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AnesthesiaAnesthesia management of management of Laparoscopic Assisted Laparoscopic Assisted

Surgery.Surgery.

Dr. Mohammed MahdyDr. Mohammed Mahdy

Consultant in Consultant in AnaesthesiologyAnaesthesiology

Al Bukariya general Al Bukariya general hospitalhospital

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IntroductionIntroduction

Laparoscopy introduced in 20Laparoscopy introduced in 20thth CenturyCentury

1962 : first laparoscopic tubal 1962 : first laparoscopic tubal ligation ligation

1970 -- 80 : used for gyne 1970 -- 80 : used for gyne proceduresprocedures

1989: laparoscopic 1989: laparoscopic cholecystectomycholecystectomy

Rapid advances in technologyRapid advances in technology

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Lap.chole - 948 Lap.append - 150

Lap.hernia - 80 Lap.ob/gyn - 60

Varicocele -10 Int. obst - 9

Lap.gastric banding -2 Gastric bandoplasty - 1

Total No of cases from 3 / 1421 to 11 / 1425

75.2%

11.9%

6.3%4.7%

Total cases: 1260

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Laparoscopic ProceduresLaparoscopic ProceduresGeneral Surgery:General Surgery:

CholecystectomyCholecystectomyAppendicectomyAppendicectomyVaricocoelectomyVaricocoelectomyHernioplastyHernioplastyDiagnostic laparoscopyDiagnostic laparoscopyHiatus hernia repairHiatus hernia repairAdhesiolysisAdhesiolysis

OBG:OBG:Ectopic pregnancyEctopic pregnancyMyomectomyMyomectomyLAVHLAVHEndometriosisEndometriosis

Thoracic Surgery:Thoracic Surgery:SympathectomySympathectomyMediastinoscopyMediastinoscopy

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Advantages of LaparoscopyAdvantages of Laparoscopy

Shorter hospital stayShorter hospital stay Faster recoveryFaster recovery Rapid return to normal activitiesRapid return to normal activities Minimal painMinimal pain Small scarSmall scar Less post-op ileusLess post-op ileus

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Contraindications for Contraindications for LaparoscopyLaparoscopy

Increased ICPIncreased ICP

V – P shuntV – P shunt

HypovolemiaHypovolemia

CCF CCF

Valvular heart diseasesValvular heart diseases

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Anaesthetic PlanAnaesthetic Plan Pre-operative assessmentPre-operative assessment Pre-medicationPre-medication

• AnxiolyticsAnxiolytics• H2 receptor blockersH2 receptor blockers• Gastro-kinetic drugsGastro-kinetic drugs

Monitoring:Monitoring:• Pulse oximetryPulse oximetry• CapnographyCapnography• ECGECG• NIBPNIBP

• FiO2FiO2

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Anaesthetic ManagementAnaesthetic Management

PreoxygenationPreoxygenation InductionInduction Intubation – mandatoryIntubation – mandatory NG tube placementNG tube placement

• Stomach decompressionStomach decompression Maintenance of anaesthesiaMaintenance of anaesthesia

• Muscle relaxantsMuscle relaxants• Volatile anaesthetic agentsVolatile anaesthetic agents

Reversal of NM blockadeReversal of NM blockade Recovery roomRecovery room

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Anesthetic Problems of Anesthetic Problems of LaparoscopyLaparoscopy

Due to pneumo peritoneumDue to pneumo peritoneum Due to patient positioningDue to patient positioning Cardiovascular effectsCardiovascular effects Respiratory effectsRespiratory effects Gastro intestinal effectsGastro intestinal effects Unsuspected viseral injuriesUnsuspected viseral injuries Difficulty in estimating blood lossDifficulty in estimating blood loss Darkness in the ORDarkness in the OR

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Pneumo PeritoniumPneumo Peritonium

Preferred gas : CO2 Preferred gas : CO2

Working pressure : 12 to 14 mm Working pressure : 12 to 14 mm HgHg

Slow inflation of 1 litre / minuteSlow inflation of 1 litre / minute

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CO2 as Insufflator GasCO2 as Insufflator Gas

More soluble in blood than airMore soluble in blood than air

Carriage is high due to Carriage is high due to bicarbonate buffering and bicarbonate buffering and combination with Hbcombination with Hb

Rapidly eliminated by lungsRapidly eliminated by lungs

Inert & not irritant to tissuesInert & not irritant to tissues

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Ventilatory problems during Ventilatory problems during LaparoscopyLaparoscopy

Increase in PaCO2Increase in PaCO2

PneumothoraxPneumothorax

Gas-embolismGas-embolism

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Causes for Increased PaCO2Causes for Increased PaCO2

Absorption of PaCO2 –peritoneal Absorption of PaCO2 –peritoneal cavitycavity

V/Q mismatchV/Q mismatch• Increased physiological dead Increased physiological dead

spacespace•Abdominal distentionAbdominal distention•Patient’s positionPatient’s position•Controlled ventilationControlled ventilation•Reduced cardiac outputReduced cardiac output

Lighter planes of anaesthesiaLighter planes of anaesthesia

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PneumothoraxPneumothorax

Patent pleuro-peritoneal Patent pleuro-peritoneal channelschannels

Pleural injuriesPleural injuries

Ruptured emphysematous Ruptured emphysematous bullaebullae

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Management of PneumothoraxManagement of PneumothoraxRecommended GuidelinesRecommended Guidelines

Stop N2OStop N2O Adjust vent settings to correct Adjust vent settings to correct

hypoxemiahypoxemia Apply PEEPApply PEEP Reduce intra-abdominal Reduce intra-abdominal

pressurepressure Communicate with surgeonCommunicate with surgeon Avoid thoracocentesisAvoid thoracocentesis

