prof. mridul panditrao's peri-operative management of patients for laparoscopy

PERI-OPERATIVE

MANAGEMENT OF

PATIENTS FOR

LAPAROSCOPY

PROF. MRIDUL M. PANDITRAO

Consultant

Department Of Anesthesiology & Critical Care

Rand Memorial HospitalFreeport

Grand Bahama

INTRODUCTION

“LAPAROSCOPIC SURGEON” Laparos & scopos

1970s, 80s & 90s Reduction Of trauma, morbidity/mortality hospital stay, health care

costs better maintenance of

homeostasis

Soper NJ, Barteau JA et al: Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy: Surg Gynecol Obstet 1992: 174:114

Grace PA, Quereshi A, Coleman J, et al: Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 1991; 78:160.

INTRODUCTION

Why Is It so Popular????? Day Care Anesthesia/ Surgery The majority of patient population:

female Various pathological conditions Various specialties and super

specialties Smooth Post-operative course Less pain and morbidity Turns out to be cost-effective

INTRODUCTION (CONTD.)

SCOPE OF LAPAROSCOPIC PROCEDURES IN FEMALE PATIENTS

N

o

Specialty Procedure

1 Gynecological

/ Obstetric

Diagnostic laparoscopy

Laparoscopic sterilization

Laparoscopic assisted vaginal

hysterectomy

Laparoscopic assisted fertilization

procedures

Removal of unruptured ectopic / tubal

pregnancies

Ovarian cyst/rupture of ovarian cyst

Ovarian apoplexy

Torsion of uterine appendages

Reflux of menstrual blood

Differentiation between gynecological and

surgical pathologies

N

o

Specialty Procedure

2.

3.

General Surgical

Urological

Laparoscopic cholecystectomy

Nissen’s Funduplication

Diaphragmatic or Hiatus hernia repair

Appendectomy

Vagotomy

Adrenalectomy

Inguinal hernia repair

Colectomy

Nephrectomies : Partial / Radical

Living donor nephrectomy

Nephro Ureterostomy

Pyeloplasty

Pelvic lymph node dissection

Total cystectomy with ileal conduit

formation

INTRODUCTION (CONTD.)

Problem Oriented

Approach!

PROBLEMS????1. Problems due to pneumoperitoneum &

altered/ increased Intra Abdominal Pressure (IAP) :

V/Q mismatch Gas in wrong place Cardiovascular system changes

2. Problems due to improper patient selection/the actual procedure gone wrong/not performed properly

3. Problems due to positioning of the patients for laparoscopic procedures

4. Problems of peri-operative period inclusive of the anaesthetic techniques

PROBLEMS DUE TO PNEUMOPERITONEUM

‘Pneumoperitoneum’ : defined as an abnormal presence of air/gas either due to disease process or iatrogenic intervention, inside the peritoneal cavity

Air / gas (CO2) is an unnatural, unwanted and interfering agent

Patho physiologic changes

Wahba RW, Tessler MJ, Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 1996; 43:77


(CONTD.)

Intra abdominal pressure (IAP) > 15 mm Hg- domes of diaphragm get elevated leading to ↓FRC ↓Thoraco-pulmonary compliance (30-50%) in

healthy, obese as well as ASA III/IV Increased V/Q mismatches and chances of

hypoxia. So it is recommended to keep the IAP to

<15 mm Hg.Andersson LE, Baath M, Thorne A, et al: Effect of carbon dioxide pneumoperitoneum on development of atelectasis

during anesthesia, examined by spiral computed tomography. Anesthesiology 2005; 102:293. Fahy BG, Barnas GM, Nagle SE, et al: Changes in lung and chest wall properties with abdominal insufflation of carbon

dioxide are immediately reversible. Anesth Analg 1996; 82:501.7 Odeberg-Wernerman S: Laparoscopic surgery—effects on circulatory and respiratory physiology: an overview. Eur J

Surg (Suppl) 2000; 585:4.

Ventilation/Perfusion changes (V/Q)


(CONTD.)Gas in Wrong place“Verress needle”

Wrong point of insertion Wrong plane of insertion Wrong direction of insertion Subcutaneous and retro-peritoneal

emphysema In laparoscopic procedures like inguinal hernia repair

(TEPP), intentional production of extra peritoneal emphysema is imperative

Lew JKL, Gin T., Oh TE., Anaesthetic Problems during Laparoscopic cholecystectomy, Anaesth Intensive care, 1992,20, 91

PROBLEMS DUE TO PNEUMOPERITONEUM (CONTD.)

