Anesthesia and

Laparoscopic Surgery

Waldemar P. Siahaan, MDAnesthesia Department

MAMC

• Advantages compared to open surgery• Relationship with pulmonary function• Relationship with patient position• Relationship with heart function• Advantages and Disadvantages of several type

of Anesthesia• Special Monitoring in Laparoscopic surgery• Complications

OBJECTIVES

• Much smaller incission.• Decreased Post-op pain.• Shorter hospital stay• Earlier ambulation• Smaller surgical scars• Medical and economic advantages.

What are the advantages of laparoscopic cholecystectomy compared

with open cholecystectomy?

• Hallmark = creation of a pneumoperitoneum with

pressurized CO2

How does laparoscopic surgery affect intraoperative pulmonary function?

How does laparoscopic surgery affect intraoperative pulmonary function?

Pressurized CO2

Increase Intra Abdominal Pressure (IAP)

Displaced diaphragm cephalad

Decrease in lung compliance

Laparoscopy

Pneumoperitoneum

High solubility of CO2

Increase systemic absorption by the vasculatur of peritoneum

Increase arterial CO2 levels

Decrease pH

Smaller Tidal

Volume

Hypoxemia

Increase in peak inspiratory Pressure

Why does patient position affect oxygenation?

Tredelenburg

Cephalad shift in abdominal viscera

and diaphragm.

Decreased FRC, Decreased Total Lung Volume, Decreased Pulmonary Compliance

TOLERATEDPresumed preexisting lung disease

Obesity

ASA III, IV

Hypoxemia

Shift trachea upward

+

insufflation of the abdomen

Migration of ET Tube to Right Main-stem bronchus

Moderate Insufflation Pressures

Blood tends to be forced out of the abdomen and into the chest

Increased effective cardiac filling

Collapse the major abdominal veins (IVC)

Does laparoscopic surgery affect cardiac function?

Higher insufflation Pressures (>25cm H2O, or 18mmHg)

Decreased Venous Return

Drop of Cardiac Output Slightly elevated (or normal) Heart Rate, Central venous pressure, and cardiac

output.

Insufflation presure of 15mmHg will decrease cardiac output 28% Insufflation presure of 7mmHg will be maintained

Recommended pressure = 12mmHg

HYPERCARBIA

Sympathetic Nervous system stimulation

Increase BP, Increase HR, Risk of dysrhytmias

Ex:Increasing the tidal volume or Respiratory Rate

Does laparoscopic surgery affect cardiac function?

Compensate attemption

Increase Mean Intrathoracic pressure

Hindering venous return

Increase the mean Pulmonary artery pressure.

• Local Anesthesia:– gynecologic procedures in young healthy and

motivated patients– Laparoscopic tubal sterilization– Intrafallopian transfers.

• Continuous Epidural or Spinal Anesthesia– High level is required

• Complete Muscle relaxant• Prevent diaphragmatic irritation

– Shoulder pain (referred pain) from diaphragmatic irritation

Describe the advantages and disadvantages of Alternative anesthetic

techniques.

• ET tube:– Decrease the risk of regurgitation from increased

intra abdomial pressure– Controlled ventilation to prevent hypercapnia– The need for muscle paralysis during surgery to

allow lower insufflation pressures– Provide better visualization

GENERAL ANESTHESIA

Describe the advantages and disadvantages of Alternative anesthetic

techniques.

reverse Trendelenburg, High Inflation Pressures, and CO2 embolism

What special monitoring should be considered?

Reduction in lung perfusion

Increase Alveolar dead space

Dilute expired CO2

Lessens ETCO2 measurement

Decrease Cardiac Output

Monitoring end tidal CO2= provides adequate guide for determining the minute ventilation required to maintain normocarbia

Perforated Viscus

What are some possible complications of laparoscopic surgery?

Trocar Introduction

Lacerated Major Abdominal Vessels

HEMORRHAGE-Inadvertent intravenous placement of veress needle

-Open vessels on the liver surface during GB dissection

Passage of CO2 into abdominal wall and peritoneal vessels, open vessels

VENOUS CO2 EMBOLISM

-Hypoxemia

-Pulmonary Hypertension

-Pulmonary Edema

-Cardiovascular collapse

What are some possible complications of laparoscopic surgery?

Insufflation of Gas into an open vein

TREATMENT!!!

-Immediate release of the pneumoperitoneum

-Insertion of a central venous catheter

-Placement of patient. Head down and LLDP

Vagal Stimulation

What are some possible complications of laparoscopic surgery?

-Trocar Insertion

-Peritoneal insufflation

-Manipulation of Viscera

Bradychardia/Arrhythmias

Sinus Arrest

Nausea and Vomiting

Emptying of the stomach with NGT

Metoclopromide / Plasil

Postoperative Considerations

Venous stasis

-Increased IAP during penumoperitoneum

Deep vein thrombosis

Pulmonary embolismNausea and Vomiting

Emptying of the stomach with NGT

Metoclopromide / Plasil