anestesi laparoskopi

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Anesthesia For LaparoscopicAnesthesia For L

aparoscopic

SurgeriesSur

geries


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Introduction

Laparoscopic techniques ofer shorterin-patient stay and reducedperioperative morbidity.

risks associated with individuallaparoscopic techniques or due to thephysiological changes associated withthe creation o a pneumoperitoneum.

anesthetic techniques or laparoscopicsurgery must be re!ned to anticipatethese diferences rom open surgery.


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History

traced back to the tenth century A."

Arabian physician Abulkasim#$%& ' ()(%*used re+ected light to inspect cervi,.

he term laparoscopy/ was coined by aSwedish physician 0ans 1hristian

2acobaeus

3ichard 4ollikoer o Swit5erlandpromoted the use o 1arbon dio,ide orinsu6ating peritoneum.


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Introduction

Laparoscopy introduced in 20 th Century

1975 : frst laparoscopic salpingectomy

1970 -- 0 : used !or gyne procedures

191: "emm# !rom $ermany#1st

lapappendectomy

199: laparoscopic cholecystectomy


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%&'I(I)I*(

Laparoscopy is a minimally invasive/procedure allowing endoscopic accessto the peritoneal cavity ater

insu6ation o a gas to create spacebetween the anterior abdominal walland the viscera.

he space is necessary or sae

manipulation o instruments andorgans.


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+hat all gases can ,e used

Air, oxygen, carbon dioxide, argon andhelium

ideal gas for insuation should be

nontoxic, colourless, readily soluble inblood, easily ventilated through lungs,nonammable and inexpensive

most widely used gas for insuation-CO2


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IA7 is the steady pressure within theclosed abdominal cavity.

normal values o IA7 are )-8 mm0g.

values more than (9-(: mm0gcompromises venous return.

Initial +ow ; :-& L


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>hat are the bene!ts olaparoscopy?

shortened recovery time and reducedmorbidity.

reduced manipulation o the bowel and

peritoneum@ decreased incidence opostoperative ileus@ early enteral intakeand decreased requirements or iv+uids.


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ene!ts contBdC.

laparoscopic wounds are smaller whencompared to open techniques.

complications associated withpostoperative pain and wound healingwill be minimal.

7articularly useul in obese patients inwhom open procedures would betechnically challenging.


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Are there any risks?

"amage to solid viscera@ bowel@ bladder orblood vessels due to surgical instuments.

Dascular inEuries o large vessels.

Denous gas embolism can result incatastrophic circulatory collapse.

severity depends on the volume o 19

inEected@ rate o inEection@ patient position@and type o laparoscopic procedure.


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3isks contBdC..

7nuemoperitoneum can causeventilation-perusion mismatch.

Gwell leg compartment syndromeB.

lower limb pain@ rhabdomyolysis@ andpotentially myoglobin-associated acuterenal ailure.


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.d/antages o! Laparoscopy %ay care surgery

"horter hospital stay

Impro/ed cosmesis

Less post-op ileus 'aster reco/ery

apid return to normal acti/ities

inimal pain

"mall scar

etter preser/ation o! resp !n


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%isd/antages33

ore e4pensi/e

ore operating time %icult in complicated cases

6otential !or maor

complications in

ine4perianced hand


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Laparoscopic 6rocedures

$eneral "urgery:

Cholecystectomy

.ppendicectomy

8aricocoelectomy

Hernioplasty

%iagnostic laparoscopy

Hiatus hernia repair

.dhesiolysis


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Contd3

*$:

%iagnostic tool !or in!ertility

&ctopic pregnancy

yomectomy L.8H

&ndometriosis

)horacic "urgery:

"ympathectomy

ediastinoscopy


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.naesthesia !or lap surgeries

Anaesthetic Hoals

.ccommodate surgical reuirements and allo;!or physiological changes during surgery

onitoring de/ices a/aila,le !or the earlydetection o! complications

eco/ery !rom anaesthesia should ,e rapid ;ithminimal residual e


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.naesthetic techniues

Heneral anaesthesia

6reloading ;ith crystalloid solution is recommended

6reo4ygenation %uring induction o! .naesthesia# a/oid stomach

in>ation

tracheal intu,ation ? mandatory

6L. should only ,e used ,y e4perienced L.