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Gas EmbolismGas Embolism

Most feared & fatal complicationMost feared & fatal complication

Seen frequently when Seen frequently when laparoscopy is associated with laparoscopy is associated with hysteroscopyhysteroscopy

Intra vascular injection of gas Intra vascular injection of gas following direct trocar placement following direct trocar placement into vesselinto vessel

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Suspicion of Gas EmbolismSuspicion of Gas Embolism

Blood on aspiration from Vere’s Blood on aspiration from Vere’s needleneedle

Pulsation of flow meter pressure Pulsation of flow meter pressure gaugegauge

Disappearance of abdominal Disappearance of abdominal distention despite sufficient distention despite sufficient volume of gasvolume of gas

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Effects of Massive Air EmbolismEffects of Massive Air Embolism Rapid insufflation of gas into bloodRapid insufflation of gas into blood Gas lock in RA & venacavaGas lock in RA & venacava Fall in cardiac outputFall in cardiac output High pressure in RAHigh pressure in RA Open foramen ovaleOpen foramen ovale Embolus in cerebral & coronary bedsEmbolus in cerebral & coronary beds Paradoxical embolismParadoxical embolism

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Diagnosis of Gas-embolismDiagnosis of Gas-embolism Detection of gas in right side of HeartDetection of gas in right side of Heart Recognition of physiological changes Recognition of physiological changes

secondary to emboli:secondary to emboli:• TachycardiaTachycardia• Cardiac arrhythmiaCardiac arrhythmia• HypotensionHypotension• CVP riseCVP rise• Mill-wheel murmurMill-wheel murmur• CyanosisCyanosis• Right heart strain pattern in ECGRight heart strain pattern in ECG• Pulmonary edemaPulmonary edema

Doppler & TEE ---- very sensitiveDoppler & TEE ---- very sensitive

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Treatment of Gas EmbolismTreatment of Gas Embolism

Immediate cessation of Immediate cessation of insufflationinsufflation

Release of pneumo-peritoneumRelease of pneumo-peritoneum Patient in Durrent’s positionPatient in Durrent’s position Cessation of N2O Cessation of N2O Give 100% oxygenGive 100% oxygen CVP insertion and aspiration of CVP insertion and aspiration of

gasgas

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Risk factor for RegurgitationRisk factor for Regurgitation

Increased intra-abdominal Increased intra-abdominal pressurepressure

Decreased lower oesophageal Decreased lower oesophageal sphincter tonesphincter tone

Head down positionHead down position

NG tube mandatoryNG tube mandatory

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Cardiac Arrhythmias during Cardiac Arrhythmias during LaparoscopyLaparoscopy

Volatile anaesthetic agents Volatile anaesthetic agents

HypercarbiaHypercarbia

Sudden stretching of peritoneumSudden stretching of peritoneum

Electro coagulation of fallopian Electro coagulation of fallopian tubestubes

Light planes of anaesthesiaLight planes of anaesthesia

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Problems related to patient’s Problems related to patient’s positioningpositioning

Head – Down tilt for pelvic and Head – Down tilt for pelvic and sub sub meso-colic surgerymeso-colic surgery

Head -Up tilt for supra Head -Up tilt for supra mesocolic surgerymesocolic surgery

Lithotomy position for gynec Lithotomy position for gynec proceduresprocedures

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Position – Respiratory EffectsPosition – Respiratory Effects

Head-down positionHead-down position• Promotes atelectasisPromotes atelectasis• Decreases FRCDecreases FRC• Decreases TLCDecreases TLC• Decreases pulmonary complianceDecreases pulmonary compliance

Head-Up position:Head-Up position:• Endo-bronchial intubationEndo-bronchial intubation

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Position- Cardio-Vascular EffectsPosition- Cardio-Vascular Effects Head down Position:Head down Position:

• Increases CVPIncreases CVP• Increases cardiac outputIncreases cardiac output• Increases cerebral circulationIncreases cerebral circulation

Increased ICPIncreased ICP Increased intra-ocular pressureIncreased intra-ocular pressure

Head up Position:Head up Position:•Decreased cardiac outputDecreased cardiac output•Decreased mean arterial Decreased mean arterial

pressurepressure•Decreased venous returnDecreased venous return

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Positions : Nerve InjuryPositions : Nerve Injury

Hyper extension of armHyper extension of arm --- --- brachial plexus injurybrachial plexus injury

Lithotomy positionLithotomy position --- --- common common peroneal injuryperoneal injury

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Bibilography:Bibilography:

Short practice of anaesthesia – Short practice of anaesthesia – Churchill DavidsonChurchill Davidson

Synopsis of anaesthesia – Synopsis of anaesthesia – Atkinson & LeeAtkinson & Lee

Text book of anaesthesia – Text book of anaesthesia – Ronald MillerRonald Miller

Anaesthesia & coexisting Anaesthesia & coexisting diseases - Stoeltingdiseases - Stoelting

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Haemodynamic Repurcussions Haemodynamic Repurcussions of Pneumo - Peritoneumof Pneumo - Peritoneum

↑ ↑ Intraabdominal pressureIntraabdominal pressure

↓ ↓ Venous returnVenous return ↑↑ Intrathoracic pressureIntrathoracic pressure

↑↑Pulmonary vascular resistancePulmonary vascular resistance

Cardiac outputCardiac output

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Haemodynamic Repurcussions Haemodynamic Repurcussions Of PneumoperitoneumOf Pneumoperitoneum

↑ ↑ Intra abdominal pressureIntra abdominal pressure

↑ ↑ Venous resistanceVenous resistance

↑ ↑ Systemic vascular Systemic vascular

resistanceresistance

↑ ↑ Arterial pressureArterial pressure