lap anesthesia

Anesthesia for Laparoscopic surgeries

DR CHANDRA SEKHAR BEHERAPG FINAL YEAR ANAESTHESIOLOGY

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DEPT OF ANAESTHESIOLOGY M.K.C.G

MEDICAL COLLEGE 1

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MEDICAL COLLEGE 2

Objectives

To understand the principles of anaesthesia for

laparoscopic surgery

To increase awareness of the risks of CO2

Peritonium

Benefits of laparoscopic surgery from patient’s

point of view

Special considerations in geriatrics, COPD,

heart disease, pregnancy, paediatrics and

obese patients

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MEDICAL COLLEGE 3

History

ALBUKASSAM 1st used reflected light for visualisation of cervix

In 1901 KILLINK has inspected viscera of dog by insufflation of abdomen with air

In 1910 JACOBIN applied this tecnique to human and named the procedure LAPAROSCOPY

In 1968 SEEM developed CO2 pneumosufflation

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MEDICAL COLLEGE 4

Laparoscopic Procedures

General Surgery:

○ Cholecystectomy

○ Appendicectomy

○ Varicocoelectomy

○ Hernioplasty

○ Diagnostic laparoscopy

○ Hiatus hernia repair

○ Adhesiolysis

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MEDICAL COLLEGE 5

Laparoscopic Procedures

OBG:

○ Diagnostic tool for infertility

○ Ectopic pregnancy

○ Myomectomy

○ Endometriosis

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MEDICAL COLLEGE 6

Advantages of Laparoscopy

Shorter hospital stay

Less post-op ileus

Faster recovery

Rapid return to normal activities

Minimal pain

Small scar

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MEDICAL COLLEGE 7

Contraindications for

Laparoscopy

Increased ICP

V – P shunt

Hypovolemia

CCF

Valvular heart diseases

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MEDICAL COLLEGE 8

Laparoscopy – Anesthetic

issues

CO2 pneumo peritoneum

Due to patient positioning

Cardiovascular effects

Respiratory effects

Gastro intestinal effects

Unsuspected visceral injuries

Difficulty in estimating blood loss

Darkness in the OR

Pneumo Peritonium…

Insufflator Gas used

N2O /CO2 /Argon /He/ Air

Preferred gas : CO2

Working pressure : 12 to 14 mm Hg

Slow inflation of 1 liter / minute

(Air is insoluble in blood –risk of embolism

high. N2O risk of thermal injury. He & Argon

not available here)

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MEDICAL COLLEGE 9

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MEDICAL COLLEGE 10

Pneumo Peritonium

CO2 as Insufflator Gas

○ More soluble in blood than air

○ Carriage is high due to bicarbonate buffering

and combination with Hb

○ Rapidly eliminated by lungs

○ Inert & not irritant to tissues

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MEDICAL COLLEGE 11

Physiological effects

Cardiovascular effects depends on

○ Patient’s preexisting cardiopulmonary status

○ The anesthetic technique

○ Intra-abdominal pressure (IAP)

○ Carbon dioxide (CO2) absorption

○ patient position

○ Duration of the surgical procedure

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MEDICAL COLLEGE 12

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MEDICAL COLLEGE 13


Cardiovascular

- There is biphasic response on CO

- If IAP <10mmHg, milking effect on veins CO

- If IAP >15mmHg, 10%-30% reduction in CO

Increase in systemic vascular resistance, meanarterial pressure, and cardiac filling pressures

More severe in patients with preexisting cardiacdisease

Significant changes occur at pressures greater than12 - 15 mmHg

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MEDICAL COLLEGE 14

Physiological Effects

1. Increased noradrenalin levels leads to increased SVR

2. increased plasma renin activity (PRA) due to

increased intra-abdominal pressure (IAP) and the

local compression of renal vessels

3. Hypertension, tachycardia leading to increased

myocardial oxygen demand

4. Hypercarbia and acidosis

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MEDICAL COLLEGE 15

Cardiac Arrhythmias during

Laparoscopy

common during insufflation and during desufflation

Volatile anaesthetic agents

Hypercarbia, hypoxia and gas embolism ppt

tachyarrythmias

Sudden stretching of peritoneum causes vagal

stimulation

Electro coagulation of fallopian tubes

Light planes of anaesthesia

Cardiovascular

Management :

