Anaesthesia for Laparoscopy

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Anaesthesia for Laparoscopy

• David Green MB FRCA MBA
• Consultant Anaesthetist
• Kings College Hospital

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Aims

• to underline the principles of anaesthesia for
  laparoscopic surgery
• to point out the dangers of peritoneal
  insufflation of CO2 and look at alternatives
• to examine claims that laparoscopic procedures
  are less stressful than open procedures

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Objectives

• to increase awareness of the risks and benefits
  of laparoscopic surgery from the anaesthetists
  (and patients) point of view
• to stimulate further interest and research in
  newer techniques which may reduce the risks

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Introduction

• Gynaecological laparoscopy
• Dangers of peritoneal insufflation of CO2
• Though laparoscopy offers advantages to both
  patients and surgeon it involves considerable
  alteration in respiratory and cardiovascular
  homeostasis and should not be regarded as yet
  another minor investigation
• Hodgson, McClelland and Newton 1970

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Anaesthetic techniques

• The role of endotracheal intubation
• The role of mechanical ventilation
• The role of muscle paralysis
• The role of nitrous oxide

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Anaesthetic techniques

• Capnography
• CO2 absorption through peritoneum, venous
  channels, retroperitoneal and subcutaneous
  tissues
• Invasive monitoring
• Insufflating gas
• air, nitrous oxide, carbon dioxide
• Helium
• Haemodynamic stability (Fleming et al., Junghans
  et al. 1997)
• Inhibition of tumour growth (Neuhauss et al.
  1999)

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Pathophysiological effects

• Haemodynamic
• head up versus head down position
• bradycardia
• blood loss
• visceral traction
• gas embolus early versus late

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Pathophysiological effects

• Respiratory Hypercapnoea
• Head down, spontaneous respiration
• CO2 absorption
• Compromised diaphragm function with raised IAP
• Pneumothorax

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Pathophysiological effects CO2 pneumoperitoneum
(Safran and Orlando AJS 1994)

• Hypertension, tachycardia leading to increased
  myocardial oxygen demand
• Increased noradrenaline levels leads to increased
  SVR (and decreased Q)
• Hypercarbia and acidosis
• Decrease in urine output and increased plasma
  renin activity (PRA)
• due to increased intra-abdominal pressure (IAP)
  and the local compression of renal vessels
• Intra-abdominal distension leads to a decrease in
  pulmonary dynamic compliance .
• Low compliance, together with an increased minute
  volume of ventilation, is accompanied by high
  peak airway pressures .
• head-up positioning and fluid deficit accounts
  for many of the adverse effects in haemodynamics
  during laparoscopic cholecystectomy (Hirvonen et
  al 2000).

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Pathophysiological effects Gasless/abdominal
wall lift techniques

• abdominal wall lift permits the conduct of
  laparoscopic procedures at an intra-abdominal
  pressure of only 6-8 mm Hg
• benefits patients with pre-existing cardiac
  disease and chronic bronchitis, especially for
  liver surgery (Banting et al. 1993).

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Pathophysiological effects Gasless versus CO2
pneumoperitoneum

• .. gasless technique provided inferior exposure
  and the operation took longer, value in
  high-risk patients with cardiorespiratory
  disease? (Vezakis et al. 1999, Johnson and Sibert
  1997)
• .. using thoracic epidural no clinically
  important differences in cardiovascular and
  systemic response were observed between patients
  undergoing CO2 or gasless laparoscopy for colonic
  disease (Schulze et al. 1999).
• .. compromised surgical exposure and thus
  increased technical difficulty. Patients realised
  no benefits from its use in terms of
  postoperative discomfort or return to activity
  (Goldberg and Maurer 1997)
• .. gasless laparoscopic cholecystectomy resulted
  in more uneventful and faster immediate and late
  postoperative recovery than conventional carbon
  dioxide pneumoperitoneum (Koivusalo et al 1996,
  1997).

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Pathophysiological effects Gasless versus CO2
pneumoperitoneum

• Conclusion
• Most studies have shown decreased surgical access
  and increased conversion rates
• Cardiorespiratory benefits are limited in most
  studies
• Side effects are similar overall
• Need a meta-analysis/more studies

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Studies of laparoscopic vs open procedures

• endocrine and metabolic changes during acute
  emergency abdominal surgery performed using
  either laparoscopy or laparotomy in children.
  Prolactin, cortisol, interleukin-6, glucose,
  insulin, lactic acid and epinephrine levels .. No
  differences were elicited (Bozkurt et al. 2000)
• stress responses after sigmoid colectomy, in
  patients undergoing lap. assisted colectomy, are
  comparable with open operation (Fukushima et al.
  1996)
• LC produces significant increases in stress
  hormone levels not physiologically minimally
  invasive. (Naude et al. 1997)

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Studies of laparoscopic vs open procedures

• significant lower values of intraoperatively and
  postoperatively measured epinephrine,
  norepinephrine, interleukin-1 beta, and
  interleukin-6 in patients with laparoscopic vs
  open cholecystectomy (Glaser et al. 1995)
• neuroendocrine stress response and inflammatory
  response following laparoscopic cholecystectomy
  were significantly reduced compared with those
  after open cholecystectomy (Karayiannakis et al.
  1997)
• activation of stress-related factors during
  gynaecologic laparoscopy seems to be less intense
  and of shorter duration (Muzii et al. 1996)

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Studies of laparoscopic vs open procedures

• Conclusion
• More studies and larger patient groups are needed
  to be certain that laparoscopic procedures
  produce less stress response than open procedures
  especially if the duration of the operation is
  longer

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Conclusion

• Laparoscopic procedures are not minimally
  invasive physiologically
• The benefits of gasless techniques are yet to be
  established