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Journal of Clinical Anesthesia (2006) 18, 67–78 Anesthesia for laparoscopy: a review

Journal of Clinical Anesthesia (2006) 18, 67–78 Anesthesia for laparoscopy: a review. Frederic J. Gerges MD (Chief Resident), Ghassan E. Kanazi MD (Associate Professor), Samar I. Jabbour-khoury MD (Associate Professor)* R 2 류 형 석. 1. Introduction.

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Journal of Clinical Anesthesia (2006) 18, 67–78 Anesthesia for laparoscopy: a review

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  1. Journal of Clinical Anesthesia (2006) 18, 67–78Anesthesia for laparoscopy: a review Frederic J. Gerges MD (Chief Resident), Ghassan E. Kanazi MD (Associate Professor),Samar I. Jabbour-khoury MD (Associate Professor)* R2류 형 석

  2. 1. Introduction 1950년대 후반 GY의 Pelvic pain의 진단에서 시작되었으며 그 후 GS수술로 확대 장점 1) Reduction of postoperative pain 2) Better cosmetic results 3) Quicker return to normal activities 4) 재원기간의 단축 -> 병원비 감소 5) Intraoperative bleeding 감소 6) Postoperative pulmonary complications 감소 7) Postoperative wound infection 감소 8) 대사 변화 감소 9) Better postoperative respiratory function

  3. 2. The choice of insufflated gas 1) Laparoscopy의 이상적인 가스의 특성 (1) Minimal peritoneal absorption (2) Minimal physiological effects : r/o nitrous oxide (3) Rapid excretion of any absorbed gas (4) Inability to support combustion(연소) : r/o Air and oxygen (5) Minimal effects from intravascular embolization : r/o Helium and nitrogen (6) High blood solubility 2) Carbon dioxide Primary gas in laparoscopy. 남은 가스가 빠르게 흡수 -> 수술 후 불편감 을 최소화 But, Peritoneum내 혈관으로 흡수 ->Hypercapnia & Intravascular embolization 가능성

  4. 3) Gasless laparoscopic technique (1) Abdominal wall lift -> an intra-abdominal space 만듦 (2) 결과적으로 다음의 문제를 일으키지않음 (vs CO2 laparoscopy) (a) Increased intra-abdominal pressure (IAP) (b) Hypercapnia, and carbon dioxide embolization. -> Better cardiovascular condition (lower preload and afterload) (3) 수술후 인지기능의 빠른회복 (4) 고령환자와 심폐기능 장애를 가진환자에 있어서 유리 ( Ex. Laparoscopic cholecystectomy) 4) Low-pressure (5-7 mm Hg) pneumoperitoneum gasless방법과 비교 시 큰 단점 없음 -> Abdominal wall lifting combined with low-pressure pneumoperitoneum: good alternative

  5. 3. Pathophysiological changes duringlaparoscopy 1.Effects of carbon dioxide absorption 2.Creation of the pneumoperitoneum 1) Cardiovascular effects 2) Respiratory effects 3) Neurologic effects 3.Patient positioning 1) Cardiovascular changes and patient positioning 2) Respiratory changes and patient positioning

  6. 1.Effects of carbon dioxide absorption 1) Extraperitoneal carbon dioxide diffuse -> Paco2 증가 (tension of carbon dioxide in arterial blood) -> Minute ventilation를 증가시켜 Etco2 감소 시킨다 2) Sympathetic nervous system의 활성화 Increase in (a) blood pressure (b) heart rate (c) myocardial contractility (d) arrhythmias

  7. 2.Creation of the pneumoperitoneum 1) Cardiovascular effects (1) Major hemodynamic changes (a) Arterial blood pressure의 변화 (b) Arrhythmias (c) Cardiac arrest (2) Cardiovascular changes 의 원인 (a) Pneumoperitoneum ( IAP ) (b) Volume of carbon dioxide absorbed (c) Intravascular volume (d) Ventilatory technique (e) Surgical conditions (f) Anesthetic agents used (3) Cardiovascular function에 영향을 미치는 요소 : IAP and patient position