Adequate preload will improve cardiac

output

Intermittent SPC to legs will improve

venous return

Use of alpha 2 agonist such as clonidine or

dexmedetomidine & or beta blocker reduces

haemodynamic changes

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MEDICAL COLLEGE 16

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MEDICAL COLLEGE 17


Pulmonary changes:

Exaggerated in obese patients, ASA classII and III patients & in those with respiratory dysfunction

Intra-abdominal distension leads to a decrease in pulmonary dynamic compliance

1. increased IAP displaces the diaphragm upward

2. Functional residual capacity and total lung compliance decreases

3. Early closure of smaller airways, basal atelectasis

4. Increased peak airway pressures

5. Increase in minute ventilation required to maintain normocarbia

6. Increase in intra pulmonary shunting

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MEDICAL COLLEGE 18

Gastro intestinal system

Risk factor for Regurgitation

Increased intra-abdominal pressure

Decreased lower esophageal sphincter tone

(if barrier pressure is increased>30cm of H2O)

Head down position

NG tube mandatory

Gastro intestinal system..

Mesentric circulation:

1. Reduced bowel circulation resulting in

decreased gastric intra mucosal pH

2. Due to IAP, collapse of capillaries and small

veins,

3. Reverse Trendelenburg position,

4. Release of vasopressin

all lead to decreased mesenteric circulation

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MEDICAL COLLEGE 19

Gastro intestinal system...

Porto Hepatic circulation:

Rise in IAP result in decreased total

hepatic blood flow due to splanchnic

compression

Hormonal release (catecholamine,

Vasopressin & Angiotensin lead on to

overall reduction in splanchnic blood

flow except for Adrenal glands

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MEDICAL COLLEGE 20

Renal function

Increased IAP

Decreased RBF

Increased sympathetic activity

Elevated plasma Renin activity

Fall in filtration pressure

Fall in urine output

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MEDICAL COLLEGE 21

Central Nervous System

Increased IAP Increased lumbar spinal

pressure Decreased drainage from

lumbar plexus Increased ICP

Hypercapnia, high systemic vascular

resistance and head low position combine

to elevate intracranial pressure.

The induction of pneumoperitoneum itself

increases middle cerebral artery blood flow

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MEDICAL COLLEGE 22

Coagulation System

Increased IAP may lead to increased

venous stasis

Causing deep vein thrombosis

especially in prolonged surgery

Deep vein thrombosis prophylaxis

should be done in such patients.

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MEDICAL COLLEGE 23

Temperature Variation

Continuous flow of dry gases into peritoneal cavity under pressure can lead to fall in body temperature.

(sudden expansion of gas produces hypothermia due to Joule Thompson effect)

0.30 C fall in core temperature/50 Lit flow of CO2

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MEDICAL COLLEGE 24

Neuro humoral response

Activation of Hypo thalamo pituitary

Adreno cortical Axis

Rise in ACTH, Cortisol and Glucogon

Altered glucose metabolism

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MEDICAL COLLEGE 25

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MEDICAL COLLEGE 26

Problems related to patient’s

positioning

Head Down tilt - for pelvic and sub meso-colic

surgery

HeadUp tilt - for supra mesocolic surgery

Lithotomy position - for gynecological

procedures

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MEDICAL COLLEGE 27

Position – Respiratory Effects

Head-down position

○ Endo-bronchial intubation

○ Promotes atelectasis

○ Decreases FRC

○ Decreases TLC

○ Decreases pulmonary compliance

Head-Up position: favorable for respiration

Position- Cardio-Vascular Effects

Head up tilt----- Blood pooling

Venous stasis

Thrombo-embolism

↓ venous return

↓cardiac output

→ ↓ Blood Pressure

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MEDICAL COLLEGE 28

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MEDICAL COLLEGE 29

Position- Cardio-Vascular

Effects

Head down Position:

○ Increases CVP

○ Increases cardiac output

○ Increases cerebral circulation

Increased ICP

Increased intra-ocular pressure

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MEDICAL COLLEGE 30

Positions : Nerve Injury

Hyper extension of arm --- brachial plexus injury

Lithotomy position --- common peroneal injury

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MEDICAL COLLEGE 31

Complications of lap surgeries

Due to trochar injury

Positioning and

compression effect

CVS and RS complications

Thermal injuries

Gas embolism

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MEDICAL COLLEGE 32

Complications of gas insufflation

Subcutaneous emphysema ○ occur if the tip of the Veress needle does not penetrate the

peritoneal cavity prior to insufflation of gas.

