Journal of Clinical Anesthesia (2006) 18, 67

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Journal of Clinical Anesthesia (2006) 18,
6778Anesthesia for laparoscopy a review

• Frederic J. Gerges MD (Chief Resident),
• Ghassan E. Kanazi MD (Associate
  Professor),Samar I. Jabbour-khoury MD (Associate
  Professor)
• R2 ? ? ?

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1. Introduction

• 1950?? ?? GY? Pelvic pain? ???? ??????
• ? ? GS??? ??
• ?? 1) Reduction of postoperative pain
• 2) Better cosmetic results
• 3) Quicker return to normal activities
• 4) ????? ?? -gt ??? ??
• 5) Intraoperative bleeding ??
• 6) Postoperative pulmonary complications
  ??
• 7) Postoperative wound infection ??
• 8) ?? ?? ??
• 9) Better postoperative respiratory
  function

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2. The choice of insufflated gas

• 1) Laparoscopy? ???? ??? ??
• (1) Minimal peritoneal absorption
• (2) Minimal physiological effects r/o
  nitrous oxide
• (3) Rapid excretion of any absorbed gas
• (4) Inability to support combustion(??) r/o
  Air and oxygen
• (5) Minimal effects from intravascular
  embolization
• r/o
  Helium and nitrogen
• (6) High blood solubility
• 2) Carbon dioxide
• Primary gas in laparoscopy.
• ?? ??? ??? ?? -gt ?? ? ??? ? ???
• But, Peritoneum? ???? ?? -gtHypercapnia
• 
  Intravascular embolization
• 
  ???

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• 3) Gasless laparoscopic technique
• (1) Abdominal wall lift -gt an intra-abdominal
  space ??
• (2) ????? ??? ??? ?????? (vs CO2 laparoscopy)
  
• (a) Increased intra-abdominal pressure
  (IAP)
• (b) Hypercapnia, and carbon dioxide
  embolization.
• -gt Better cardiovascular condition
• (lower preload and afterload)
• (3) ??? ????? ????
• (4) ????? ???? ??? ????? ??? ??
• ( Ex. Laparoscopic cholecystectomy)
• 4) Low-pressure (5-7 mm Hg) pneumoperitoneum
• gasless??? ?? ? ? ?? ??
• -gt Abdominal wall lifting combined with
  low-pressure
• pneumoperitoneum good alternative

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3. Pathophysiological changes duringlaparoscopy

• 1.Effects of carbon dioxide absorption
• 2.Creation of the pneumoperitoneum
• 1) Cardiovascular effects
• 2) Respiratory effects
• 3) Neurologic effects
• 3.Patient positioning
• 1) Cardiovascular changes and patient
  positioning
• 2) Respiratory changes and patient
  positioning

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• 1.Effects of carbon dioxide absorption
• 1) Extraperitoneal carbon dioxide diffuse
• -gt Paco2 ?? (tension of carbon dioxide in
  arterial blood)
• -gt Minute ventilation? ???? Etco2 ?? ???
• 2) Sympathetic nervous system? ???
• Increase in (a) blood pressure
• (b) heart rate
• (c) myocardial
  contractility
• (d) arrhythmias

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• 2.Creation of the pneumoperitoneum
• 1) Cardiovascular effects
• (1) Major hemodynamic changes
• (a) Arterial blood pressure? ??
• (b) Arrhythmias
• (c) Cardiac arrest
• (2) Cardiovascular changes ? ??
• (a) Pneumoperitoneum ( IAP )
• (b) Volume of carbon dioxide
  absorbed
• (c) Intravascular volume
• (d) Ventilatory technique
• (e) Surgical conditions
• (f) Anesthetic agents used
• (3) Cardiovascular function? ??? ??? ??
• IAP and patient position

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• IAP
• IAP lt 15 mmHg -gt venous return ??
• Lower IAP -gt cardiac output ?? cardiac filling
  pressures??
• Hypercapnia -gt cardiac efferent sympathetic
  activity??
• -gtsystemic vascular
  resistance ??
• cardiac index??
• If, IAP gt 15 mm Hg Venous return ??
• -gt cardiac
  output?? -gthypotension
• ???? IAP? 12mmHg??? ??
• Patient position
• Horizontal position? head-up down??
  hemodynamic changes? ??
• Hemodynamic changes
• (a) Vasovagal reflex (stimulation from trocars
  or insufflation)
• (b) Myocardial sensitization by halothane
• (c) Reduced venous return ( by reverse
  Trendelenburg position)
• (d) Inferior vena cava compression

