound healing
will be minimal.
Particularly useful in obese patients in
whom open procedures would be
technically challenging.

Are there any risks?

Damage to solid viscera, bowel, bladder or
blood vessels due to surgical instuments.
Vascular injuries of large vessels.
Venous gas embolism can result in
catastrophic circulatory collapse.
severity depends on the volume of CO2
injected, rate of injection, patient position,
and type of laparoscopic procedure.

Risks contd..
Pnuemoperitoneum can cause
ventilation-perfusion mismatch.

well leg compartment syndrome.

lower limb pain, rhabdomyolysis, and

potentially myoglobin-associated acute
renal failure.

Advantages of Laparoscopy

Day care surgery

Shorter hospital stay

Improved cosmesis

Less post-op ileus

Faster recovery

Rapid return to normal activities

Minimal pain

Small scar

Better preservation of resp fn

Disdvantages
More expensive
More operating time
Difficult in complicated cases
Potential for major
complications in
inexperianced hand

Laparoscopic Procedures

General Surgery:

Cholecystectomy

Appendicectomy

Varicocoelectomy

Hernioplasty

Diagnostic laparoscopy

Hiatus hernia repair

Adhesiolysis

Contd..
OBG:
Diagnostic tool for infertility
Ectopic pregnancy
Myomectomy
LAVH
Endometriosis

Thoracic Surgery:
Sympathectomy

Mediastinoscopy

Anaesthesia for lap surgeries

Anaesthetic Goals

Accommodate surgical requirements and allow

for physiological changes during surgery.

Monitoring devices available for the early

detection of complications.

Recovery from anaesthesia should be rapid with

minimal residual effects.

The possibility of the procedures being converted

to open laparotomy to be considered

Anaesthetic techniques

General anaesthesia

Preloading with crystalloid solution is recommended

Preoxygenation

During induction of Anaesthesia, avoid stomach

inflation

tracheal intubation mandatory

PLMA should only be used by experienced LMA

users

NG tube placement for Stomach decompression

Catheterisation to empty the urinary bladder

Conduct of anaesthesia
The most common technique used for
laparoscopic surgeries is General
anaesthesia.
protects against gastric acid aspiration,
allows optimal control of CO2, and facilitates
good surgical access.

Pre-anaesthetic check up
Pneumoperitoneum stresses cardiovascular
and respiratory system more.
Lee cardiac risk index can be used for
quantification of cardiac risk.
For patients with heart disease the
postoperative benefits of laparoscopy must
be balanced against the intraoperative risks.

Pre-anaesthetic check up
In a patient with poor pulmonary reserve
preoperatively like individuals with COPD
more extensive preoperative evaluation
including PFT is advisable.
Pulmonary function tests (PFT) identify
patients who are likely to experience
hypercarbia and acidosis.

Anaesthetic Plan

Pre-operative assessment

The cardiac and pulmonary status of all patients

should be carefully assessed

Pre-medication

Anxiolytics

antiemetic

H2 receptor blockers

Gastro-kinetic drugs

Preemptive analgesia with NSAIDs

Atropine to prevent vagally mediated

bradyarrhythmias

Pre-medication

Anxiolytics

Inj. Midazolam 1-2 mg iv.

Antiemetic

Inj. Promethazine 12.5-25 mg im.

Inj. Ondansetron 4 mg iv.
Inj. Ramosetron 0.3mg iv.

Pre-medication contd..

Antacids

Inj. Ranitidine 50 mg iv.

Inj. Pantoprazole 40 mg iv.

Pro-kinetic drugs

DM & Pregnancy.
Inj. Metoclopromide 10 mg iv.

Preemptive analgesia with

NSAIDs.
Atropine to prevent vagally
mediated bradyarrhythmias.

Monitoring
1.Routine Patient Monitoring
Include

Continuous ECG

Intermittent NIBP

Pulse oximetry (SpO2)

Capnography (EtCO2)

Temperature

Intraabdominal pressure

2. Optional Monitoring Include

Pulmonary airway pressure

Oesophageal stethoscope

Precordial doppler

Transoesophageal echocardiography

Monitoring contd..
Effects of pneumoperitoneum on the
respiratory system can be assessed using by
information available on work stations such
as peak and plateau airway pressures,
delivered tidal volumes, and observing
dynamic flow-volume loops.

G.A. for laproscopic surgery

bag and mask ventilation before
intubation should be minimized to avoid
gastric distension.
insertion of a nasogastric tube may be
required to deflate the stomachimprove surgical view, avoid gastric
injury on trochar insertion.

Induction
Propofol : 2-2.5 mg/kg.
Thiopentone : 4-6 mg/kg.
Advantages of propofol:
1. significantly quicker recovery
2. an earlier return of psychomotor function
compared with thiopental or methohexital.
3. incidence of nausea and vomiting is markedly
less than other IV anaesthetics.
4. because of its pharmacokinetics, it is superior to
barbiturates for maintenance of anaesthesia

Induction
Midazolam : 0.1- 0.2 mg/kg.