○ Occur in inguinal hernia repair, renal surgery

○ During fundoplication for hiatus hernia repair

Extraperitoneal insufflation, which is associated with higher levels of CO2 absorption than intraperitoneal insufflation, is reflected by a sudden rise in the EtCO2, excessive changes in airway pressure

and respiratory acidosis

CO2 subcutaneous emphysema readily resolves after insufflation has ceased

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MEDICAL COLLEGE 33

Complications of gas

insufflation

Pneumothorax, Pneumomediastinum and

Pneumopericardium

Patent pleuro-peritoneal channels

Pleural injuries

Ruptured emphysematous bullae

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MEDICAL COLLEGE 34

Complications of gas

insufflation

Pneumothorax, Pneumomediastinum and Pneumopericardium

Sudden hypoxia, rise in peak airway pressure, hypercarbia, haemodynamic alterations

abnormal movement of the hemidiaphragm on laparoscopic view should raise a suspicion of pneumothorax

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MEDICAL COLLEGE 35

Management of

Pneumothorax

Recommended Guidelines ◦ Stop N2O ◦ Adjust ventilator settings to correct hypoxemia ◦ If due to pleuro peritoneal channel route Apply

PEEP ◦ Reduce intra-abdominal pressure ◦ Communicate with surgeon ◦ Avoid thoracocentesis unless necessary◦ Avoid PEEP if there is rupture of

emphysematous bulla and thoracocentesis is mandatory

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MEDICAL COLLEGE 36

Gas Embolism

Most feared & fatal complication Seen frequently when laparoscopy is associated with

hysteroscopy

Intra vascular injection of gas following direct trocar placement into vessel

Gas insufflation into abdominal organ

Suspicion of Gas Embolism Blood on aspiration from Vere’s needle

Pulsation of flow meter pressure gauge

Disappearance of abdominal distention despite sufficient volume of gas

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MEDICAL COLLEGE 37

Effects of Massive Air Embolism

Depends on volume of air and rate of iv entry

Rapid insufflation of gas into blood (2ml/kg)

-> larger bubbles -Gas lock in RA & venacava

-> Fall in cardiac output

->High pressure in RA

-> Open foramen ovale

->Embolus in cerebral & coronary beds

-> Paradoxical embolism

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MEDICAL COLLEGE 38

Diagnosis of Gas-embolism

Detection of gas in right side of Heart –foamy blood aspirated in the central venous catheter

Recognition of physiological changes secondary to emboli: ○ Tachycardia

○ Cardiac arrhythmia

○ Hypotension

○ CVP rise

○ Mill-wheel murmur

○ Cyanosis

○ Right heart strain pattern in ECG

○ Pulmonary edema

Doppler & TEE ---- very sensitive (0.5ml/kg)

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MEDICAL COLLEGE 39

Treatment of Gas Embolism

Immediate cessation of insufflation

Release of pneumo-peritoneum

Patient in head down and left lateral decubitus(Durant’s) position

Cessation of N2O

Give 100% oxygen

CVP insertion and aspiration of gas

CPR help to fragment CO2 emboli into small bubbles

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MEDICAL COLLEGE 40

Postoperative morbidity

Postoperative Pain

Abdominal and shoulder tip pain after laparoscopic

surgery

Complete removal of the insufflating gas is essential

Infiltration of the portal sites with a local anaesthetic

reduces pain

Right-sided subdiaphragmatic instillation with a local

anaesthetic reduces shoulder tip pain

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MEDICAL COLLEGE 41

Postoperative morbidity

Post Operative Nausea & Vomiting (PONV)

Peritoneal insufflation, bowel manipulation and

pelvic surgery are some of the causative factors

A meticulous anaesthetic technique along with

antiemetics is helpful in reducing the incidence

of PONV

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MEDICAL COLLEGE 42

Gasless laparoscopy

Peritoneal cavity is expanded using

abdominal wall lifter.