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• 2.Creation of the pneumoperitoneum
• 2) Respiratory effects
• (1) Lung volumes? ??
• (2) Peak airway pressures ??
• (3) Pulmonary compliance ??( By IAP??
  position )
• Noneffective ventilation?? pulmonary
  vasoconstriction?
• ???? hypercapnia and hypoxemia? ???? ??
• Higher IAP
• Thoracic compliance ??-gtpneumothorax
  pneumomediastinum
• Pulmonary dysfunction ??
• Preoperative pulmonary function
  testing??
• (including arterial blood gas analysis)
• Intraoperative radial artery
  cannulation
• If refractory hypoxemia, hypercapnia, or
  high airway pressures

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• 2.Creation of the pneumoperitoneum
• 3) Neurologic effects
• Systemic vascular resistance? ??,
  head-down positioning,
• and elevated IAP? ??? hypercapnia ? ????
  ?? ??
• -gt cerebral perfusion pressure? ?? -gt
  ICP??

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• 3.Patient positioning
• 1) Cardiovascular changes and patient
  positioning
• (1) Head-up position
• (a) Venous return and cardiac output
  ??
• (b) Mean arterial pressure and
  cardiac index ??
• (c) Peripheral and pulmonary
  vascular resistance ??
• (2) Head-down position
• Venous return ?? and normalizes
  blood pressure
• 2) Respiratory changes and patient
  positioning
• Trendelenburg position? reverse
  trendelenburg position
• ?? respiratory function ? ?????

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4. Patient monitoring

• Routine moniotoring
• o Electrocardiogram
• o Noninvasive arterial pressure monitor
• o Airway pressure monitor
• o Pulse oximeter
• o Etco2 concentration monitor
• o Peripheral nerve stimulation
• o Body temperature probe
• For hemodynamically unstable patients
• Arterial cannulation urine output
  measurement

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• End-tidal carbon dioxide
• Ventilation? ???? ???? Paco2? ???? ??
• V/Q mismatching? ????? ?? ?? ? ??
• Cardiopulmonary function? ??? ?? ?? arterial
  blood gas analysis? ?? Paco2? ?? (hypercarbia??)
• Radial artery cannulation ? ??? ??
• Preoperative cardiopulmonary disease
• Intraoperative hypoxemia? ??? ??
• High airway pressures
• Etco2 ? ??? ? ??

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• Airway pressure monitor
• High airway pressure alarm
• detection of excessive elevation in IAP
• Nerve stimulation
• Adequate muscle paralysis?? ??
• Reduces the IAP
• Prevents sudden patient movement
• Awareness
• Bispectral Index, a possible monitor of depth
  of hypnosis,

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5. Anesthetic techniques

• 1. General anesthesia for laparoscopy
• 2. Regional anesthesia for laparoscopy
• 1. Peripheral nerve blocks
• 1. Rectus sheath block. The rectus
  sheath block,
• 2. Rectus sheath block and mesosalpinx
  block.
• 3. Inguinal block
• 4. Pouch of Douglas block
• 5. Paravertebral block
• 2. Neuraxial blocks
• 1. Epidural anesthesia
• 2. Spinal anesthesia
• 3. Combined spinal-epidural anesthesia
• 4. Caudal epidural block
• 3. Local anesthetic infiltration

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1. General anesthesia for laparoscopy

• Inhalational agents N2O, Sevo., Iso., Des.
• Intravenous agents thiopentone, propofol,
  etomidate
• Muscle relaxants succinylcholine, mivacurium,
  atracurium,
• vecuronium
• Agents of choice Shorter-acting drugs
• Ex. Sevoflurane., Desflurane, and propofol
• Propofol Less postoperative nausea and
  vomiting (PONV)
• Rapid and shorter-acting volatile anesthetics (
  Des Sevo)
• and ultrashort-acting opioid analgesics (
  Remifentanil)
• Auditory evoked potential or Bispectral Index
  monitor
• -gt Reduction in the anesthetic requirement
• -gt Shorter postanesthesia care unit stay
• Improved quality of recovery

