Anesthesia for

Laparoscopic Surgery
History and Benefits
1910 Hans Christian Jacobaeus (Sweden)
performed first laparoscopic procedure on a
human
Benefits
Smaller incision
Reduced post-op pain
Decreased post-op ileus
Earlier ambulation and shorter hospital stay
Procedures
Cholecystectomy
Herniorrhaphy
Appendectomy
Splenectomy
Ileo-anal pull through
Pyeloplasty
Intra-abdominal
inspection
Nissen fundoplication
Pyloromytomy
Nephrectomy
Tumor excision
Colectomy

ADVANTAGES
1. Reduced Stress Response
2. Reduced Analgesic Requirements
3. Improved Post-Operative Respiratory Function
4. Reduced Recovery Time
5. Reduced post operative ileus
6. Reduced fasting and IV infusion
7. Hospital stay significantly reduced
8. Improved Cosmetic Appearance
9. Improved visualisation of the Operative field

1) REDUCED STRESS
RESPONSE



Afferent neurones from the operative site convey impulses via
the hypothalamus to trigger a neuroendocrine response
Stimulation of the SNS catecholamines
Humoural response that Increases the release of catabolic hormones
ACTH, Prolactin, Glucagon, Catecholamines, Growth
hormone
Reduces the release of anabolic hormones
Insulin, Testosterone, T3
Net effect increased breakdown of carbohydrates, lipids and protein
reduced peripheral utilization of glucose.
2) REDUCED ANALGESIC
REQUIREMENTS
Acute pain: significantly less and of shorter duration

Less superficial trauma Smaller incision
Less dissection through tissue layers
Long term pain less common

3) IMPROVED POST-OPERATIVE
RESPIRATORY FUNCTION
Reduced postoperative pain causes less
splinting of the rib cage
tachypnoea
shallow breathing
suppression of the cough reflex

Reducing atelectasis (better Oxygenation) and respiratory infection

FRC, FEV1, FVC and FEF 25-75% were significantly better

Post-op respiratory function recovery is slower
in elderly, obese, COPD and smokers,
but less impaired than after laparotomy
DISADVANTAGES
1. Physiological consequences of pneumoperitoneum
2. Raised intra-abdominal pressure
3. Operative position of the patient
4. Technical difficulty of the procedure
5. Unsuspected visceral injury
6. Difficulty in evaluating amount of blood loss
7. Gas embolism / Pneumothorax / Surgical
8. Emphysema
9. Vessel trauma
Insufflation with Carbon Dioxide
Insufflation of the abdominal cavity with CO
2
via
a small infra/supra-umbilical trocar
12-15mm Hg, tolerable in healthy patients
Possible vascular injuries from trocar
Foley catheter and NG tube may be placed to
reduce risk of trauma with trocar insertion
CO
2
is readily absorbed, non-combustible and
non-toxic
Why Not Nitrous Oxide?
Concerns due to its ability to diffuse into the bowel
leading to distention and expand in closed spaces, which
may interfere with surgical field
Nitrous oxide can leave blood and enter air filled cavity 34x more
rapidly then nitrogen can leave the cavity to enter blood
Combustible
Egar & Saidman (1965) noted an increase of >200% in
the intestinal lumen after 4 hours of breathing nitrous
oxide
Taylor, et. al (1992) no difference in surgical conditions
during lap chole lasting 80-90 minutes with/without NO
2
.
Bowel distention did not increase with time.
Tramer, et. al (1996) - emetic effect of NO
2
is not
significant



Cardiovascular
in MAP, SVR and variable/ CO
SVR secondary to PaCO2 increase due to carbon dioxide
absorption from the peritoneal cavity.
Hypercarbia initial reduction of HR (~28% @ 15mm Hg)
and contractility Sympathetic/catecholamine
release/vasopressin mild increase in HR and BP
CO due to pre-load (VC compression), LV-EDV and
afterload
Prevent by giving adequate fluids to keep CO increased
myocardial wall tension myocardial oxygen demand

Cardiac filling pressures
Compression of abdominal organs due to increased
abdominal pressures and increased sympathetic response
Increased intra-thoracic pressures

Esmolol (B-blocker), or Fentanyl (opioid) to HR and BP
Hemodynamic Effects

Depends on the interaction of:
patients pre-existing cardiopulmonary status
anesthetic technique
intra-abdominal pressure
carbon dioxide absorption
patient position
duration of surgery.





INCREASED INTRA
ABDOMINAL PRESSURES
Approximately 14mmHg
25mmHg for pelvic procedures (9).
Higher pressures are associated with faster CO2 absorption,
gas embolism and significant cardiorespiratory effects. (9)
Pulmonary
CO2 insufflation into peritoneal cavity PaCO2 minute
ventilation (TV, RR)
Mullet, et al. (1993)
CO2 absorption reached a plateau within 10min after starting
intra-peritoneal insufflation but increased slowly throughout
extra-peritoneal insufflation
During only intra-peritoneal insufflation PaCO2 rises and
plateaus at 15-30min
If CO2 continues to rise search for other etiology including
subcutaneous emphysema
Important to monitor ET-CO2 and may need ABG for patients with
pulmonary disease
PVR secondary to intra-thoracic pressure
Pulmonary
Intra-Abdominal pressures
Pushes the diaphragm upward leading to
intrathoracic pressure, airway pressure
FRC and TLC
May need to use PEEP for alveolar recruitment,
prevent alveolar collapse, increase oxygenation,
improve lung compliance
Embryonic channels may open
pneumomediastinum, pneumoperdicardium, PTX
Diffusion of gas from mediastinum to extra-
peritoneal may lead to subcutaneous emphysema
of face/neck
Capnography will show increase in end-tidal CO2
after plateau, and crepitus over abdominal wall
Tx stop surgery and deflate, correct increased
CO2 levels
SUBCUTANEOUS
EMPHYSEMA
1. Inadvertent extraperitoneal insufflation
2. Lap fundoplication
3. HH diaphragmatic hiatus CO2 mediastinum