This avoids haemodynamic & respiratory

repercussions of increased IAP

It increases technical difficulty

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MEDICAL COLLEGE 43

Anaesthesia for lap surgeries

Anaesthetic Goals

Accommodate surgical requirements and allow for

physiological changes during surgery.

Monitoring devices available for the early detection

of complications.

Recovery from anaesthesia should be rapid with

minimal residual effects.

The possibility of the procedures being converted to

open laparotomy to be considered

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MEDICAL COLLEGE 44

Anaesthetic Plan

Pre-operative assessment

The cardiac and pulmonary status of all patients should be carefully assessed

Pre-medication ○ Anxiolytics

○ Antiemetic

○ H2 receptor blockers

○ Gastro-kinetic drugs

○ Preemptive analgesia with NSAIDs

○ Atropine to prevent vagally mediated bradyarrhythmias

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MEDICAL COLLEGE 45

Monitoring

1.Routine Patient Monitoring Include Continuous ECG Intermittent NIBP Pulse oximetry (SpO2) Capnography (EtCO2) Temperature Intraabdominal pressure

2. Optional Monitoring Include Pulmonary airway pressure Oesophageal stethoscope Precordial doppler Transoesophageal echocardiography

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MEDICAL COLLEGE 46

Anaesthetic techniques

General anaesthesia

◦ Preloading with crystalloid solution is recommended

◦ Preoxygenation

◦ During induction of Anaesthesia, avoid stomach

inflation

◦ Tracheal Intubation – mandatory

◦ PLMA should only be used by experienced LMA

users

◦ NG tube placement for Stomach decompression

◦ Catheterisation to empty the urinary bladder

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MEDICAL COLLEGE 47

G.A : Anaesthetic Management

…

Maintenance of Anaesthesia

Intermittent positive pressure ventilation (IPPV) .

Normocarbia (34-38mmHg) to be maintained by adjusting the

minute volume

The use of nitrous oxide during laparoscopic surgery is

controversial (bowel distension during surgery and the increase in

postoperative nausea) .

Halothane increases the incidence of arrhythmia

Isoflurane / sevoflurane comparatively better

Reversal of NM blockade

General anaesthesia

Recovery room -Post-op Period

1.Continue monitoring

2.Post-op pain relief

3.Post-op shivering

4.O2 thru’ Mask

5.Measures to Prevent pulmonary

atelectasis

6.DVT prophylaxis

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MEDICAL COLLEGE 48

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MEDICAL COLLEGE 49

Regional anaesthesia

○ Epidural anaesthesia for outpatient gynaecological

laparoscopic procedures to reduce complications and

shorten recovery time after anaesthesia .

○ Not Been Reported For laparoscopic cholecystectomy or

other upper abdominal surgical procedures except in patients

with cystic fibrosis .

○ The high block produces myocardial depression and

reduction in venous return, aggravating the haemodynamic

effects of tension pneumoperitoneum

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MEDICAL COLLEGE 50

Local Anesthesia

Local Anesthesia With IV Sedation

Quick Recovery

Less PONV

Less Haemodynamic Changes

Early Diagnosis Of Complications

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MEDICAL COLLEGE 51

Nerve blocks for lap surgery

Peripheral nerve blocks

Rectus sheath block

Inguinal block

Para vertebral block

Pouch of Douglas block

Pre requisites:

relaxed cooperative patient

low IAP

reduced tilt

precise gentle surgical technique

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MEDICAL COLLEGE 52

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MEDICAL COLLEGE 53

COPD and LAP surgery

Risk for post operative pulmonary complications can be minimised by meticulous pre op.preparation.

Procedure time should be minimized to less than 2hrs

PFT,CXR,ABG, SpO2 in addition to history and physical examination

Cessation of smoking, adequate bronchodilators, steroids and chest physiotherapy with incentive spirometry help to reduce post op pul c/o

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MEDICAL COLLEGE 54

COPD and LAP surgery

Standard monitoring

IAP less than 12mmHg

GA with controlled ventilation

Helium for pneumo peritonium

Monitor peak airway pressure to avoid barotraumas

Minimal tilt

Multimodal approach for P.O.analgesia to avoid respiratory depression

Laparoscopic surgery in obese

patients

Obesity is defined as a body mass index (BMI) >30kg/m2.

