Anesthesia for Laparoscopic Surgery
Blaj Mihaela
Sef lucrari UMF IASI
Spitalul Judetean De Urgente Sf Spridon Iasi
CURS DE CHIRURGIE LAPAROSCOPICA
+
➢ anterior resection of the rectum
➢ Gastrectomy
➢ radical cystectomy
The laparoscopic approach has become a
standard of care for many abdominal
surgical procedures.
Compared with laparotomy
➢ laparoscopy allows smaller incisions,
➢ reduces the postoperative stress response,
➢ reduces postoperative pain,
➢ reduced postoperative discomfort
➢ a lower incidence of postoperative wound
infections
➢ results in shorter recovery time.
Consequently,
many major procedures that once required prolonged
postoperative recovery such as anterior resection of the rectum
or radical cystectomy are now increasingly performed using
laparoscopic techniques to improve patient outcomes.
Laparoscopic surgery is not without its own
specific risks
➢the risks associated with individual
laparoscopic techniques
➢ or due to the physiological changes associated
with the creation of a pneumoperitoneum.
Anaesthetic techniques for laparoscopic surgery
must be refined to anticipate these differences
from open surgery.
Risks and benefits of laparoscopic surgery
Benefits Risks
➢ laparoscopy allows smaller
incisions
➢ Visceral and vascular damage
➢ Complications associated with
➢ Faster recovery
extremes of positioning
➢ reduces the postoperative
stress response
➢ Acute kidney injury
➢ Reduced pain
➢ Reduced wound infection ➢ Cardiocerebral vascular
➢ reduces the postoperative insufficiency
stress response
➢ Pulmonary atelectasis
➢ Venous gas embolism
➢ ‘Well leg compartment syndrome’
Laparascopic surgery is most routinely
performed with general anesthesia
- improve exposure of the abdominal organs
❑pneumoperitoneum,
❑Trendelenburg position.
- induce specific and potentially
deleterious pathophysiologic changes to
the patient.
While the goal of the surgeon is to operate safely and
efficaciously, the goal of the anesthesiologist is to help
improve surgical conditions when possible, while also
preventing (or mitigating) the side effects of these
conditions and mantaining vital organ function.
❑decompression of the gastrointestinal tract (GI),
❑establishment of adequate muscle relaxation,
both the surgeon and the
anesthesiologist –
understand the physiologic
consequences of laparascopy and to
work in cooperation to achieve a good
surgical outcome.
Patient-specific contraindications
➢ severe ischaemic heart disease, valvular disease,
➢ significant renal dysfunction,
➢ end-stage respiratory disease.
➢ pre-existing raised intracranial pressure,
➢ severe uncorrected hypovolaemia,
➢ and patients with known right-to-left cardiac shunts or
patent foramen ovale
However, the risk to the individual patient must be balanced
between the risk of complications due to the position, duration,
degree of carbon dioxide (CO2) absorption, and physiological
effects of pneumoperitoneum for a particular laparoscopic
procedure vs the shortened postoperative recovery time which
may outweigh the increased intraoperative risk.
Surgical risks
The insertion of large trocars into the abdominal cavity,
frequently without direct vision,
➢ carries the potential for damage to solid viscera,
bowel, bladder, or blood vessels.
➢ Although vascular injury within
the pneumoperitoneum is usually apparent immediately,
venous tamponade may occur with pneumoperitoneum,
masking apparent bleeding.
➢ retroperitoneal haematomas are often insidious in
nature and diagnosis may be delayed until the
postoperative period, allowing significant haemorrhage to
occur.
Venous gas embolism can result in catastrophic
circulatory collapse and may be caused by
direct trocar insertion into a vessel, or
inadvertent inflation of a solid organ, and
usually occurs as gas insufflation commences.
The severity depends on the volume of CO2
injected, rate of injection, patient position, and
type of laparoscopic procedure.
Fortunately, compared with venous air
embolism, the risks are somewhat lower due to
the increased solubility and rapid absorption of
CO2.