  8. IAP IAP < 15 mmHg -> venous return 증가 Lower IAP -> cardiac output 증가 : cardiac filling pressures증가 Hypercapnia -> cardiac efferent sympathetic activity증가 ->systemic vascular resistance 증가 & cardiac index감소 If, IAP > 15 mm Hg : Venous return 감소 -> cardiac output감소 ->hypotension 최근에는 IAP는 12mmHg이하를 추천 Patient position Horizontal position이 head-up & down보다 hemodynamic changes가 안정 Hemodynamic changes (a) Vasovagal reflex (stimulation from trocars or insufflation) (b) Myocardial sensitization by halothane (c) Reduced venous return ( by reverse Trendelenburg position) (d) Inferior vena cava compression (e) High insufflation pressures (f) Hypovolemia, hypercapnia in longer procedures (g) Venous gas embolism.

  9. 2.Creation of the pneumoperitoneum 2) Respiratory effects (1) Lung volumes의 감소 (2) Peak airway pressures 증가 (3) Pulmonary compliance 감소( By IAP증가 &position ) * Noneffective ventilation으로 pulmonary vasoconstriction을 야기시켜 hypercapnia and hypoxemia를 일으킬수 있다 * Higher IAP Thoracic compliance 감소->pneumothorax & pneumomediastinum * Pulmonary dysfunction 환자 : Preoperative : pulmonary function testing시행 (including arterial blood gas analysis) Intraoperative: radial artery cannulation * If refractory hypoxemia, hypercapnia, or high airway pressures occur during the laparoscopy -> Pneumoperitoneum should be released followed by slow reinsufflation using lower IAPs. If complications recur -> open procedure로 전환

  10. 2.Creation of the pneumoperitoneum 3) Neurologic effects Systemic vascular resistance의 증가, head-down positioning, and elevated IAP로 인하여 hypercapnia 가 발생하며 이로 인해 -> cerebral perfusion pressure의 감소 -> ICP증가

  11. 3.Patient positioning 1) Cardiovascular changes and patient positioning (1) Head-up position (a) Venous return and cardiac output 감소 (b) Mean arterial pressure and cardiac index 감소 (c) Peripheral and pulmonary vascular resistance 증가 (2) Head-down position Venous return 증가 and normalizes blood pressure 2) Respiratory changes and patient positioning Trendelenburg position이 reverse trendelenburg position 보다 respiratory function 을 악화시킨다

  12. 4. Patient monitoring Routine moniotoring o Electrocardiogram o Noninvasive arterial pressure monitor o Airway pressure monitor o Pulse oximeter o Etco2 concentration monitor o Peripheral nerve stimulation o Body temperature probe * For hemodynamically unstable patients : Arterial cannulation & urine output measurement

  13. End-tidal carbon dioxide Ventilation의 적정성을 평가하는 Paco2의 비침습적 대용 V/Q mismatching의 가능성으로 인해 다를 수 있다 Cardiopulmonary function이 떨어져 있는 경우 arterial blood gas analysis를 통해 Paco2를 측정 (hypercarbia여부) Radial artery cannulation 이 필요한 경우 Preoperative cardiopulmonary disease Intraoperative hypoxemia가 나타난 경우 High airway pressures Etco2 의 변화가 클 경우

  14. Airway pressure monitor High airway pressure alarm : detection of excessive elevation in IAP Nerve stimulation Adequate muscle paralysis정도 판별 Reduces the IAP Prevents sudden patient movement Awareness Bispectral Index, a possible monitor of depth of hypnosis,

  15. 5. Anesthetic techniques 1. General anesthesia for laparoscopy 2. Regional anesthesia for laparoscopy 1. Peripheral nerve blocks 1. Rectus sheath block. The rectus sheath block, 2. Rectus sheath block and mesosalpinx block. 3. Inguinal block 4. Pouch of Douglas block 5. Paravertebral block 2. Neuraxial blocks 1. Epidural anesthesia 2. Spinal anesthesia 3. Combined spinal-epidural anesthesia 4. Caudal epidural block 3. Local anesthetic infiltration