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• TIVA
• propofol, midazolam and ketamine alfentanil
  vecuronium
• ?? outpatient laparoscopy.
• ?????? ?? ?? Propofol-based anesthesia ?
  PONV? ?? ???? ???? ??? ??? more frequent movement
  ???
• Perioperative awareness and PONV
• Opioid-based techniques ? ?????? ??
• Opioid supplementation of intravenous or
  inhalation-based anesthesia ? ??
• Ultrashort-acting opioid remifentanil?? (vs
  alfentanil )
• Advantage of remifentanil
• o Cardiovascular responses? ???
• o Postoperative respiratory depression? ??
• o Delayed recovery? ???.
• o ???, Postoperative analgesia? support ?? ?
• Nonopioids (acetaminophen, NSAID, a2-agonists,
  N-methyl D-oaspartate antagonists)? ???? ???
  opioid ??? ??? ??? ??? ??? ??.

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• Nitrous oxide
• o Perioperative analgesia
• o Inhaled or intravenous anesthetics??? ??
• o Nausea and vomiting ?? still controversial
• Succinylcholine
• o choice for short laparoscopic procedures
• o postoperative muscle pains???? ??
• Nondepolarizing NeuroMuscular Blocking Agents
• o Currently considerable choice
• o Muscle pain (especially in the neck) ??
• o Shoulder pain is still common
• (consequence of the pneumoperitoneum)

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• Endotracheal intubation and controlled
  ventilation
• Safest technique
• Long laparoscopic procedures? ??
• COPD and pneumothorax or bullous emphysema ???
  ??
• Increase in respiratory rate rather than tidal
  volume
• avoid increased alveolar inflation
• reduce the risk of pneumothorax
• Anesthetic agents that directly depress the
  heart
• avoided in patients with compromised cardiac
  function
• -gt Vasodilating properties such as
  isoflurane
• Infusion of vasodilating agents, such
  as nicardipine
• pneumoperitoneum ?? ?? hemodynamic ???
  ??
• Increases of vagal tone during laparoscopy
• Atropine? ???? ??
• ??? ?? ??

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2. Regional anesthesia for laparoscopy

• Advantages
• (a) Quicker recovery (b) Decreased
  PONV
• (c) Less postoperative pain (d) Shorter
  postoperative stay
• (e) Cost effectiveness (f) Improved
  patient satisfaction
• (g)Overall safety (h) Early
  diagnosis of complications
• (i) Fewer hemodynamic changes
• Regional anesthesia for laparoscopy ? ??
• o Relaxed and cooperative patient
• o Low IAP to reduce pain and ventilatory
  disturbances
• o Reduced tilt
• o Precise and gentle surgical technique
• o Supportive operating room staff
• Intravenous sedation anxiety, pain, and
  discomfort
• Pneumoperitoneum and sedation ?? ???
  Hypoventilation and Arterial oxygen desaturation
  ???
• Laparoscopic tubal ligation good indication

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2. Regional anesthesia for laparoscopy

• 1. Peripheral nerve blocks
• 1. Rectus sheath block.
• 2. Rectus sheath block and mesosalpinx block.
• 3. Inguinal block.
• 4. Pouch of Douglas block.
• 5. Paravertebral block.
• 2. Neuraxial blocks
• 1. Epidural anesthesia.
• 2. Spinal anesthesia.
• 3. Combined spinal-epidural anesthesia.
• 4. Caudal epidural block.
• 3. Local anesthetic infiltration

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• 2. Neuraxial blocks
• ?? GY Laparoscopy???? ? ??? ?? ???? ??
• Awake patients? arterial blood gases ? ????
  ??
• Advantages
• o Reducing the need for sedatives and
  narcotics
• o Better muscle relaxation
• ??
• 1. Epidural anesthesia.
• 2. Spinal anesthesia.
• 3. Combined spinal-epidural anesthesia.
• 4. Caudal epidural block.