Obesity is associated with Diabetes Mellitus, hypertension and hypercholesterolemia, angina and sudden death.

Laparoscopy is not contraindicated in healthy obese patients who experience reduced pain, faster recovery and fewer postoperative problems compared to laparotomy

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MEDICAL COLLEGE 55


patients Detrimental effect in respiratory

mechanics is due to supine position and increased weight

Carbon dioxide production and oxygen consumption are increased.

Reduced chest wall compliance & decreased lung compliance.

Functional residual capacity (FRC) will be reduced 25 per cent in the supine position, with a further reduction of 20 per cent with Anaesthesia.

Airway closure and hypoxemia, Increase in intrapulmonary shunting. Alterations to gastric function and drug

distribution.

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MEDICAL COLLEGE 56


patients

Potential airway and intubation problems

Difficulties may be encountered during intravenous access, positioning, pneumoperitoneum induction, trocar access

In obese patients, the umbilicus is located 3-6cm caudal to the aortic bifurcation, making trocarplacement more difficult.

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MEDICAL COLLEGE 57


patients Two tables may be necessary. Mechanical

lifting devices, with extra padding should be available.

Monitoring equipment such as a large blood pressure cuff, compression lower extremity stockings and pneumatic boots should be available.

Intravenous access may need to be central rather than peripheral in some cases.

Positioning should include padded stirrups with extra padding, compression devices

Towels behind shoulder blades to elevate the head, facilitating intubation and airway access .

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MEDICAL COLLEGE 58


patients

complications may be reduced by filling the peritoneal cavity with carbon dioxide (CO2) to a predetermined pressure level rather than to a preset volume

Tilt Test:Placing the patient in steep Trendelenburg for two to five minutes following intubation and positioning, observing the patient’s cardiac and respiratory indices. Patients who remain Normotensive and maintain peak airway pressures at < 30-40mmHg during the Tilt Test before and after insufflation , the surgery is relatively straightforward, producing excellent results.

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MEDICAL COLLEGE 59


patients

Postoperative Care: Early mobilisation and avoidance of the

supine position will facilitate early recovery. oxygen therapy Aggressive pulmonary care and

positioning. Abdominal pain may restrict ventilation and

ambulation. analgesia is paramount. Obese patients must have sequential

compression devices on their lower extremities

Prophylactic anticoagulation to prevent pulmonary emboli (five to 12 per cent obese patients)7.

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MEDICAL COLLEGE 60

Laparoscopy in the Elderly

Age related physiological and pathological

changes and age related concomitant

diseases

Narrow margin of safety

decrease in organ reserve

Lead to high incidence of Peri operative

complications

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MEDICAL COLLEGE 61

Laparoscopy in the Elderly

Positioning the patient:

1.Fragile osteoporotic & spondylytic

changes in vertebrae

2.Protect from nerve injury

3.Prevention of venous stasis

4.Careful tilting (increment of 5° )

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MEDICAL COLLEGE 62

Anaesthesia For Laparoscopy In

The Elderly

During intra-op period:

- to maintain EtCO2 – 35mm.Hg.

- Isoflurane less arrhythmogenic

- IAP maintained below 15mm.Hg

- Atropine to counteract ref.vagal tone

- Monitor urine out put & Electrolytes

- Careful titration of all anaesthetic agents-

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MEDICAL COLLEGE 63

Anaesthesia For Laparoscopy In

The Elderly

-During recovery—

-Exaggerated hypotension on

correcting lithotomy

- Expected delay in recovery

Inc.sensitivity to drugs.

Imp.metabolism

Delayed excretion

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MEDICAL COLLEGE 64

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MEDICAL COLLEGE 65

Lap during pregnancy

Indications:

Appendicectomy

Cholecystectomy

Ovarian cystecomy

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MEDICAL COLLEGE 66


Increased risk of acid aspiration

Increased risk of abortion/ miscarriage / premature

labor

Greater distribution volume due to increase in

blood volume

More prone to hypoxemia due to decrease in FRC

and increase in O2 consumption


Difficult airway due to wt. gain, soft tissue in the neck, breast enlargement, and laryngeal edema

Relatively safe in 8-24 wks of pregnancy.