  16. 1. General anesthesia for laparoscopy Inhalational agents : N2O, Sevo., Iso., Des. Intravenous agents : thiopentone, propofol, etomidate Muscle relaxants : succinylcholine, mivacurium, atracurium, vecuronium Agents of choice : Shorter-acting drugs Ex. Sevoflurane., Desflurane, and propofol Propofol : Less postoperative nausea and vomiting (PONV) Rapid and shorter-acting volatile anesthetics ( Des & Sevo) and ultrashort-acting opioid analgesics ( Remifentanil) Auditory evoked potential or Bispectral Index monitor -> Reduction in the anesthetic requirement -> Shorter postanesthesia care unit stay & Improved quality of recovery

  17. TIVA : propofol, midazolam and ketamine + alfentanil + vecuronium 주로 outpatient laparoscopy. * 흡입마취제의 사용 선호 : Propofol-based anesthesia 는 PONV의 낮은 발생에도 불구하고 수술중 각성및 more frequent movement 가능성 Perioperative awarenessand PONV Opioid-based techniques시 발생가능성이 높음 Opioid supplementation ofintravenous or inhalation-based anesthesia 가 적당 Ultrashort-acting opioid remifentanil선호 (vs alfentanil ) Advantage of remifentanil o Cardiovascular responses가 약하다 o Postoperative respiratory depression이 적다 o Delayed recovery가 약하다. o 그러나, Postoperative analgesia를 support 해야 함 * Nonopioids (acetaminophen, NSAID, a2-agonists, N-methyl D-oaspartate antagonists)의 복합적이 사용은 opioid 요구량 감소와 회복의 지연을 막는데 유용.

  18. Nitrous oxide o Perioperative analgesia o Inhaled or intravenous anesthetics요구량 감소 o Nausea and vomiting 에는 still controversial Succinylcholine o choice for short laparoscopic procedures o postoperative muscle pains가능성이 높다 Nondepolarizing NeuroMuscular Blocking Agents o Currently considerable choice o Muscle pain (especially in the neck) 감소 o Shoulder pain is still common (consequence of the pneumoperitoneum)

  19. Endotracheal intubation and controlled ventilation Safest technique Long laparoscopic procedures에 적당 COPD and pneumothorax or bullous emphysema 환자의 경우 Increase in respiratory rate rather than tidal volume : avoid increased alveolar inflation reduce the risk of pneumothorax Anesthetic agents that directly depress the heart avoided in patients with compromised cardiac function -> Vasodilating properties such as isoflurane Infusion of vasodilating agents, such as nicardipine pneumoperitoneum 으로 인한 hemodynamic 영향을 감소 Increases of vagal tone during laparoscopy Atropine을 마취전에 투여 필요시 투여 가능

  20. 2. Regional anesthesia for laparoscopy Advantages: (a) Quicker recovery (b) Decreased PONV (c) Less postoperative pain (d) Shorter postoperative stay (e) Cost effectiveness (f) Improved patient satisfaction (g)Overall safety (h) Early diagnosis of complications (i) Fewer hemodynamic changes Regional anesthesia for laparoscopy 의 조건 o Relaxed and cooperative patient o Low IAP to reduce pain and ventilatory disturbances o Reduced tilt o Precise and gentle surgical technique o Supportive operating room staff Intravenous sedation : anxiety, pain, and discomfort Pneumoperitoneum and sedation 으로 인하여 Hypoventilation and Arterial oxygen desaturation 가능성 Laparoscopic tubal ligation : good indication Cix : Multiple puncture sites가 필요한 수술 considerable organ manipulation & 가파른 tilt voluminous pneumoperitoneum

  21. 2. Regional anesthesia for laparoscopy 1. Peripheral nerve blocks 1. Rectus sheath block. 2. Rectus sheath block and mesosalpinx block. 3. Inguinal block. 4. Pouch of Douglas block. 5. Paravertebral block. 2. Neuraxial blocks 1. Epidural anesthesia. 2. Spinal anesthesia. 3. Combined spinal-epidural anesthesia. 4. Caudal epidural block. 3. Local anesthetic infiltration

  22. 2. Neuraxial blocks 주로 GY Laparoscopy의호흡에 큰 장애가 없는 환자에서 적용 Awake patients는 arterial blood gases 가 정상치를 유지 Advantages o Reducing the need for sedatives and narcotics o Better muscle relaxation 종류 1. Epidural anesthesia. 2. Spinal anesthesia. 3. Combined spinal-epidural anesthesia. 4. Caudal epidural block.

