????? ???????? Chapter 32 Anesthesia for laparoscopic Surgery ?????????

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Chapter 32 Anesthesia for
laparoscopic Surgery ?????????
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• The field of abdominal surgery has been radically
  changed with the introduction of laparoscopy.

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• Recent advance in robotic and video technology
  have made the use of laparoscopic procedures more
  widely applicable.
• With the evolution of laparoscopy,a substantial
  number of abdominal procedures are being
  performed using this approach, including
  cholecystectomy, myomectomy, and so on.

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• Compared with the traditional open abdominal
  approach.the laparoscopic approach is
• less postoperative pain.
• shorter hospital stay.
• fewer overall adverse event.
• more rapid return to normal activity
• significant cost savings.

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• However, it is important that the benefits of
  laparoscopic procedures be weighed against
  associated complications.
• A thorough knowledge of potential perioperative
  complications is necessary to provide optimal
  patient care

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Part I Physiological changes
during laparoscopic surgery

• The first step in laparoscopy is establishment of
  pneumoperitoneum.
• The ideal insufflating gas would be colorless,
  nonexplosive, Physiologically inert
• and readily soluble
• in plasma.

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Part I Physiological changes
during laparoscopic surgery

• CO2 is used extensively in clinic. The speed and
  pressure of the pneumoperitioneum effect the
  absorption of CO2.
• Positioning changes will effect the physiological
  function.

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I. Cardiovascular system

• The pressure of pneumopertioneum effect
  three aspects .
• systemic vascular resistance (SVR.
  Afterloail).
• venous return (preload ).
• cardiac function.

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I. Cardiovascular system

• During laparoscopic cholecystectomy
• If intraabdominal pressure (IAP) gt10mmHg
• CVP ?PAWP? SVR? CO and MAP?
• If intraabdominal pressure (IAP) gt20mmHg
• CVP ? SVR?? CI CO? MAP??or normal

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I. Cardiovascular system

• The cause
• Intraabdominal positive pressure
  intrathoracic pressure cardiac blood flow
  CO
• IPPV or PEEP intrathoracic pressure
  CO

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I. Cardiovascular system

• The arrhythmias during laparoscopy is
  approximately 14, Bradyarrhythemias including
  bradycardia, nodal rhythm are attributed to a
  vagal response due to rapid insufflations.

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2.The patients were placed in different body
position (Table1)

• During cholecystectomy , the patient is placed on
  head-up about 10-20.

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2.The patients were placed in different body
position (Table1)

• During gynecological surgery, the patient is
  placed on head-down position.

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Table-1 Hemodynamic measurements before and
during pneumoperitoneum(PP)during
laparoscopic cholecystectomy in
healthy patients
Supine Head-down Head-up Supine with pp Head-down with pp Head-up With pp
Heart rate(beats/min) 617 53 4 66 9 66 16 53 3 70 8
MAP(mmHg) 69 7 76 6 64 9 91 11 87 8 84 13
CVP(mmHg) 6.2 2.9 10.2 3.5 0.8 3.5 10.9 2.7 15.9 4.6 3.1 2.6
MPAP(mmHg) 14.1 1.5 17.4 1.2 8.5 3.5 18.4 3.7 20.0 6.1 10.8 2.5
SVR(dynes/sec/cm5) 1310 302 1381 313 1419 342 1795 444 1577 344 2047 430
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3. Carbon dioxide absorption

• The absorption of CO2 is influenced
  significantly by
• duration of interoperation insufflations
• IAP and the solubility of CO2 .

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3. Carbon dioxide absorption

• Hypercarbia resulting from
• CO2 insufflations has direct and
• indirect homodynamic effects.

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3. Carbon dioxide absorption

• The direct effects include peripheral
  vasodilatation and depression of myocardial
  contractility.
• The indirect effects include activation of the
  central nervous system and sympathizes system,
  which increase myocardial contractility and
  causes tachycardia and hypertension

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II. Pulmonary function

• Changes in pulmonary function with
• pneumoperitoneum
• positioning
• anesthesia
• Elevation of diaphragm may be associated
  with reduction in lung
• volumes.

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II. Pulmonary function

• In patients undergoing laparoscopic
• procedure with 15 degree head-down tilt, the
  total pulmonary compliance
• decreased by 40.
• with 20 degree head-up tilt, the total
  pulmonary compliance decreased by 20.

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II. Pulmonary function

• Increased IAP and upward
• displacement of the diaphragm can cause
  alveolar collapse and
• ventilation/perfusion mismatching,
• resulting in hypoxemia and
• hypercarbia.

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III. The other physiological changes

• Increased IAP can result in reduction in
  splanchenic and renal perfusion.
• Hepatic blood flow is decreased .