Gas in Wrong placePneumothorax

Pneumomediastinum Pneumopericardium

Operator related Through congenital / potential communications Rarely actual rupture of pericardium or dome of diaphragm.

The detection of these, entirely depends upon:

High degree of suspicion Progressively increasing ETCO

2 levels in spite of good/adequate

controlled ventilation If ABG done: increased PaCO

2 – ETCO

2 gradient

Clinically / radiologically evident gas in these areas

Spielman FJ: Laparoscopic surgery. In: Kirby DD, Hood RR, Brown DL, ed. Problems in Anesthesia: Anesthesia in Obstetrics and Gynecology, Philadelphia: JB Lippincott; 1989:151.

Knos GB, Sung YF, Toledo A: Pneumopericardium associated with laparoscopy. J Clin Anesth 1991; 3:56.Whiston RJ, Eggers KA, Morris RW, et al: Tension pneumothorax during laparoscopic cholecystectomy. Br J

Surg 1991; 78:1325.


(CONTD.)

Gas in Wrong place CO2 absorption via peritoneal cavity

Increased levels of PaCO2 in laparoscopy : from various sites & not from problems in ventilation or V/Q mismatch

ASA I-II Patients : not significant , initially In patients with pre-existing cardio-respiratory involvement,

problem becomes significant with, increased morbidity & mortality

CO2 embolism Accidental intravascular entry of needle or trocar Excessive intra abdominal insufflations leading to puncture of

vessel

Fitzgerald SD, Andrus CH, Baudendistel LJ, et al: Hypercarbia during carbon dioxide pneumoperitoneum. Am J Surg 1992; 163:186.

Wulkan ML, Vasudevan SA: Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonates with cyanotic congenital heart disease?. J Pediatr Surg 2001; 36:1234


(CONTD.)Cardiovascular System changes

Etiology: Effects of pneumoperitoneum & ↑I A P Position of the patient Preoperative cardio respiratory status of the

patient & state of intravascular volume Levels of CO2 absorption and its effects The effects of Anaesthesia / Anaesthetic agents Autonomic response of the patient’s body to

these manipulations


(CONTD.)Cardiovascular System changes

Effects Increased preload (due to indirect increase in IAP) Increased afterload due to increased systemic

vascular resistance & pulmonary vascular resistance Decreased myocardial contractility usually as a

result of general anaesthesia decreased effective cardiac output, initially

decreased MAP, increased heart rate, and later on increased blood pressure

Smith I., Benzie RJ, Gordon NLM, et al, Cardiovascular effects of peritoneal insufflations of carbon dioxide for laparoscopy Br. Med. J. 1971,:3: 410

Joris J, Honore P, Lamy M, Changes in oxygen transport and ventilation during laparoscopic cholecystectomy, Anesthesiology, 1992, 77, A149


(CONTD.)Cardiovascular System changes How to offset them: Adequately preloading the patient Using vasoconstrictors (alpha 2 agonists),p.r.n. Adequate analgesia / good sedation with Opioids

Rarely drugs like beta blockers : esmolol, metoprolol vasodilators like Clonidine or glyceryl trinitrate Rarely, acute hypoxemia, hypotension, cardiac dysrrythmias

leading to cardio-vascular collapselife threatening ventricular dysrrythmias due to vagal

stimulation, or lighter planes of general anaesthesia Shifren Jl, Adelstein L, Finkler NJ, Asystolic cardiac arrest: a rare complication of laparoscopy. Obstet.

Gynaecol.1992, 79: 840 Beck DH, McQuillon PJ, Fatal carbon Dioxide embolism and severe haemorrhage during laparoscopic

cholecystectomy, Br. J. Anaesth.1994:72: 243

PROBLEMS DUE TO IMPROPER PATIENT SELECTION/ INCOMPETENTLY CONDUCTED PROCEDURE/OPERATOR ORIENTED PROBLEMS

Conversion of closed to open procedure “Improper trocar insertion” Trocar site hernia formation Implantation of aggressive malignant

tumors Bile duct injuries, accidental division,

resection and obstruction due to accidental clamping with haemostatic clamps

PROBLEMS DUE TO IMPROPER PATIENT SELECTION/ INCOMPETENTLY CONDUCTED

PROCEDURE/OPERATOR ORIENTED PROBLEMS

Improper trocar insertion Haematomas due to injuries to inferior epigastrics,

iliac vessels Gastro-intestinal hollow visceral perforations leading

sepsis and mortality. Intra abdominal solid organ injuries like

hepatic/splenic tears. Major vessel (IVC/ abdominal aorta) injuries. Peritoneal/omental/mesenteric injuries. Retroperitoneal haematomas especially in post

operative period.