Midazolam is safe and effective for induction even in

patients with severe aortic stenosis.
Etomidate : 0.3-0.45 mg/kg.

Good choice in cardiac patients as there is no

change in HR, MAP, PCWP, CVP, SV, CI, PVR & SVR.

Inhalational agents
Maintaining deep level of anaesthesia with
agents like Halothane, Isoflurane & Sevoflurane
blunt the haemodynamic response to
pneumoperitoneum.
Nitrous oxide causing nausea & vomiting is
controversial. But it may distend the bowel, in
patients with intestinal obstruction.
Once adequate depth of hypnosis is achieved,
use of vasoactive drugs such as esmolol or
labetalol may be more appropriate to treat
hypertension.

Muscle relaxants
Prevents high intra-abdominal and intrathoracic pressures due to
pneumoperitoneum.
Decreases PIP, thereby minimizing effects on
haemodynamics, risk of pneumothorax and
respiratory dead space.
Muscle paralysis reduces the IAP needed for
the same degree of abdominal distention.

G.A. for laproscopic surgery

contd
Succinylcholine 1-2mg/kg iv.
Non depolarizing muscle relaxants
Vecuronium 0.04-0.05mg/kg or Atracurium: 0.5mg/kg,
Rocuronium: 0.6-1mg/kg iv.

Reversal :
Inj. Neostigmine : 0.05 mg/kg IV
Inj. Glycopyrolate : 0.01 mg/kg IV

Intra operative
complications
Injury from surgical instruments.
Arrythmias
Congestive cardiac failure & cardiac
arrest.
Gas embolism.
Pneumothorax & pneumopericardium.
Subcutaneous emphysema.
Gastric aspiration.

Use of L.M.A
remains controversial.
There is increased risk of aspiration.
Difficulties are encountered when trying to
maintain effective gas transfer while
delivering higher airway pressures required
during pneumoperitoneum.

Use of Proseal
LMA
Several randomized controlled trials
assessing the use of Proseal LMA (PS-LMA) vs
COTT, with data advocating the use of PSLMA as effective and efficient for pulmonary
ventilation in laparoscopic surgery has been
published.

Maintenance of Anaesthesia
intermittent positive pressure ventilation (IPPV).
Normocarbia (34-38mmHg) to be maintained by
adjusting the minute volume
The use of nitrous oxide during laparoscopic surgery is
controversial (bowel distension during surgery and the
increase in postoperative nausea) .
Halothane increases the incidence of arrhythmia
Isoflurane / sevoflurane comparatively better

Reversal of NM blockade

Pressure control Vs volume

control..
The use of pressure controlled modalities
affords higher instantaneous flow peaks,
minimizing peak pressures, and have been
shown to provide improved alveolar
recruitment and oxygenation in laparoscopic
surgery.
Volume control modalities use constant flow
to deliver a pre-set tidal volume and ensure
an adequate minute volume at the expense
of an increased risk of barotrauma and high
inflation pressures.

About PEEP
Various studies support that a PEEP of 5 cm
H2O should be considered essential during
laparoscopic surgeries to decrease
intraoperative atelectasis.
Addition of titrated levels of PEEP can be
used to minimize alveolar de-recruitment.
But must be used cautiously as increasing
PEEP may further compromise cardiac
output.

General anaesthesia
Recovery room -Post-op Period
1.Continue monitoring
2.Post-op pain relief
3.Post-op shivering
4.O2 thru Mask
5.Measures to Prevent pulmonary
atelectasis
6.DVT prophylaxis

Analgesia
Up to 80% of patients will require opioid
analgesia at some stage perioperatively.

Antiemetics
Laparoscopy is associated with high
incidence of postoperative nausea and
vomiting.

This may worsen pain, and extend the

period of hospital admission for
patients.

Antiemetics contd.
General measures such as deflating the
stomach, avoiding known emetogenic
drugs and ensuring good quality
postoperative analgesia decreases
PONV.
Multi-modal regime such as
ondansetron, cyclizine, and
dexamethasone seems effective.

danke

Objectives
to understand the principles of
anaesthesia for laparoscopic surgery
to increase awareness of the risks of CO2
peritonium
benefits of laparoscopic surgery from
patients point of view
special considerations in geriatrics, COPD,
heart disease, pregnancy, paediatrics and
obese patients

Contraindications for
Laparoscopy

Diaphragmatic hernia

Acute or recent MI

Severe obstructive lung disease

Increased ICP

V P shunt

Hypovolemia

CCF

Valvular heart diseases

Laparoscopy Anesthetic
issues
CO2 pneumo peritoneum
Due to patient positioning
Cardiovascular effects
Respiratory effects
Gastro intestinal effects
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR

Anaesthetic management

Anaesthetic goals:

All the standard which are set for in patient anesthetic

care should be followed. They are:

Hemodynemic stability

Respiratory stability

Adequate muscle relaxation

Control of diaphragmatic excursion

Intra and post operative analgesia

Control of PONV

Deep vein thrombosis

Protection against hypothermia

Monitoring during
laparoscopic surgery
Recommendation for routine patient monitoring:
Pulse rate
Continuous ECG
Intermittent NIBP
SPO2
Capnography
Temperature
IAP
PAW

Optional monitoring include

Esophageal Stethoscope
Precordial Doppler
Trans-esophageal echocardiography
Arterial blood gas analysis
Most importantly a vigilant anaesthetist

Technique of anaesthesia

General anesthesia with endotracheal intubations and controlled ventilation is the safest technique
and therefore is recommended for long laparoscopic procedure

Atropine is administered at the time of induction to prevent bradycardia .

The choice of anaesthetic technique does not seem to play a major role in patients outcome.

Adequate abdominal and diaphragmatic muscle relaxation is essential

Rapid sequence induction with suxamethonium is recommended in anti reflux surgery

Due to raised IAP and increase in the mechanical ventilation pressure is required to achieve
adequate ventilation.Normocarbia is maintained by increasing respiratory rate.

Following induction the patient is catheterized to empty urinary bladder and nasogastric tube is
inserted to avoid stomach injury.

Insufflation flow rate should be low, initially 1-1.5 Ltr/min.

Use of nitrous oxide(N2O) is controversial for maintenance of anesthesia because of concern about
its ability to produce bowel distension during surgery and PONV.

Halothane in the presence of hypercarbia can cause arrhythmia.

The position of ET tube to be checked repeatedly because of the likelihood of endobronchial

intubatiion.

Intraoperative
complication:

1. Trochar may cause abdominal vessel injury, GIT perforation,

hepatic and splenic tear and omental injury.

Hassen minilaparotomy technique has been advocated for

pneumoperitoneum creation .

2. Extraperitoneal insufflation of CO2 is a common

complication of laparoscopy.ET CO2, VCO2 and PACO2 all
increases more than expected.

Once diagnosed, insufflation should be stopped and

ventilation should be continued to wash out extra CO2.

3) Pneumothorax pneumomediastinum and

pneumopericardium :-

Causes :- Trespass of gases through embryonic remnants ,

defects in diaphragm, weak points in aortic and esophageal
hiatus.

Rupture of emphysematous bullae .

By pleural tear caused by surgical tear.

It can be diagnosed by

Progressive hypoxemia ,increasing paw and

subcutaneous emphysema.

Observation of abnormal motion of

diaphragm by laparoscopist

By auscultation

Chest x ray

With out any associated pulmonary trauma

this condition resolve after 15 to 30 mins
after exsufflation.

The recommended guidelines are as

follows

Stop N2O
Adjust ventilation to correct hypoxaemia
Apply PEEP
Maintain close communication with surgeon
Avoid thoracocentesis unless necessary
In case of pneumothorax from rupture of pre
existing bullae ,PEEP must not be applied and
tharococentesis is mandatory

CARE FOR PREVENTION POST OPERATIVE

PROBLEMS

O2 administration for couple of hours to

prevent alveolar hypoxia as CO2 excretion
continues
Energetic care for prevention of sickness
must be taken as PONV can jeopardize all
the benefits of laparoscopy and
anesthesiologist gets total blame .
Proper warming of patient.
Attention must be paid for pain relief.

FUTURE TRENDS:
.

INERT GASES : Use of inert gases like helium ,argon

can reduce hypercarbia but other changes due to
increased IAP remain same .Since solubility of these
gases is low, there is always a chance of gas
embolism.

GASLESS LAPAROSCOPY:Here the peritoneal cavity is

expanded with a fan retractor.this technique avoids
hemodynamic and respiratory repercussions.Post
operative PONV and port site metastasis are
reduced.This thing is very appealing in severe cardiac
and pulmonary diseases.Disadvantages are poor
surgical site and increased technical
difficulty.Combined this technique with low IAP(<5mm
of Hg) is an interesting prospect .

Summary
Despite multiple advantages,
Laparoscopy is not a synonym for risk
free operation. The death rate during
laparoscopic surgery is 0.1 to 1 per
1000 cases. Anesthesiologist must be
aware, able to detect and manage
those life threatening complication.
.Capnography is one of the most
important tool to tackle these
complication and every one should
know how to interrelate ETCO2 with
other important findings

CO2 remains the insufflation gas of

choice because of

Its readily availability

Low cost
A high ostwald blood / gas partion co efficient
makes it highly soluble in blood. So the gas
embolism is rare.
Non combustible.
rapidly buffered in the blood by bicarbonates
and excreted via lungs