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• 1. Epidural anesthesia
• o Outpatient laparoscopy? ?? ??
• (without associated respiratory depression)
• o Abdominal distension?? ?? diaphragmatic
  irritation?
• Shoulder pain? ??
• -gt Extensive sensory block (T4 through L5)
  is necessary for
• surgical laparoscopy and may also
  lead to discomfort.
• o Epidural administration of opiates and/or
  clonidine might
• help to provide adequate analgesia
• o Gasless laparoscopy for GY surgery with
  epidural anesthesia
• -gt comfort and more adequate pain relief
• cardiorespiratory function? ? ?? X
• o COPD?? Epidural anesthesia ? ? safely
  and effect
• Ix gt Laparoscopic cholecystectomy,
• Laparoscopic extraperitoneal
  herniorrhaphy

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• 2. Spinal anesthesia.
• Trendelenburg position? spinal block? cephalad
  spread ???
• -gt a greater sympathetic block, bradycardia,
  hypotension
• -gt reduced doses of the local anesthetics
  
• or hypobaric solutions minimizes
  side effects
• Ex.) hypotension, bladder
  distension,
• prolonged sensory and
  motor block
• traditionally associated
  with conventional doses
• EX.gt
• o Lapa. extraperitoneal inguinal hernia repair
  under spinal Ane.
• extraperitoneal nitrous oxide
  insufflation
• o Lapa. cholecystectomy under spinal Ane. with
  nitrous oxide pneumoperitoneum
• Severe COPD Pt. Lapa. intraperitoneal
  inguinal hernia repair
• spinal anesthesia using hyperbaric
  bupivacaine is an effective
• Gasless laparoscopy and microlaparoscopy??? ??
  ?? spinal ane? ? ??? ???

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• 3. Combined spinal-epidural anesthesia.
• ???? ???? chest pain? ?? severe agitation??
• -gt not recommend
• 4. Caudal epidural block.
• effective modality for providing
  postoperative analgesia after laparoscopic hernia
  surgery in children.
• -gt lower pain scores ??? ???? ???? ??? ??
  ??
• -gt earlier hospital discharge

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• 3. Local anesthetic infiltration
• microlaparoscopy external diameters 1.2
  2.2 mm.
• Local anesthetic infiltration safe,
  effective, and less cost
• Ix. Infertility, chronic pelvic pain, and
  tubal ligation
• polycystic ovarian syndrome
• ??
• o Early hospital discharge,
• o ???? postoperative additional analgesia????
• unsuitable for microlaparoscopy
• Obese patients
• Patients with multiple adhesions from previous
  surgery
• Laparoscopic cholecystectomy under GA
• preinsertion of local anesthesia at the
  trocar site
• -gt Reduces postoperative pain
• and decreases medication usage costs

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6. Recovery after laparoscopy

• 1. Postoperative pain
• 1. Local anesthesia.
• 2. Nonsteroidal anti-inflammatory drugs
• 3. Opioids
• 4. Multimodal analgesia techniques
• 5. Other analgesic techniques
• 1. Anticholinergic drugs.
• 2. Tramadol.
• 3. Acetaminophen.
• 4. a2 Agonist.
• 2. Postoperative nausea and vomiting
• 1. Anesthetic technique
• 2. Antiemetic medications

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• 1. Postoperative pain
• 1) Local anesthesia.
• Reduce postoperative pain
• Delay the requirement for rescue
  analgesics
• 2) Nonsteroidal anti-inflammatory drugs
• opioid-related side effects???
• adjuvant during and after surgery
• desirable in outpatients
• 3) Opioids
• Effective in treating pain after
  laparoscopic procedures
• associated with numerous side effects
• nausea, respiratory depression, and
  sedation,
• Especially undesirable in outpatients.
• 4) Multimodal analgesia techniques
• Combining opioids, local anesthetics, and
  NSAIDs

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• 5). Other analgesic techniques
• (1) Anticholinergic drugs.
• Glycopyrrolate reduced patient pain scores
• reduced requirements
  for morphine
• But, buscopan failed to achieve the same
  results
• (2) Tramadol.
• weak opioid
• reducing pain scores and opioid analgesic
  requirements
• (3) Acetaminophen.
• Combinations of acetaminophen
• with either dextropropoxyphene or
  codeine
• effective as tramadol
• (4) a2 Agonist.
• Dexmedetomidine has sedative, hypnotic,
  and analgesic properties.