users ($ tu,e placement !or "tomach decompression

Catheterisation to empty the urinary ,ladder


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1onduct o anaesthesia

)he most common techniue used !orlaparoscopic surgeries is $eneralanaesthesia

protects against gastric acid aspiration#

allo;s optimal control o! C*2# and !acilitatesgood surgical access


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7re-anaesthetic check up

6neumoperitoneum stresses cardio/ascularand respiratory system more

Lee cardiac ris@ inde4 can ,e used !or

uantifcation o! cardiac ris@

'or patients ;ith heart disease thepostoperati/e ,enefts o! laparoscopy must,e ,alanced against the intraoperati/e ris@s


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7re-anaesthetic check up

In a patient ;ith poor pulmonary reser/epreoperati/ely li@e indi/iduals ;ith C*6%more e4tensi/e preoperati/e e/aluation

including 6') is ad/isa,le 6ulmonary !unction tests A6')B identi!y

patients ;ho are li@ely to e4periencehypercar,ia and acidosis


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.naesthetic 6lan

6re-operati/e assessment

)he cardiac and pulmonary status o! all patientsshould ,e care!ully assessed

6re-medication .n4iolytics

antiemetic

H2 receptor ,loc@ers

$astro-@inetic drugs

6reempti/e analgesia ;ith (".I%s

.tropine to pre/ent /agally mediated,radyarrhythmias


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7re-medication

An,iolytics

InE. =ida5olam (-9 mg iv.

AntiemeticInE. 7rometha5ine (9.8-98 mg im.

InE. ndansetron : mg iv.

InE. 3amosetron ).%mg iv.


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7re-medication contBd..

Antacids

InE. 3anitidine 8) mg iv.

InE. 7antopra5ole :) mg iv.

7ro-kinetic drugs"= 7regnancy.

InE. =etoclopromide () mg iv.

7reemptive analgesia with

JSAI"s. Atropine to prevent vagally

mediated bradyarrhythmias.


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=onitoring(.3outine 7atient =onitoringInclude Continuous C!

"ntermittent #"$%

%ulse oximetry &'pO2(

Capnography &tCO2(

)emperature

"ntraabdominal pressure

9. ptional =onitoring Include %ulmonary airway pressure

Oesophageal stethoscope

%recordial doppler

)ransoesophageal echocardiography


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=onitoring contBdC..

&o;-/olume loops


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H.A. or laproscopic surgery

bag and mask ventilation beoreintubation should be minimi5ed to avoid

gastric distension.

insertion o a nasogastric tube may berequired to de+ate the stomach-improve surgical view@ avoid gastricinEury on trochar insertion.


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Induction

6ropo!ol : 2-25 mg@g

)hiopentone : D-E mg@g

.d/antages o! propo!ol:

1 signifcantly uic@er reco/ery

2 an earlier return o! psychomotor !unctioncompared ;ith thiopental or methohe4ital

F incidence o! nausea and /omiting is mar@edlyless than other I8 anaesthetics

D ,ecause o! its pharmaco@inetics# it is superior to,ar,iturates !or maintenance o! anaesthesia


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Induction

idaGolam : 01- 02 mg@g

idaGolam is sa!e and e


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Inhalational agents

aintaining deep le/el o! anaesthesia ;ithagents li@e Halothane# Iso>urane "e/o>urane,lunt the haemodynamic response topneumoperitoneum

(itrous o4ide causing nausea /omiting iscontro/ersial ut it may distend the ,o;el# inpatients ;ith intestinal o,struction

*nce adeuate depth o! hypnosis is achie/ed#

use o! /asoacti/e drugs such as esmolol orla,etalol may ,e more appropriate to treathypertension


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=uscle rela,ants

6re/ents high intra-a,dominal and intra-thoracic pressures due topneumoperitoneum

%ecreases 6I6# there,y minimiGing e


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H.A. or laproscopic surgerycontBdC

"uccinylcholine 1-2mg@g i/

(on depolariGing muscle rela4ants

8ecuronium 00D-005mg@g or .tracurium: 05mg@g#ocuronium: 0E-1mg@g i/

3eversal ;

In (eostigmine : 005 mg@g I8

In $lycopyrolate : 001 mg@g I8


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Intra operativecomplications

InEury rom surgical instruments.

Arrythmias

1ongestive cardiac ailure cardiacarrest.

Has embolism.

7neumothora, pneumopericardium.

Subcutaneous emphysema.

Hastric aspiration.


