CHAPTER 28

ANAESTHESIA FOR ABDOMINAL SURGERY

Outline:

Points of importance associated with anaesthesia for abdominal

surgery

Techniques for anaesthesia

Regional
General

Anaesthesia for Laparoscopy

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POINTS OF IMPORTANCE ASSOCIATED WITH ANAESTHESIA
FOR ABDOMINAL SURGERY
Good relaxation of the anterior abdominal wall muscles
The posterior sheath of the rectus and the transversus muscles are fused
with the peritoneum in the upper abdomen. Hence when the peritoneum
is sutured at the end of the operation the muscles need to be well relaxed. If
the surgeon is unable to close the peritoneum due to inadequate muscle
relaxation, a further dose of relaxant may be given.
It is, however, important to make sure that the problem is due to a lack of
relaxant and not to some other factor, e.g. gastric distension. If the patient
has not had any relaxant drugs for a period of 20 minutes and if there is no
contraindication, then another small dose of relaxant may be given to assist
the surgeon.
The maintenance of adequate ventilation
This is achieved by IPPV using a relaxant technique. However, ventilation
may be impaired by the presence of packs and retractors in the upper
abdomen.
The prevention of shock and cardiovascular depression
This may be caused by:
• Pre-operative hypovolaemia
• Intra-operative bleeding
• Loss of fluid from the gut, by prolonged exposure during surgery.
• Handling of the gut and traction on the mesentery.
• Compression of the inferior vena cava by packs, retractors and even
abdominal tumours.
Cardiac arrhythmias
These may occur if there is excessive traction on the gut or mesentery.
Protection of the airway and prevention of aspiration.
This precaution is necessary in all types of surgery but especially in
abdominal surgery. A naso-gastric tube must be used for aspiration of
stomach contents if a full stomach is suspected. A rapid sequence induction
is indicated if there is any danger at all of vomiting or regurgitation.

Hiccups
This may be encountered, especially in upper abdominal surgery. The
topic is covered in Anaesthetic complications involving the Gastro-intestinal
system in Chapter 46.

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Respiratory complications
These are common in the post-operative period. Patients who have upper
abdominal surgery are more prone to post-operative respiratory
complications than others. Adequate ventilation during the operation and
attention to adequate analgesia (e.g. opioids) to enable the patient to cough
and take deep breaths post–operatively, is vital to prevent post–operative
pneumonia. It is important to give opioids both during and after surgery. An
appropriate regime would be:
− Intra–operatively boluses of up to 0.1–0.2 mg/kg of morphine IV.
− Post–operatively 0.1mg/kg IM 3 hourly.
Unless otherwise indicated, the patient is best nursed supported in a semi-
sitting position in the post-operative period. Good preoperative and
postoperative physiotherapy are very important in preventing chest
complications. It cannot be stressed enough that adequate pain relief in the
post-operative period is very important.
Deep vein thrombosis
This is more likely after lower abdominal and pelvic surgery. Prophylactic
measures include:
• The use of calf stimulators
• Elastic stockings
• The peri–operative use of sub-cutaneous heparin preparations
• Avoidance of hypotension
• Early ambulation
• Physiotherapy in the post–operative period.
Post-operative nausea and vomiting
This is discussed under Anaesthetic complications in Chapter 46

TECHNIQUES FOR ANAESTHESIA

Regional techniques.
Spinal anaesthesia is usually the method of choice for surgery below
the level of the umbilicus, provided there is no contraindication. The
advantages of a spinal anaesthetic are detailed in Chapter 19.
Ensure adequate fluid replacement.
Local infiltration. If a general or spinal anaesthetic is contraindicated
(e.g. in a moribund patient), then it may be necessary to resort to local
infiltration by the surgeon.

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General anaesthesia
The techniques of controlled ventilation are outlined in Chapters 14 and 16.
A rapid sequence induction technique must be used for patients with a full
stomach. For a full description of this technique see Chapter 16.
The depth of anaesthesia needs to be greatest during:
− The skin incision
− Initial abdominal exploration
− Closure of the peritoneum.
If the patient is very hypotensive or moribund, ventilate with oxygen and a
very small dose of ketamine or N2O to prevent awareness. At the earliest
sign of the patient beginning to waken, increase these agents and/or give a
small dose of opioid or halothane.

ANAESTHESIA FOR LAPAROSCOPY

Most anaesthetists favour general anaesthesia, although local and regional
anaesthetics have been used. The following points should be noted:
• Endotracheal intubation (using a cuffed tube) is advisable:
− For controlling ventilation. The insufflation of gas into the
peritoneal cavity raises the diaphragm and interferes with
breathing. It is important that the patient be paralysed and
ventilated.
− To prevent regurgitation of gastric contents. This is more likely
with the high intra-abdominal pressure.
In spite of these potential risks some anaesthetists will use a LMA and
ventilation with a short acting muscle relaxant (eg mivacurium/
atracurium/ vecuronium) for elective surgery of short duration,
(e.g. gynaecology) in fasted, non-obese patients.
• The introduction of gas into the peritoneal cavity can result in
hypotension (secondary to inferior vena caval obstruction) and also
cardiac arrhythmias. Carbon dioxide embolus can cause hypotension
and cardiac arrest.
It is important to limit intraperitoneal pressures to no greater than
15mmHg.
Laparoscopy is often associated with bradycardia. Careful monitoring
is essential. Atropine or glycopyrrolate is often required and should be
readily available.
• The patient is placed in a steep Trendelenburg position (head down)
which carries its own hazards. (See Chapter 30)

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