• A.k.a PERITONEOSCOPY, is a minimal invasive surgical procedure which allows

endoscopic access to the peritoneal cavity after insufflation of a gas (CO2) to create

space between the anterior abdominal wall and the viscera.

• Term coined by HANS CHRISTIAN JACOBAEUS in 1910.

• Air was the first gas to be used, followed by O2:- Discarded because of O2 being

COMBUSTIBLE and Air being poorly soluble in blood causing EMBOLIC

PHENOMENON.

N2O also supported COMBUSTION , when mixed with the METHANE in the bowels.

Inert gases like Helium, Argon & Xenon are EXPENSIVE and cause GAS EMBOLISM.

• CO2 - 1924 by RICHARD ZOLLIKOFER – Inert, Cheap, Exhaled by Lungs, Relatively

high blood-gas solubility (less chances of gas embolism).

INTRA-ABDOMINAL GYNAECOLOGICAL

Cholecystectomy

Vagotomy

Appendectomy

Colectomy

Inguinal Hernia Repair

Nephrectomy

Adrenalectomy

Splenectomy

Diagnostic Fertility

workup

Tubectomy & Ligation

Ovarian Cyst Puncture

Hysterectomy

INDICATIONS FOR LAPAROSCOPIC SURGICAL PROCEDURE

Also has been used in Also has been used in Breast surgeries (non-oncologic)Breast surgeries (non-oncologic) and and Thyroid Thyroid surgeriessurgeries at our center at our center

Contraindications for laparoscopy are Contraindications for laparoscopy are relativerelative and include:

•the uncooperative patient

•uncorrectable coagulation defects

•severe congestive heart failure

•respiratory system compromise

•metabolic disturbances – Severe DM & its complications, Thyro-metabolic

diseases etc.

•suspected acute diffuse peritonitis

•the presence of distended bowel

If tense ascites is present, large volume paracentesis can be performed as

the preliminary step in the laparoscopy.

TRENDELENBERG POSITION of 10-15 degree for lower abdominal

Sx

REVERSE TRENDELENBERG POSITION in upper abdominal Sx.

Reverse Trendelenberg Position

Trendelenberg Position

Normal IAP is between 0-5mmHg; any value above 12 mmHg is considered as an increased IAP

In LAPAROSCOPY, a standard IAP can be considered between 12-15 mmHg

PATIENT PATIENT POSITIOPOSITIO

NN

BIOCHEMICABIOCHEMICAL L

CHANGES(gaCHANGES(gas s

absorptionabsorption))

MECHANICAL MECHANICAL CHANGES(by CHANGES(by raised raised IAP)IAP)

PHYSIOLOGICAL CHANGES DURING PHYSIOLOGICAL CHANGES DURING PNEUMOPERITONEUMPNEUMOPERITONEUM

1 2

34

5

6 7

8

9

10

GENERAL ANAESTHESIA UNDER CONTROLLED MECHANICAL VENTILLATION (CMV)GENERAL ANAESTHESIA UNDER CONTROLLED MECHANICAL VENTILLATION (CMV)::

•Always preferred; pt is sedated, paralyzed, with full control of pt’s respirationAlways preferred; pt is sedated, paralyzed, with full control of pt’s respiration•Immobile field gives ease of operabilityImmobile field gives ease of operability•Protection from aspirationProtection from aspiration•Better psychological outcome for patients-less chances of intra-op awarenessBetter psychological outcome for patients-less chances of intra-op awareness•More hemodynamic stabilityMore hemodynamic stability•Pt has no intra-op discomfortPt has no intra-op discomfort•A compromised respiratory system may contradict GAA compromised respiratory system may contradict GA

REGIONAL ANAESTHESIA-HIGH SPINAL / EPIDURAL:REGIONAL ANAESTHESIA-HIGH SPINAL / EPIDURAL:

•Quicker recovery, decreased PONVQuicker recovery, decreased PONV•Can be planned in patients with contraindications to GACan be planned in patients with contraindications to GA•Abdominal discomfortAbdominal discomfort•Pneumoperitoneum + sedation = Hypoventilation; Hypoxia & HypercarbiaPneumoperitoneum + sedation = Hypoventilation; Hypoxia & Hypercarbia•Complete sensory block is not always assuredComplete sensory block is not always assured•Compelled low IAP inhibits field of visionCompelled low IAP inhibits field of vision

• Proper history and examination of patient, related to organ systems is of utmost importance

• Review of investigation reports prior to commencement of surgery

• Anticholinergic drugs – Atropine & Glycopyrrolate

• Sedation and Analgesia- Midazolam and Fentanyl

• Anti-acid and Antiemetic Prophylaxis

• α2- agonists- Clonidine and Dexmedetomidine

• Oxygenation – Saturation; Pulseoximetry

• Ventilation – Capnometry ( <2Hrs) Venous BGA (>2Hrs, >60yrs, Pulmonary disease) Transcutaneous CO2 monitoring (>2Hrs, Pulmonary disease, Extraperitoneal &

Retroperitoneal procedures)

• Haemodynamic Monitoring – ASA1 – ECG, NIBP Pts. With IHD – Automated ST analysis of ECG ASA3, ASA4 – IABP, Serial BGA, CVP, PAC, TEE, CO monitoring