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se o L.=.A

remains contro/ersial

)here is increased ris@ o! aspiration

%iculties are encountered ;hen trying tomaintain e


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se o 7roseal

L=A

"e/eral randomiGed controlled trials

assessing the use o! 6roseal L. A6"-L.B /sC*))# ;ith data ad/ocating the use o! 6"-L. as e


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aintenance o! .naesthesia

intermittent positi/e pressure /entilation AI668B

(ormocar,ia AFD-FmmHgB to ,e maintained ,y

adusting the minute /olume

)he use o! nitrous o4ide during laparoscopic surgery iscontro/ersial A,o;el distension during surgery and theincrease in postoperati/e nauseaB

Halothane increases the incidence o! arrhythmia

Iso>urane se/o>urane comparati/ely ,etter

e/ersal o! ( ,loc@ade


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7ressure control Ds volumecontrol..

)he use o! pressure controlled modalitiesao; pea@s#minimiGing pea@ pressures# and ha/e ,eensho;n to pro/ide impro/ed al/eolar

recruitment and o4ygenation in laparoscopicsurgery

8olume control modalities use constant >o;to deli/er a pre-set tidal /olume and ensure

an adeuate minute /olume at the e4penseo! an increased ris@ o! ,arotrauma and highin>ation pressures


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About 7MM7C

8arious studies support that a 6&&6 o! 5 cmH2* should ,e considered essential during

laparoscopic surgeries to decrease

intraoperati/e atelectasis .ddition o! titrated le/els o! 6&&6 can ,e

used to minimiGe al/eolar de-recruitment

ut must ,e used cautiously as increasing6&&6 may !urther compromise cardiacoutput


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$eneral anaesthesia

eco/ery room-6ost-op 6eriod

1Continue monitoring

26ost-op pain relie! F6ost-op shi/ering

D*2thru as@

5easures to 6re/ent pulmonaryatelectasis

E%8) prophyla4is


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Analgesia

Jp to 0K o! patients ;ill reuire opioidanalgesia at some stage perioperati/ely


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Antiemetics

Laparoscopy is associated with highincidence o postoperative nausea andvomiting.

his may worsen pain@ and e,tend theperiod o hospital admission or

patients


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Antiemetics contBdC.

Heneral measures such as de+ating the

stomach@ avoiding known emetogenicdrugs and ensuring good qualitypostoperative analgesia decreases7JD.

=ulti-modal regime such asondansetron@ cycli5ine@ andde,amethasone seems efective.


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dan@e


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*,ecti/es

to understand the principles o!anaesthesia !or laparoscopic surgery

to increase a;areness o! the ris@s o! C*2

peritonium

,enefts o! laparoscopic surgery !rompatients point o! /ie;

special considerations in geriatrics# C*6%#heart disease# pregnancy# paediatrics ando,ese patients


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Contraindications !orLaparoscopy

%iaphragmatic hernia

.cute or recent I

"e/ere o,structi/e lung disease

Increased IC6

8 ? 6 shunt

Hypo/olemia

CC'

8al/ular heart diseases


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Laparoscopy ? .nestheticissues

C*2pneumo peritoneum

%ue to patient positioning

Cardio/ascular e


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Anaesthetic management

Anaesthetic goals;

.ll the standard ;hich are set !or in patient anestheticcare should ,e !ollo;ed )hey are:

Hemodynemic sta,ility

espiratory sta,ility

.deuate muscle rela4ation

Control o! diaphragmatic e4cursion

Intra and post operati/e analgesia

Control o! 6*(8

%eep /ein throm,osis

6rotection against hypothermia


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=onitoring duringlaparoscopic surgery

ecommendation !or routine patient monitoring:

6ulse rate

Continuous &C$

Intermittent (I6

"6*2

Capnography

)emperature I.6

6.+


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ptional monitoring include

&sophageal "tethoscope

6recordial %oppler

)rans-esophageal echocardiography .rterial ,lood gas analysis

ost importantly a /igilant anaesthetist


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echnique o anaesthesia $eneral anesthesia ;ith endotracheal intu,ations and controlled /entilation is the sa!est techniue

and there!ore is recommended !or long laparoscopic procedure

.tropine is administered at the time o! induction to pre/ent ,radycardia

)he choice o! anaesthetic techniue does not seem to play a maor role in patients outcome

