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Anesthesia for Laparoscopic Interventions. Peter Biro Department of Anesthesiology University Hospital Zurich peter.biro@usz.ch. The „Good“. Advantages. Better cosmetic results Less pain, less analgesics required Shorter in-hospital stay Less complications (outcome?)

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Anesthesia for Laparoscopic Interventions


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anesthesia for laparoscopic interventions

Anesthesia for Laparoscopic Interventions

Peter Biro

Department of Anesthesiology

University Hospital Zurich

peter.biro@usz.ch

advantages
Advantages
  • Better cosmetic results
  • Less pain, less analgesics required
  • Shorter in-hospital stay
  • Less complications (outcome?)
  • Better pulmonary function (in particular in obese patients)
  • Fast recovery, better comfort
cholecystectomies in my hospital

240

210

180

150

120

90

60

30

0

1990

1991

1992

1993

1994

1995

1996

1997

2001

2002

Open

Laparoscopic

Cholecystectomies in my Hospital
cholecystectomies in my hospital5

240

Open portion

50%

210

180

150

120

90

60

30

0

1990

1991

1992

1993

1994

1995

1996

1997

2001

2002

Open

Laparoscopic

Cholecystectomies in my Hospital
cholecystectomies in my hospital6

240

Open portion

33%

210

180

150

120

90

60

30

0

1990

1991

1992

1993

1994

1995

1996

1997

2001

2002

Open

Laparoscopic

Cholecystectomies in my Hospital
cholecystectomies in my hospital7

240

Open portion

13%

210

180

150

120

90

60

30

0

1990

1991

1992

1993

1994

1995

1996

1997

2001

2002

Open

Laparoscopic

Cholecystectomies in my Hospital
slide8

Gynecologist

Surgeon

Urologist

Diagnostic

Intestinal

Herniotomy

Liver

Spleen

Fundioplication

Cholecystectomy

Esophagus

Axillar lymphonodes

Gastric banding

Adrenalectomy

Parathyreoidectomy

Diagnostic

Nephrectomy

Kidney cysts

Prostatectomy

Varicocele

Lymphadenectomy

Testicular descensus

Diagnostic

Tubar ligation

Adnexectomy

Ovarectomy

Lymphadenectomy

Endometriosis

Myomectomy

Axillar lymphonodes

what about the anesthetist
What about the Anesthetist?

General Anesthesia

&

Perioperative maintenanceof vital functions

...and comfort

mechanical effects of pneumoperitoneum
Mechanical Effects of Pneumoperitoneum
  • Elevated intra- and retroperitoneal pressure
  • Diaphragma displacement to cranial
  • Elevated intrathoracic pressure
  • Increase of airway pressure
  • Decrease of total respiratory compliance
  • Gas embolism (risk of)
effects on pulmonary function
Effects on Pulmonary Function
  • Change of FEV1 (post- vs. preoperative) ―55% ―30%
  • Duration till return to baseline FEV1 9.5 days 5 days
  • FRC on 1st postoperative day ―20% ―34%
  • PEF25-75% on 2nd postoperative day ―50% ―25%
  • Confirmed post operative atelectasis (X-ray) ―90% ―40%

Open vs. Laparoscopic

Cholecystectomy

other effects of pneumoperitoneum
Other Effects of Pneumoperitoneum
  • Resorption of CO2 (hypercarbia, acidosis)
  • Increase of PCO2 (arterial and end-tidal)
  • Acidosis
  • Increase of lactic acid
  • Hormonal changes (catecholamines, vasopressin)
  • Aggravation or improvement of side effects due to posture...but oxygenation remains basically unchanged
hemodynamic effects of pneumoperitoneum
Hemodynamic Effects of Pneumoperitoneum
  • Increase of atrial filling pressures (right: CVP, left: wedge pressure)
  • Increase of heart rate
  • Increase of both, systemic and pulmonary vascular resistance
  • Increase of both, arterial and pulmonary blood pressure
  • Cardiac output and intrathoracic blood volume show unconsistent changes in both directions
hormonal effects of pneumoperitoneum
Hormonal Effects of Pneumoperitoneum
  • Increase of...
    • Vasopressine
    • Dopamine
    • Adrenaline
    • Noradrenaline
    • Renine
    • Cortisone

► sympatho-adrenergical stimulation, „stress“ metabolism

example for overlaping effects

Baseline

Pneumoperitoneum

Example for Overlaping Effects

mmHg

Beats/min

Dyne/s/cm-5/20

120

120

120

100

100

100

80

80

80

60

60

60

40

40

40

MAP

HR

SVR

co 2 homeostasis and pneumoperitoneum
CO2 Homeostasis and Pneumoperitoneum
  • CO2 uptake in 2 phases:
    • Initially fast resorption for app. 30 minutes
    • Followed by equlibration on higher level (>30% of baseline)
  • If spontaneous ventilation possible ►increase of alveolar ventilation
  • V/Q mismatch leads to arterio-alveolar CO2 difference. ► invasive blood gas measurements mandatory in high risk patients (>ASA III)
patients at cardial risk
Patients at Cardial Risk
  • Due to...
    • acute elevated afterload
    • and sometimes decreased preload (head up posture)
  • ► one must aplly:
    • invasive arterial blood pressure measurement
    • In case of cardial insufficiency / pulmonary hypertension: TEE, Swann-Ganz catheter
    • IAP not above 10 mmHg