Chances for damage to gravid uterus by Verees needle

Fetal acidosis common

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MEDICAL COLLEGE 67

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MEDICAL COLLEGE 68

SAGES recommendations for safe

lap in pregnancy

Operation in 2nd trimester before 24 wks Tocolytics therapy if risk of preterm labor Open laparoscopy for abdominal access

(HASSON’S) to avoid damage to gravid uterus IAP less than 12mmHg Continuous Fetal heart monitoring with trans

vaginal USG PaCO2 to be maintained at normal levels with the

help of EtCO2 monitor/ABG Mechanical ventilation to maintain physiologic

maternal alkalosis (pH7.44) Pneumatic compression devices to calf muscles to

prevent DVT

Lap surgery in children

Small abdominal surface and organs demand small telescopes for laparoscopy.

The abdominal surface / cavity ratio in infants and children is less than that of adults.

The abdominal wall in children is pliable and attention is needed while placing the cannulas and trocars to prevent intraabdominal injuries.

The trans umbilical open laparoscopic technique for insufflation under direct vision is recommended to prevent complications with veress-needle

Gasless laparoscopic surgery can now be performed in these children and smaller infants .

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MEDICAL COLLEGE 69


In neonates, the foramen ovale or the ductus arteriosus is potentially patent and may reopen during the procedure.

The pulmonary arterial resistance is relatively high, predisposing to reverse flow through a patent ductus arteriosus or foramen ovale.

There is a risk of reopening of right-to-left shunts, cardiac insufficiency and gas embolism into the systemic circulation which may result in cardiac ischemia and neurological damage.

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MEDICAL COLLEGE 70


In infants less than 5 kg weight, periumbilical area should not be used for port access because of risk of puncture of umbilical vessels.

Cold, non-humidified CO2 directly in to the abdominal cavity also contributes to a major risk of hypothermia

A fluid bolus of 20 ml.kg-1 can be used to offset hemodynamic effects

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MEDICAL COLLEGE 71

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MEDICAL COLLEGE 72


CO2 absorption is more intense and faster in infants

Volume of gas for creation of pneumo peritoneumis less

IAP should be limited to 5 – 10 mm Hg in neonates and infants and 10 – 12 mm Hg in older children.

Risk of injuries to vitals is higher, so care is must.

Prone for hypothermia & PONV

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MEDICAL COLLEGE 73

Key points

CO2 peritoneum results in ventilatory /respiratory changes

PaCO2 rise will aggravate cardio respiratory disturbances

Increase in EtCO2 >25% later than 30mts after beginning, suspect CO2

sub.cut.emphysema

Haemodynamic changes decrease CO and this is more in haemo

dynamically compromised patients

Preload augmentation, use of vaso dilators, clonidine and

Dexmedetomedine, high dose opioids, & beta blockers – will attenuate

pathophysiologic hemodynamic changes

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MEDICAL COLLEGE 74

Key points

In pregnancy, lap surgery can be safely performed before23 wks (avoid hypercarbia) & open laparoscopic approach to avoid injury to gravid uterus.

Gasless laparoscopy may be helpful but technical difficulty is more

Laparoscopy has proven benefits allowing quick recovery, shorter hospital stay, less p.o.pain

General anesthesia with controlled ventilation has proved to be clinically superior anesthetic technique

Improved knowledge of pathophysiology and good perimoperative monitoring permit safe management in patient with severe cardio respiratory disease

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MEDICAL COLLEGE 75

Conclusion

Laparoscopy surgery presents new

challenges to the anaesthesiologist.

A thorough knowledge of the patho

physiological changes during laparoscopy

along with vigilant monitoring is the backbone

for an uneventful and complete success.

References

Miller anaesthesia

Anaesthesia by Wiley

Anesthesia for laparoscopic surgery

review article by Jayasree Sood &V.P

Kumar

RACE-2009

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MEDICAL COLLEGE 76

THANK

YOU

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MEDICAL COLLEGE 77

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MEDICAL COLLEGE 78

Freshers

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