• Temperature Monitoring

• Urine Output monitoring - >2Hrs, Elderly pts, Cardiopulmonary compromise

• Neuromuscular Monitoring – TOF stimulation and TOF ratio

PREOXYGENATION: 100% o2 in 3mins of TV breathing OR 8 VC breaths in 1 min

INDUCTION: Thiopentone Sod. 4-5 mg/kg; Propofol 2-2.5 mg/kg

RELAXATION AND INTUBATION: Succinylcholine 1-2 mg/kg & appropriate size of

ETT

NG tube/Ryle’s tube

MAINTAINANCE: O2 + N2O + NDPMR(Vecc / Atra) + PPV

Maintain MV to an ETCO2 of 30 – 40mmHg

Choice of Inhalational Agent: ISO>DES>SEVO>ENF; HALO is

contraindicated

N2O may cause distension of hollow viscera, causes PONV

REVERSAL: Neostigmine + Glycopyrrolate

INCREASED PaCO2 (Hypercapnia):

• Influenced by duration of Pneumoperitoneum

• Causes are – absorption of CO2 from peritoneal cavity

V/Q mismatch; pt position

• Chances are more in procedures under regional anaesthesia

• Usual initial presentations are tachycardia, HTN, pt triggering, mild desaturation,

wound oozing, increased body temperature

• Can lead to accidental events like tachyarrhythmias, CO2 emphysema,

capnothorax, CO2 embolism

• Usually prevented by maintaining alveolar ventilation to a PaCO2 of 30-40mmHg

RESPIRATORY COMPLICATIONS:

CO2 subcutaneous emphysema:

• d/t accidental Extraperitoneal insufflation

• An increase in PetCO2 after Pet CO2 has plateaued should raise the suspicion

• CO2 pressure determines the extent of the emphysema and the magnitude of

CO2 absorption

• Temporary halt of the procedure and the route of extraperitoneal rent is to be

looked for Capnothorax, capnomediastinum and capnopericardium:•via embryonic remnants of communication between the peritoneal cavity, pleural and pericardial spaces•There is reduced thoracopulmonary compliance and increased Paw•PaCO2, PetCO2 all increase•Confirmed by chest auscultation and CXR•Capnothorax is treated by stopping N2O administration, reducing IAP, adjust ventilator settings to correct hypoxia, applying PEEP

Gas Embolism:•Most serious complication of laparoscopic surgery•Pathophysiology is determined by the size of the bubbles and the rate of intravenous gas entry•Gas embolism into an artery, termed arterial gas embolism (AGE), is a more serious matter than in a vein, because a gas bubble in an artery may directly stop blood flow to an area fed by the artery•Mayer, et al. described a mortality of 60% at a continuous intravenous carbon dioxide infusion rate of 1.2 mL/kg/min, which is equivalent to a rate of 72 mL/min for a 60 kg person. That volume is only 5% of the volume of carbon dioxide that may be infused into a vein, intentionally cannulated by a Veres needle, in one minute at a low-flow rate.Mayer KL, Ho HS, Mathiesen KA, Wolfe BM. Cardiopulmonary responses to experimental venous carbon dioxide embolism. Surg Endosc. 1998;12:1025–1030.•Signs and symptoms – With 0.5ml/kg of gas or less – Changes in Doppler sound and increased mean PAP.With 2ml/kg of gas – Dysrhythmias, Hypotension, desaturation, increased CVP, millwheel murmur(A temporary loud, machinery-like, churning or splashing sound due to blood mixing with air in the right ventricle, best heard over the precordium)•TEE >Doppler USG for detecting intracardiac gas•Rx – Stop insufflation, head down with left lateral decubitus, 100% O2 hyperventilation, gas aspiration if a CV catheter is present, pericardiac message to fragment gas bubbles, HBOT if cerebral gas embolism is suspected

CARDIAC DYSRHYTHMIAS:

• Bradydysrhythmia leading to asystole is the most common, due to vagal

stimulation by peritoneal distension

• Tachydysrhythmia and ventricular ectopic, due to SNS activation by hypercarbia

or hypoxia

RISK OF ASPIRATION

HEMORRHAGE

INTERNAL ORGAN INJURY

PERIOPERATIVE PERIPHERAL NEUROPATHY

POST LAPAROSCOPY PAIN & PAIN RELIEF:

• Incidence is 35%-63%

• Sites are upper abdomen, lower abdomen, back or shoulder

• Most common site being upper abdomen

• From transient to up to 3 days

• Pain relief by:

Pre-op NSAIDS

Abdominal drain for 6 hrs to release the residual CO2

Pre-incisional infiltration of trocar sites with LA

Thoracic epidural analgesia

Intraperitoneal instillation of LA solution prior removing trocars

0.25% of Intrapleural Bupivacaine injection reduces shoulder pain

Mechanism

• Trocar Insertion• Intra-abdominal trauma• Rapid distension of

peritoneum causing traumatic traction on vessels and nerves

• Irritation of phrenic nerve• Release of inflammatory

mediators

Laparoscopic surgery tends to set conditions that leads the exaggeration of the

normal physiological aspect of the human body. Those with able and stable

physiology tend to cope up with the scenario with minor supports, while the

lesser counterparts need substantial support.

With the help of newer monitoring and advent in the field of anaesthesia, this

procedure can be made safe for the patient population as well as provide ease

of operability on the part of the medical fraternity .