or even better

...arrangement for or transition to

open surgical procedure

in neutral horizontal position

patients at cardial risk19
Patients at Cardial Risk
  • Measures to improve situation (before transition to open surgical approach)...
    • Reduction of afterload with vasodilators
    • Carefull fluid replacement (under continuous TEE controll)
    • Application of positive inotropic and vasodilating agents such as dobutamine or phosphodiesterase inhibitors
  • Immediate measures in case of dramatic cardial deterioration:
    • reversal of pneumoperitoneum (stop CO2 inflow, deflate abdomen)
    • reversal of head down position to neutral or slightly elevated
organ perfusion and pneumoperitoneum
Organ Perfusion and Pneumoperitoneum
  • Decrease of...
    • gastrointestinal blood flow (in particular with IAP > 15 mmHg)
    • renal blood flow
  • Increase of...
    • cerebral blood flow (cave: patients with elevated intracranial pressure)
pneumoperitoneum and pregnancy
Pneumoperitoneum and Pregnancy
  • Increase of intrauterine pressure
  • Decrease of uterine blood flow
  • Decrease of fetal blood pressure

Consequences have to be evaluated on an individuall scale. Eventually consideration of

open surgical procedure

in neutral horizontal position

pneumoperitoneum and pregnancy22
Pneumoperitoneum and Pregnancy
  • Cholecystectomy is the most often perfomed non-obstetric surgical intervention in pregnancy
  • Meanwhile 50% are performed in laparoscopic mode
  • However,...
    • surgery before 20th week of gestation bears elevated risk for preterm birth
    • No evidence for difference in malformation frequency in open vs. laparoscopic surgery

Actually there is no general contraindication for

laparoscopic surgery

in pregnancy

pediatric surgery
Pediatric Surgery
  • Since the nineties laparoscopy usual for neonates and toddlers
  • Hemodynamic effects are more pronounced
  • ►Therefore...
    • ► limit IAP to < 8 mmHg
    • ► table positioning angle not exceeding ±15°
    • ► avoid vagal reflexe (bradycardia)
    • ► not recommended for emergency operations
morbid obesity
Morbid Obesity
  • Higher rate of complications (+18%)
  • Longer in-hospital stay (4-5 days more)
  • However, laparoscopic procedures have strong advantages...
    • less problems with wound healing
    • less tendency for burst abdomen
    • early mobilization
co 2 homeostasis and pneumoperitoneum25
CO2 Homeostasis and Pneumoperitoneum
  • Amount of CO2 uptake is dependent on intraabdominal pressure (IAP) and duration of pneumoperitoneum
  • With IAP < 10 mmHg hyperkapnia is unlikely
  • After discontinuation of pneumoperitoneum fast reversal of hypercarbia even without forced hyperventilation
complications
Complications
  • Aspiration of gastric content
    • Intraoperative occurrence up to 6%
    • in 50% of cases reflux of gastric acid
  • Consequences
    • ► gastric tubing
    • ► tracheal intubation (no laryngeal mask or similar supraglottic devices)
complications27
Complications
  • Secondary unilateral bronchial ETT displacement
  • Etiology
    • diaphragma elevation
    • airway shifts upwards while ETT is fixed at teeth level
  • Consequences
    • ► ETT advancement not deeper than 20 cm
    • ► carefull checking and ►re-checking of bilateral ventilation (in case of doubt fiberbronchoscopy)
complications28
Complications
  • Hypothermia
    • not less than in open surgery ► use patient warming devices as usual
  • Smoke resorption
    • carbon monoxide (CO) poisoning possible ►check blood gases regularly
  • Surgical emphysema
    • due to improper CO2 insuflation ►check for airway obstruction
  • Vascular injury and bleeding
    • may occurr during insertion of scope ►avoidance by muscular relaxation
complications29
Complications
  • Pneumothorax
    • ► stop CO2 inflow, ► deflate abdomen, ► insert thoracic drainage
  • Pneumomediastinum
    • typical for surgery of diaphragma or esophagus
    • differencial diagnosis to pneumothorax or gas embolism necessary
    • risk of pericardial tamponade
    • ► diagnosis to be made with echoecardiography
complications30
Complications
  • Gas (CO2) embolism
  • Etiology
    • intravasal gas insufflation (CO2 voulme 5x larger than for air)
  • Symptoms
    • fast decrease of PetCO2
    • decrease of oxygen saturation (SpO2) without change of airway pressure
    • Hypotension
    • Cardiac arrhytmia
    • Precordial „mill wheel sound“
  • ► Measures
    • stop CO2 inflow, ► deflate abdomen, ► left tilt position, ► aspiration of gas via central venous line
side effects
Side Effects
  • Postoperative pain
    • positive correlation to level and duration of IAP and intraabdominal pH
    • projection into the shoulder due to irritation of diaphragm
    • sometimes free interval up to 24 hours
    • duration up to 3-4 days
  • ►Therapy
    • multi modal analgesia (combination of different drugs and application modalities according to standardized protocolls)
side effects32
Side Effects
  • Postoperative Nausea and Vomiting (PONV)
    • more in laparoscopic than in open surgery (in particular gynecology)
    • young females < 30 years
    • non smokers
    • early pregnancy
    • first phase of menstruation
    • amount of CO2 uptake
  • Therapy
    • corticoids, 5-HT3 antagonists, dehydrobenzperidol

Schulte Steinberg H., Euchner Wamser I., Zalunardo M.P. Anästhesie für laparoskopische Eingriffe. Anaesthesist 1999, 48: 755-768