ESTABLISHMENT OF SURGICAL
CONDITIONS
• optimal surgical conditions for laparascopy,
• the abdominal organs must be adequately exposed and the
laparascopic ports and instruments must be inserted safely
and in proper position.
• This is achieved with a multi-part approach that includes
- decompression of the GI tract followed by establishment of
general anesthesia,
- muscle relaxation,
- pneumoperitoneum,
- Trendelenburg position
Positioning
Patient positioning is determined by the view that the
surgeon is trying to optimize, but often involves the
extremes of the Trendelenburg or reverse Trendelenburg
position with significant physiological effects.
Extreme positions place the patient at risk of movement
on the table, so meticulous attention must be paid to
ensure that the patient is securely positioned with
vulnerable pressure points and eyes being protected
throughout the procedure.
Prolonged steep Trendelenburg position +
pneumoperitoneum
➢ increases the risk of cerebral oedema,
➢ upper airway oedema which may present
with stridor after operation.
Prolonged steep Trendelenburg position
• Functional residual capacity and ventilation and perfusion (V/Q)
mismatch are worsened,
• cephalad movement of the lungs, the tracheal tube may migrate
endobronchially.
• One rare but devastating complication of prolonged surgery in
the steep Trendelenburg position is the onset of ‘well leg
compartment syndrome’ induced by the combination of impaired
arterial perfusion to raised lower limbs, compression of venous
vessels by lower limbs supports, and reduced femoral venous
drainage due to the pneumoperitoneum.
The resultant compartment syndrome of the lower limbs presents
after operation with disproportionate lower limb pain,
rhabdomyolysis, and potentially myoglobin-associated acute
renal failure leading to significantly increased morbidity and
mortality.
Risk factors include:
✓ surgery >4 h duration,
✓ muscular lower limbs,
✓ obesity,
✓ peripheral vascular disease,
✓ hypotension,
✓ steep Trendelenburg positioning.
Risks may be mitigated by :
➢ - moving the patient’s legs at regular intervals during surgery, and using
heel/ankle supports instead of calf/knee supports.
➢ - For prolonged surgery the patient is returned to the horizontal
position at least every 2 h and the lower limbs are massaged for 5–10 min
before returning to the Trendelenburg position.
➢ - A pulse oximeter is also placed on the great toe throughout surgery to
assess the adequacy of pulsatile flow to distal areas of the lower limbs.
In the reverse Trendelenburg position, the
extreme ‘head-up’ posture results in reduced
venous return, leading to hypotension and
potentially myocardial and cerebral
ischaemia.
Particularly vulnerable are
➢ the elderly,
➢ hypovolaemic patients,
➢ and those with pre-existing ischaemic heart
disease or cerebrovascular disease.
Pneumoperitoneum
Decompression of the GI tract/ , neuromuscular
blockade
• GI tract decompression starts preoperatively with a bowel preparation and
continues intraoperatively with the placement of an oro- or naso-gastric tube
immediately after induction of anesthesia.
• Both maneuvers decrease intraabdominal volume.
• The latter maneuver, in particular, decompresses the stomach of air that may
have been insufflated from mask ventilation during induction of anesthesia and is
important for reducing the risk of gastric injury from insertion of the Veress
needle.
With induction of anesthesia, neuromuscular blockade is
established to relax the abdominal wall muscles, thereby
facilitating placement of laparascopic ports and induction of
the pneumoperitoneum. Neuromuscular blockade also prevents
sudden patient movement that can lead to accidental injuries of
intra-abdominal structures by laparascopic instruments.
The pneumoperitoneum is then
achieved by insufflating the
abdomen, most commonly with
carbon dioxide (CO2).
Finally, the patient is positioned
in Trendelenburg, so that the
abdominal contents fall away
from the lower abdomen to reveal
the pelvic organs.