  23. 1. Epidural anesthesia o Outpatient laparoscopy에 보다 안전 (without associated respiratory depression) o Abdominal distension으로 인한 diaphragmatic irritation은 Shoulder pain을 유발 -> Extensive sensory block (T4 through L5) is necessary for surgical laparoscopy and may also lead to discomfort. o Epidural administration of opiates and/or clonidine might help to provide adequate analgesia o Gasless laparoscopy for GY surgery with epidural anesthesia -> comfort and more adequatepain relief cardiorespiratory function에 큰 영향 X o COPD환자 : Epidural anesthesia 가 더 safely and effect Ix > Laparoscopic cholecystectomy, Laparoscopic extraperitoneal herniorrhaphy

  24. 2. Spinal anesthesia. Trendelenburg position은 spinal block을 cephalad spread 가능성 -> a greater sympathetic block, bradycardia, & hypotension -> reduced doses of the local anesthetics or hypobaric solutions minimizes side effects Ex.) hypotension, bladder distension, prolonged sensory and motor block traditionally associated with conventional doses EX.> o Lapa. extraperitoneal inguinal hernia repair underspinal Ane. : extraperitoneal nitrous oxide insufflation o Lapa. cholecystectomy under spinal Ane. with nitrous oxide pneumoperitoneum * Severe COPD Pt.:Lapa. intraperitoneal inguinal hernia repair : spinal anesthesiausing hyperbaric bupivacaine is an effective * Gasless laparoscopy and microlaparoscopy등으로 인해 추후 spinal ane가 더 늘어날 것이다

  25. 3. Combined spinal-epidural anesthesia. 대부분의 환자에서 chest pain과 함께 severe agitation생김 -> not recommend 4. Caudal epidural block. effective modality for providing postoperative analgesia after laparoscopic hernia surgery in children. -> lower pain scores & 수술후 추가적인 진통제를 필요로 하지 않음 -> earlier hospital discharge

  26. 3. Local anesthetic infiltration * microlaparoscopy : external diameters 1.2 ~ 2.2 mm. Local anesthetic infiltration : safe, effective, and less cost Ix. : Infertility, chronic pelvic pain, and tubal ligation polycystic ovarian syndrome 장점 o Early hospital discharge, o 추가적인 postoperative additional analgesia필요없음 unsuitable for microlaparoscopy Obese patients Patients with multiple adhesions from previous surgery Laparoscopic cholecystectomy under GA preinsertion of local anesthesia at the trocar site -> Reduces postoperative pain and decreases medication usage costs Intraperitoneal spray of local anesthetic -> significantly postoperative pain감소

  27. 6. Recovery after laparoscopy 1. Postoperative pain 1. Local anesthesia. 2. Nonsteroidal anti-inflammatory drugs 3. Opioids 4. Multimodal analgesia techniques 5. Other analgesic techniques 1. Anticholinergic drugs. 2. Tramadol. 3. Acetaminophen. 4. a2 Agonist. 2. Postoperative nausea and vomiting 1. Anesthetic technique 2. Antiemetic medications

  28. 1. Postoperative pain 1) Local anesthesia. Reduce postoperative pain Delay the requirement for rescue analgesics 2) Nonsteroidal anti-inflammatory drugs opioid-related side effects가없다 adjuvant during and after surgery desirable in outpatients 3) Opioids Effective in treating pain after laparoscopic procedures associated with numerous side effects : nausea, respiratory depression, and sedation, Especially undesirable in outpatients. 4) Multimodal analgesia techniques Combining opioids, local anesthetics, and NSAIDs Limiting side effects Reducing postoperative pain & analgesic requirements Earlier return to normal activities

  29. 5). Other analgesic techniques (1) Anticholinergic drugs. Glycopyrrolate reduced patient pain scores reduced requirements for morphine But, buscopan failed to achieve the same results (2) Tramadol. weak opioid reducing pain scores and opioid analgesic requirements (3) Acetaminophen. Combinations of acetaminophen with either dextropropoxyphene or codeine : effective as tramadol (4) a2 Agonist. Dexmedetomidine has sedative, hypnotic, and analgesic properties.