Hasson’s mini laparotomy techniqueHasson H: A modified instrument and method for laparoscopy. Aus. J. Obste.t Gynecol. 1971:70:

886

PROBLEMS DUE TO POSITIONING OF PATIENTS FOR LAPAROSCOPIC

PROCEDURES Trendelenberg/head down for

pelvic/lower abdominal surgeries, While reverse or rT/ head up for upper

abdominal quadrant surgeries eg. Cholecystectomy, Nissen’s funduplication….

In addition lithotomy in Gynecological lateral posture for Cholecystectomies


PROCEDURES

Respiratory system

Head down tilt: respiratory embarrassment, rarely endo bronchial intubation

Head up tilt/lateral tilt: may increase the dead space & V/Q mismatch

compromising an already compromised patient.


PROCEDURES

Cardiovascular system Head up tilt: fall in preload due to peripheral pooling of blood increased systemic vascular resistance Isoflurane offsets this effect in healthy patients Head down tilt: congestion to head, neck, face leading to intracranial

congestion increased ICP, increased IOP

Odeberg S, Ljungqvist O, Svenberg T, et al: Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthesiol Scand 1994; 38:276.

Batra MS, Driscoll JJ, Coburn WA, et al: Evanescent nitrous oxide pneumothorax after laparoscopy. Anesth Analg 1983; 62:1121.


PROCEDURES

Hepato/Renal and splanchnic blood flow decreased RBF, GFR, urinary output by nearly

50% Similarly elevated hepatic enzymes and

bilirubin levels Peripheral problems

femoro-popliteal venous stasis, deep venous thrombosis and thrombo-embolization

Peripheral nerve/Plexus injuries in ‘head down, arm over extended,

Common peroneal nerve injury due to improperly padded lithotomic positions.

PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC

TECHNIQUES

Related to nitrous oxide administration

Related to intravenous drugs especially opioids

Related to anaesthetic technique specifically.

ANAESTHETIC PROBLEMS????

Role of nitrous oxide Riddled with controversies?!?!?!

Available evidence: Does not interfere!!!!!

Krogh B, Jensen PJ, Henneberg Sw, et al. Nitrous Oxide does not influence operating conditions or post operative course in colonic surgery. Br. J. Anaesth. 1994; 72:55.

Taylor E, Feinstein R, White PF, Sopor N. Anesthesia for laparoscopic cholecystectomy: is nitrous oxide contraindicated? Anesthesiology; 1992: 76:541

Lemaire BM, van Erp WF: Laparoscopic surgery during pregnancy. Surg Endosc 1997; 11:15.Sukhani R, Lurie J, Jabamoni R: Propofol for ambulatory gynecologic laparoscopy: Does omission

of nitrous oxide alter postoperative emetic sequelae and recovery?. Anesth Analg 1994; 78:831.


Intravenous anaesthetics Propofol as TIVA and its cardio inhibitory effects Fentanyl and the spasm of sphincter of

Oddi/PONV Addition of isoflurane improves overall outcome Nalbuphine with minimal biliary stasis activity Parenteral NSAIDs may actually make the use of opioids redundant.

Humphrey HK, Fleming NW. Opioid induced spasm of the Sphincter of Oddi apparently reversed by nalbuphine. Anesth analg 1992; 74: 308


Anaesthetic techniques Which technique to use:

General regional

combination local

Choice is yours!

ANAESTHETIC TECHNIQUE OF CHOICE

Balanced General Anaesthesia intravenous/inhalational induction

oxygen, nitrous oxide,

muscle relaxant, endo tracheal

intubation and an opioid!

PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC TECHNIQUES

Inclusion Criteria Before opening abdomen Female patients in reproductive age

group ASA I- II grade Upper abdominal procedures Pelvic surgical procedures Moderate Obesity Adequate infra structure and surgical

skill level

PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF THE ANAESTHETIC TECHNIQUES

Exclusion Criteria Emergent, suspected coagulopathy/Sepsis Cardiopulmonary disorders:IHD, Asthma,

COPD H/O Old surgical operations in the lower

part of the abdominal cavity/ Total adhesive process in abdominal cavity

Third trimester of pregnancy Sizeable pathological formation Decompensated internal hemorrhage

PRE-OPERATIVE PREPARATION

Detailed History Thorough Examination/Clinical

Assessment Routine Investigations Special Investigations Intravenous Access Pre-Anaesthetic Medications Monitoring