.deuate a,dominal and diaphragmatic muscle rela4ation is essential

apid seuence induction ;ith su4amethonium is recommended in anti re>u4 surgery

%ue to raised I.6 and increase in the mechanical /entilation pressure is reuired to achie/eadeuate /entilation(ormocar,ia is maintained ,y increasing respiratory rate

'ollo;ing induction the patient is catheteriGed to empty urinary ,ladder and nasogastric tu,e isinserted to a/oid stomach inury

Insuation >o; rate should ,e lo;# initially 1-15 Ltrmin

Jse o! nitrous o4ideA(2*B is contro/ersial !or maintenance o! anesthesia ,ecause o! concern a,outits a,ility to produce ,o;el distension during surgery and 6*(8

Halothane in the presence o! hypercar,ia can cause arrhythmia

)he position o! &) tu,e to ,e chec@ed repeatedly ,ecause o! the li@elihood o! endo,ronchialintu,atiion


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Intraoperativecomplication;

1 )rochar may cause a,dominal /essel inury# $I) per!oration#hepatic and splenic tear and omental inury 0assen minilaparotomytechniue has ,een ad/ocated !or

pneumoperitoneum creation

2 &4traperitoneal insuation o! C*2 is a commoncomplication o! laparoscopy&) C*2# 8C*2 and 6.C*2 allincreases more than e4pected

*nce diagnosed# insuation should ,e stopped and/entilation should ,e continued to ;ash out e4tra C*2

FB 6neumothora4 pneumomediastinum andpneumopericardium :-

Causes :- )respass o! gases through em,ryonic remnants #

de!ects in diaphragm# ;ea@ points in aortic and esophagealhiatus

upture o! emphysematous ,ullae

y pleural tear caused ,y surgical tear


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It can ,e diagnosed ,y

6rogressi/e hypo4emia #increasing pa; andsu,cutaneous emphysema

*,ser/ation o! a,normal motion o!diaphragm ,y laparoscopist

y auscultation

Chest 4 ray

+ith out any associated pulmonary traumathis condition resol/e a!ter 15 to F0 minsa!ter e4suation

)h d d id li


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)he recommended guidelines are as!ollo;s

"top (2*

.dust /entilation to correct hypo4aemia

.pply 6&&6

aintain close communication ;ith surgeon

./oid thoracocentesis unless necessary

In case o! pneumothora4 !rom rupture o! pree4isting ,ullae #6&&6 must not ,e applied andtharococentesis is mandatory


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C.& '* 6&8&()I*( 6*") *6&.)I8&


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C.& '* 6&8&()I*( 6*") *6&.)I8&6*L&"

*2 administration !or couple o! hours topre/ent al/eolar hypo4ia as C*2 e4cretion

continues &nergetic care !or pre/ention o! sic@ness

must ,e ta@en as 6*(8 can eopardiGe allthe ,enefts o! laparoscopy andanesthesiologist gets total ,lame

6roper ;arming o! patient

.ttention must ,e paid !or pain relie!

'J)J& )&(%"


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'J)J& )&(%":

I(&) $."&" : Jse o! inert gases li@e helium #argoncan reduce hypercar,ia ,ut other changes due toincreased I.6 remain same "ince solu,ility o! thesegases is lo;# there is al;ays a chance o! gas

em,olism

$."L&"" L.6.*"C*6M:Here the peritoneal ca/ity ise4panded ;ith a !an retractorthis techniue a/oidshemodynamic and respiratory repercussions6ostoperati/e 6*(8 and port site metastasis arereduced)his thing is /ery appealing in se/ere cardiacand pulmonary diseases%isad/antages are poorsurgical site and increased technicaldicultyCom,ined this techniue ;ith lo; I.6AN5mmo! HgB is an interesting prospect


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"ummary

%espite multiple ad/antages#Laparoscopy is not a synonym !or ris@!ree operation )he death rate duringlaparoscopic surgery is 01 to 1 per

1000 cases .nesthesiologist must ,ea;are# a,le to detect and managethose li!e threatening complicationCapnography is one o! the mostimportant tool to tac@le thesecomplication and e/ery one should@no; ho; to interrelate &)C*2 ;ithother important fndings


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C*2 i th i ti !


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C*2 remains the insuation gas o!choice ,ecause o! ?

Its readily a/aila,ility

Lo; cost

. high ost;ald ,lood gas partion co ecientma@es it highly solu,le in ,lood "o the gasem,olism is rare

(on com,usti,le rapidly ,u


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