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• 2. Postoperative nausea and vomiting
• 1. Anesthetic technique
• Propofol lowest incidence of PONV,
• Nitrous oxide increase the incidence
• Opioids potent cause of PONV
• NSAIDs and opioids better control
  postoperative pain
• 
  decreasing opioid-related side effects.
• 2. Antiemetic medications
• o Ondansetron (an antagonist of the 5-HT3
  receptor)
• effectiv, end of surgery? ???
• o Dolasetron and granisetron (other 5-HT3
  antagonists)
• effective
• o Dexamethasone
• reduced PONV in the first 24
  hours
• after laparoscopic
  sterilization
• and reduced the requirement
  for rescue antiemetics

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7. Contraindications for laparoscopy

• Absolute contraindications
• Laparoscopy include shock
• Markedly increased ICP
• Severe myopia and/or retinal detachment
• Inadequate surgical equipments
• Inadequate monitoring devices.
• Relative contraindications
• Bullous emphysema
• History of spontaneous pneumothorax
• Pregnancy
• Life-threatening emergencies
• Prolonged laparoscopy more than 6 hours
  associated
• with
  acidosis and hypothermia
• New laparoscopic procedures

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8. Complications of laparoscopy

• 1. Inadvertent extraperitoneal insufflation
• 2. Pneumothorax
• 3. Pneumomediastinum and pneumopericardium
• 4. Vascular injuries
• 5. Gastrointestinal injuries
• 6. Urinary tract injuries

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• 1. Inadvertent extraperitoneal insufflation
• 1) Misplacement of the Veress needle
• intravascular,subcutaneous tissue,
  preperitoneal space,
• viscus, omentum, mesentery, or
  retroperitoneum
• -gt insufflation of carbon dioxide
• 2) Direct intravascular gas insufflation
• ( abdominal wall or peritoneum vessel )
• -gt gas embolism
• -gt hypotension, cyanosis,
  dysrhythmias,and asystole
• Initially, sudden increase in etco2
  concentration
• If gas embolism is suspected
• -gt a) carbon dioxide insufflation stop
  abdomen deflated
• b) ??? left lateral decubitus with a
  head-down position
• ( gas to rise into the apex of the
  right ventricle
• and prevent entry into the
  pulmonary artery.)
• c) Hyperventilation with 100 O2
• d) central venous catheter -gt aspiration
  of gas

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• subcutaneous emphysema.
• Subcutaneous insufflation of carbon dioxide
• crepitus over the abdominal and chest wall
• Sx.gt
• Increase in airway pressures and etco2
  concentrations-gt Significant hypercapnia and
  respiratory acidosis
• Mx.gt
• resolves soon after the abdomen is
• deflated and nitrous oxide is discontinued to
  avoid expansion
• of carbon dioxidefilled space

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• 2. Pneumothorax
• 1) gas ? thorax? ??
• through a tear in the visceral
  peritoneum
• breach of the parietal
  pleura
• during dissection around the
  esophagus
• 2) spontaneous rupture of preexisting
  emphysematous bulla.
• 3) subcutaneous emphysema in the neck and
  face
• -gt gas tracking to the thorax and
  mediastinum
• -gt pneumothorax or pneumomediastinum
• ??
• asymptomatic
• increase peak airway pressures
• decrease oxygen saturation
• ( severe cases) significant hypotension
  and cardiac arrest
• Treatment
• close observation

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• 3. Pneumomediastinum and pneumopericardium
• subcutaneous emphysema? cervical region??
  thorax? mediastinum?? ??? ?????
• management
• o depends on the severity of associated
  cardiopulmonary
• dysfunction
• o Release of the pneumoperitoneum
• 4. Vascular injuries
• Accidental insertion of the Veress needle or
  trocar into major vessels aorta
• common iliac vessels
• inferior vena cava
• cystic or hepatic
  artery
• Other minor vascular injuries involve the
  abd. wall vessels

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• 5. Gastrointestinal injuries
• Gastrointestinal injuries small intestine,
  colon, duodenum, and stomach
• Lacerations of the liver, spleen, and colonic
  mesentery
• minimize stomach injuries
• Gastric decompression before placement of
  Veress needle
• 6. Urinary tract injuries
• Although injuries to the bladder and ureters
  are rare, decompression of thebladder by
  placement of a urinary
• catheter before laparoscopy is advisable