Pneumoperitoneum in the These maneuvers induce a
morbidly obese can lead to number of clinically relevant
pathophysiologic effects during
alteration of cardiac,
surgery. We will review these
respiratory, hepatic, and effects by organ system.
renal function
PHYSIOLOGIC EFFECTS OF
LAPAROSCOPIC SURGERY
• Hemodynamic disturbances
• The pneumoperitoneum is established by insufflating
the abdomen with pressures of 15 to 20 mm Hg.
• Normal intra-abdominal pressure (IAP) is 0 to 5
mm Hg.
• Increases in IAP above 10 mm Hg are clinically
significant, and above 20mm Hg can result in an
abdominal compartment syndrome, which affects
multiple organ systems.
Hemodynamic disturbances
• The cardiovascular manifestations can be
understood via the following simple
relationship, which expresses the determinants
of blood pressure:
Mean Arterial Pressure (MAP) =
• Cardiac Output (CO) x Systemic
Vascular Resistance (SVR)
Pneumoperitoneum increase in SVR
The mechanism compression
of the abdominal organs and vessels.
Resistance to flow through arterial beds is increased MAP is increased
due to both mechanical and neurohumoral factors
(e.g., release of catecholamines and vasopressin, and
activation of the renin-angiotensin system).
decrease in CO (10 to 30%)
due to decreased venous return (i.e., decreased cardiac preload)
compression of the inferior vena cava, from increased resistance in the
venous circulation, and from hypovolemia due to preoperative bowel preparation
increase in IAP
However, despite a decrease in intracardiac blood volume, intracardiac filling
pressures may be elevated due to pressure transmitted across the diaphragm to
the heart.
There are analagous effects in the pulmonary circulation that manifest as an
increase in pulmonary vascular resistance (PVR) and decrease in CO to the
lungs.
Effects of Pneumoperitoneum on Effects of Pneumoperitoneum on
Intraoperative Respiratory Intraoperative Hemodynamics
Mechanics and Cardiac Functio
Effects of Pneumoperitoneum on
Intraoperative Urine Output and
Postoperative Renal Functio
Perioperative management
Airway
The most common technique for airway management involves placement of a
cuffed oral tracheal tube (COTT), neuromuscular relaxation, and positive pressure
ventilation. This protects against gastric acid aspiration, allows optimal control of
CO2, and facilitates surgical access.
It is recommended that bag and mask ventilation before intubation should be
minimized to avoid gastric distension and the insertion of a nasogastric tube may be
required to deflate the stomach, not only to improve surgical view but also
to avoid gastric injury on trochar insertion.
The use of the laryngeal mask airway (LMA) in laparoscopic surgery remains
controversial due to the increased risk of aspiration and difficulties encountered
when trying to maintain effective gas transfer while delivering the higher airway
pressures required during pneumoperitoneum.
Despite these concerns, there have been several randomized controlled trials
assessing the use of Proseal LMA (PS-LMA) vs COTT with data advocating the
PS-LMA as effective and efficient for pulmonary ventilation in laparoscopic
surgery.
Ventilation
Both pneumoperitoneum and steep Trendelenburg positioning
inhibit effective ventilation during laparoscopic surgery.
Traditional 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, particularly in obese patients. The use of
pressurecontrolled modalities affords higher instantaneous flow
peaks, minimizing peak pressures, and have been shown to provide
improved alveolar recruitment and oxygenation in laparoscopic
surgery for obese patients. The addition of titrated levels of
PEEP can be used to minimize alveolar de-recruitment, but
this must be used cautiously as increasing PEEP may further
compromise cardiac output in addition to the effects of
pneumoperitoneum.
Bibliografie:
• Anaesthesia for laparoscopic surgery
• Paul Hayden, BSc MRCP FRCA DICM FFICM Sarah Cowman, FRCA
• Continuing Education in Anaesthesia Critical Care & Pain, Volume 11, Issue 5, 1 October 2011, Pages 177–
180, [Link]
14 July 2011