INTRA-OPERATIVE MANAGEMENT

Preoperative evaluation ASA I and II patients - routine In IHD or COPD- proper evaluation with 2D ECHO and

dynamic pulmonary function tests; minimal requirement of LVEF in IHD patients is < 30%

Hepato renal compromising drugs- avoided: halothane, anti-biotics…

Precautions for prevention of venous stasis, nerve injury : deep vein thrombosis prophylaxis, padding with elastic bandages

Monitoring: Routine ---- to ---- TEE, Pre-induction oxygenation: To avoid need of mask

ventilation inadvertent stomach inflation & accidental puncture during trocar placement & to reduce incidence of PONV

TECHNIQUE OF CHOICE

Induction with intravenous agent in compromised patients sevoflurane Cuffed ET tube: using newer non

depolarizing muscle relaxants like rocuronium

Controlled ventilation, ETCO2 , NMBD and Isoflurane/ Desflurane

Preemptive preloading with a suitable crystalloid or colloid

TECHNIQUE OF CHOICE

Nasogastric tube, urinary catheter which decrease: the problems of bladder puncture, GI puncture improved visualization post operative gastric distension and PONV. Positioning of patient requires meticulousness Reconfirmation of endotracheal tube position insertion of needle, production of

pneumoperitoneum: gentle and gradual Trocar placement :professionally perfect

TECHNIQUE OF CHOICE

IPPV adjusted to avoid hyperventilation & paradoxical pressure increase: to increase the rate than tidal volume

The ETCO2 to be maintained between 35-40 mm Hg intravenous fluids, colloids, dobutamine/ inotropic

support, Isoflurane will help in decreasing SVR If required glyceryl trinitrate infusion to be used arrhythmias due to peritoneal stretching :

stoppage of insufflations atropine or glycopyrrolate deepening the plane of anaesthesia Continuous monitoring of IAP

TECHNIQUE OF CHOICE Complications like subcutaneous emphysema, pneumothorax

or pneumomediastinum must be kept in mind If not possible to monitor PaCO2 with Serial ABG: signs of

hypercapnia: unexplained tachycardia, hypertension, dysrrythmias, without significant rise in ETCO2, : high degree of suspicion.

Multimodal analgesia : preoperative / intraoperative opioids like Butorphanol / Nalbuphine,

intramuscular/ intravenous parenteral NSAIDs/paracetamol at the end of surgery local infilteration using Bupivacaine

Extubation

Michaloliakou C, Chung F, Sharma S. Pre-operative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth analg; 1996: 82: 44-51.

INTRA-OPERATIVE MANAGEMENT

laparoscopy in its true sense is a team approach

Respect for each member specialty of the team!

Absolutely essential!!!!!

POST-OPERATIVE MANAGEMENT

Monitoring Pain Management is easier Road worthiness of Day cases Follow up or Decision to admission and inpatient

care

RECENT ADVANCES

Laparoscopy & it’s anaesthesia have not yet matured !

Surgical techniques: Robotic laparoscopy Noble gases for insufflations: Inert gases like

helium and argon Laplift / Gasless laparoscopy Combination of laplift with low IAP< 5 mm Hg

with CO2

RECENT ADVANCES Anaesthetic management: Suitable number of young healthy patients :

laryngeal mask airway, spontaneous respiration Local analgesic solutions infusion: intra-peritoneal,

port site or in abdomen layers Local / regional techniques; patient discomfort,

shoulder pain, high level & CVS instabilty Local / regional techniques: Combination of spinal

bupivacane 0.75%+ I V Propofol (bolus- .4mg/kg &

infusion .1- 1.5 mg/kg/hr) or I V ketamine (bolus- .1mg/kg &

infusion .3- 1.0 mg/kg/hr or Ketofol (Their combination)

Ali Y, El masry MN et al: The feasibility of Spinal anesthesia with sedation for laparoscopic general abdominal proceduresin moderate risk patients: MEJ Anaes 19 (5)Yi JW, Choi SE: Laparoscopic cholecystectomy performed under regional anesthesia in a pt undergone pneumonectomy: Korean J. Anesthesiol 56 (3) 330-33.

CONCLUSION

Laparoscopy has come in as a boon Conventional/ Open methods definitely

have higher morbidity and mortality Should not be taken lightly Deep circumspection of patho

physiologic changes involved, complications that can happen and how to prevent them and overcome them.

CONCLUSION

A problem oriented team approach

Interdisciplinary respect total peri-operative management dispel myths / auras very precise, clear cut and

evidence based guidelines

prof. mridul panditrao's peri-operative management of patients for laparoscopy

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