  30. 2. Postoperative nausea and vomiting 1. Anesthetic technique Propofol : lowest incidence of PONV, Nitrous oxide : increase the incidence Opioids : potent cause of PONV NSAIDs and opioids : better control postoperative pain decreasing opioid-related side effects. 2. Antiemetic medications o Ondansetron (an antagonist of the 5-HT3 receptor) : effectiv, end of surgery시 효과적 o Dolasetron and granisetron (other 5-HT3 antagonists) : effective o Dexamethasone : reduced PONV in the first 24 hours after laparoscopic sterilization and reduced the requirement for rescue antiemetics

  31. 7. Contraindications for laparoscopy Absolute contraindications Laparoscopy include shock Markedly increased ICP Severe myopia and/or retinal detachment Inadequate surgical equipments Inadequate monitoring devices. Relative contraindications Bullous emphysema History of spontaneous pneumothorax Pregnancy Life-threatening emergencies Prolonged laparoscopy more than 6 hours associated with acidosis and hypothermia New laparoscopic procedures

  32. 8. Complications of laparoscopy 1. Inadvertent extraperitoneal insufflation 2. Pneumothorax 3. Pneumomediastinum and pneumopericardium 4. Vascular injuries 5. Gastrointestinal injuries 6. Urinary tract injuries

  33. 1. Inadvertent extraperitoneal insufflation 1) Misplacement of the Veress needle intravascular,subcutaneous tissue, preperitoneal space, viscus, omentum, mesentery, or retroperitoneum -> insufflation of carbon dioxide 2) Direct intravascular gas insufflation ( abdominal wall or peritoneum vessel ) -> gas embolism -> hypotension, cyanosis, dysrhythmias,and asystole Initially, sudden increase in etco2 concentration * If gas embolism is suspected -> a) carbon dioxide insufflation stop & abdomen deflated b) 환자를 left lateral decubitus with a head-down position ( gas to rise into the apex of the right ventricle and prevent entry into the pulmonary artery.) c) Hyperventilation with 100% O2 d) central venous catheter -> aspiration of gas e) aggressive cardiopulmonary resuscitation

  34. subcutaneous emphysema. Subcutaneous insufflation of carbon dioxide crepitus over the abdominal and chest wall Sx.> Increase in airway pressures and etco2 concentrations-> Significant hypercapnia and respiratory acidosis Mx.> resolves soon after the abdomen is deflated and nitrous oxide is discontinued to avoid expansion of carbon dioxide–filled space

  35. 2. Pneumothorax 1) gas 가 thorax로 이동 through a tear in the visceral peritoneum breach of the parietal pleura during dissection around the esophagus 2) spontaneous rupture of preexisting emphysematous bulla. 3) subcutaneous emphysema in the neck and face -> gas tracking to the thorax and mediastinum -> pneumothorax or pneumomediastinum 특징 asymptomatic increase peak airway pressures decrease oxygen saturation ( severe cases) significant hypotension and cardiac arrest Treatment close observation chest tube placement

  36. 3. Pneumomediastinum and pneumopericardium subcutaneous emphysema가 cervical region에서 thorax와 mediastinum으로 나가서 만들어진다 management o depends on the severity of associated cardiopulmonary dysfunction o Release of the pneumoperitoneum 4. Vascular injuries Accidental insertion of the Veress needle or trocar into major vessels aorta common iliac vessels inferior vena cava cystic or hepatic artery Other minor vascular injuries involve the abd. wall vessels

  37. 5. Gastrointestinal injuries Gastrointestinal injuries : small intestine, colon, duodenum, and stomach Lacerations of the liver, spleen, and colonic mesentery minimize stomach injuries :Gastric decompression before placement of Veress needle 6. Urinary tract injuries Although injuries to the bladder and ureters are rare, decompression of thebladder by placement of a urinary catheter before laparoscopy is advisable

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