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III. The other physiological changes

• Reduction in urine output.
• the compression of renal vessel
• increased plasma renin activity .
• Increased IAP can result in
• aspiration and regurgitation.

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Part II Anesthesia for
laparoscopic surgery
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?. Preoperative evaluation and preparation for
anesthesia.

• 1. Evaluation
• Elderly, obesity, hypertension, coronary
  artery disease.
• Serious hypertension , cardiac dysfunction
  , COPD .
• The open surgery (open cholecystectomy)
  duo to medical problem (serious hypercarbia).

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?. Preoperative evaluation and
preparation for anesthesia.

• 2. Preparation and premedication
• Same as general surgery.
• Meperidine and opioid is thought to cause
  sphincter of oddi spasm.
• Atropine may help decease spasm.
• H2 antagonist (ranitidine) may be given
  (the patient being at risk for gastric
  aspiration).
• To open upper extremity vein.

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?.The choice of anesthesia

• 1.The principle of choice
• The principle is rapidly, shorter, safety
  comfortable and return to a normal activity
  early.
• General anesthesia is may be more
• suitable than other anesthesia.

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?.The choice of anesthesia

• 2.Method of anenthesia
• A. General anesthesia
• Advantage
• ? Proper depths of anesthesia.
• ? Effective ventilation.
• ? To control the relax of muscle.
• ? Adjusting MVV.

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?.The choice of anesthesia

• Anesthetic Management
• The endotracheal intubation is suggested.
• An oral gastric tube should be inserted to
  ensure that gastric distension does not exist.

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?.The choice of anesthesia

• Anesthetic agents.
• Propofol, Etomidate, Midazolam.
• Fentanyl, Remifentanyl,
• Succinyicholine Vecuronium Atracurium.
• Isoflurane, desflurane.
• The use of N2O is controversial.
• It increases bowel distention, and
  produce
• conflicting results on the rate of N2O on
• postoperative nausea.

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?.The choice of anesthesia

• B.Epidural anesthesia?
• A high level is required for complete
  muscle relaxation?
• 70prevent diaphragmatic irritation caused
  by gas insufflation and surgical manipulations.

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?.The choice of anesthesia

• B.Epidural anesthesia?
• Serious respiratorg depression is possible
• a high regional block
• the use of opioid
• the diaphragm is rised during
  insufflation.
• The occasional occurrence of referred shoulder
  pain

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?.The choice of anesthesia

• C. General Aesthesia and Epidural
• anesthesia.
• D. Regional anesthesia.

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?.Perioprative monitoring

• Cardiovascular function
• Respiratory function
• Urinary volume
• Neuromuscular transmission

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?.Special considerations in the anesthesia

• Control of intra-abdominal pressure
• laparoscopic cholecystetomy, IAP10-15mmHg
• Prevention of aspiration of gastric contents.
• Gynecologic laparoscopy,IAP20- 40mmHg
• obesity,abdominal wall lift is used

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?.Special considerations in the anesthesia

• Position
• Laparoscopic cholecystetomy ,supine is
  placed,reverse trendelenburg with right side
  elevates.
• Gynecologic laparoscopy, head-down and
  feet-up.

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?.Special considerations in the anesthesia

• Enhance respiratory management during
  operation
• The use of neuromuscular blockers and
  complete muscle relaxation are required

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?.Special considerations in the anesthesia

• If it is not possible to complete the
  laparoscopic procedure, for example a major
  abdominal vessel lacerated ,peritonitis and
  hemorrhage, a open surgery will be performed.

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?.Special considerations in the anesthesia

• Epidural anesthesia represent alternative for
  laparoscopic surgery. But a high level is
  required. A disadvantage is the occurrence of
  referred shoulder pain.

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?.Special considerations in the anesthesia

• After operation, the residual pheumoperitoneum
  should be discharged.
• Prevention of the regurgitation of gastric
  contents

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PART ?.COMPLICATION

• 1.Cardiovescular system
• hypertention
• bradycardia
• tachycardia

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PART ?.COMPLICATION

• 2. Hypoxemia, Hypercarbia and Acidosis
• High LAP
• Head-down position
• morbid obesity
• COPD (chronic obstructive
• pulmonary disease)
• mechanical ventilation

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PART ?.COMPLICATION

• 3.CO2 embolism
• The most common cause of clinically apparent
  co2 embolism is inadvertent intravascular
  placement of the needle
• An open vein has a lower pressure than the
  surrounding pressure

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PART ?.COMPLICATION

• 4.Regurgitation and aspiration
• High LAP
• Change of position
• Epidural and spinal aneasthesia

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PART ?.COMPLICATION

• 5.Nausea and vomiting
• They are common following laparoscopic
  procedures.
• Pharmacologic prophylaxis is recommended,
  for example Renitidine, Droperidol,ondansetron.

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