Increase in PETCO2 after plateau conc reached SE

Management
1. Interrupt surgery
2. Readily resolves
POSITION
Positions commonly used are:
Trendelenburg
Reverse trendelenburg
Lithotomy
Lateral

Positions for surgery can further stress the CVS

Avoid injury to the patient
Disconnections of IV lines & ETT
NERVE INJ URY
Nerve compression is always a potential hazard

Prevent over extension of arms and padding over bony
prominences

The common peroneal nerve is particularly vulnerable
during lithotomy
PNEUMOTHORAX /
PNEUMOMEDIASTIUM
1. Potential channels of communications
2. Defects in diaphragm
3. Pleural tears during surgery
4. Increased alveolar inflation from increased MV
5. Pre-existing bullae

6. CO2 - spont resolution within 30 - 40 mins
Gas embolism
CV changes

Tachycardia
Hypotension
Peaked P waves (first
ECG change)
Dysrhythmias
Mill wheel murmur

Respiratory changes
reflex gasp
increased resistance,
decreased compliance
decreased oxygen
saturation
no consistent change in
ETCO2
increased from embolized
CO2
decreased from
increased dead space

Gas embolism
ventilate with 100% oxygen
stop administration of CO2
release IAP, deflate abdomen
aspirate from central line
fluid resuscitation
inotropic agents
Durants maneuver

Regional Circulatory Changes
Renal
GFR (up to 50%) and renal plasma flow urine
output
GI
Compression bowel circulation decreased
gastric pH
Brain
CO2 cerebral blood flow ICP

Position of the Patient
Supine reduces CV changes
Reverse Trendelenburg (head up)
moves abdominal organs away from operative site and
will help respiration
May venous return and CO, thus fluid replacement
necessary
femoral venous pressure risk of DVT or PE
Trendelenburg (head down)
venous return, CVP and CO
lung compliance and atelectasis of bases of lung
V/Q mismatch
Anesthetic Management
General Anesthesia with tracheal intubation and muscle
paralysis
Because ventilatory function may be compromised
due to pneumoperitoneum and patient positions
Controlled ventilation necessary to prevent
hypercarbia
Muscle paralysis to avoid further increase in intra-
thoracic pressure
Large-bore peripheral IV especially if arms are to be
tucked during case
Orogastric tube to aspirate gas from stomach before
trocars placed

Post-Op Care
Pain control opiods, NSAIDs
Unrecognized intra-abdominal visceral and/or
vascular injury
Progressive hypotension, increased abdominal size,
decreased Hct
Increased N/V
Ondansetron, Dexamethasone, Scopolamine patch
PE due to venous stasis
Risk of 0.016% vs. open surgery 0.8%
Limitation of Laparoscopic Surgery

4
o
of freedom vs. 6
o

of freedom
2-D view
Introduces a fulcrum (abdominal wall)
Hands move counterintuitively
Instruments magnify tremor and
reduce tactile sense and force feedback

Robotic Surgery
Surgeon at console
3-D image
3 or 4 arms
6
o
of freedom
Space, cost and hands-on issues
Intuitive Surgical - [2005] Intuitive Surgical, Inc.
Humans and Robots:
Characteristics
Comparison of Degrees of Freedom
ROBOTIC SURGERY
LAPAROSCOPY
OPEN SURGERY
2
3
1
4
5
6
2 3
4
1
2
3
4
5
1
6
Intuitive Surgical - [2005] Intuitive Surgical, Inc.
Surgeons Perspective
View is incredible!
3-D view, high definition, magnetized
Intuitive
1
st
class seat on a long flight
Anatomy never seen before (prostate & valves)

Cost
Cumbersome
Large
Lacks versatility
Infancy
Tremor
Fatigue
Imprecision
Variability in skill, age and
state of mind
Ineffective at submillimeter
scale
Humans Robots
Camarillo et al, Am J. Surg 188(Suppl to Oct 2004)29-59
Disadvantages
The Learning Curve
Setup time decreases with experience
OR Time:
- cholecystectomy - 37 min
- prostatectomy - 100 min
Minimize instrument exchanges with experience
Fewer cases converted
Mechanical problems:
- computer system failure, frozen arm, damage
- during setup, malfunctioning instrument(>10 uses)



Henley, EJ et al. Am J. Surg 187(2004);309-315
Current Usage of Robotic Surgery
Radical retropubic prostatectomy
Cardiac surgery (valve, IMA)
Antireflux procedure
Bariatric procedure
Esophageal resection
Tubal reanastomosis
Radical Retropubic Prostatectomy
Open procedures blood loss and recovery time is variable
Laparoscopic prostatectomy technically difficult
Robotic prostatectomy:

Intraoperative blood loss
Postop hemoglobin decrease
Postop pain
LOS (4 days vs. <23 hours)




Menon et al, J Endo 2004;18:611-619
Other General Surgery Applications
Robotic esophagectomy
Endoscopic robotics
Bariatric surgery
Hepatobiliary
Pancreatic
Rectal

Advantages in Bariatric Surgery
107 robotically assisted Roux-en-Y Gastric bypasses
Hand sewn gastrojejunostomy
Stapler device avoided
Ability to create smaller gastric pouch
Stiffer instruments and mechanical power
No leaks/mortality


Horgan, S et al. J Laparoendo Surg Tech 11:415-419
Works Cited
Dunn, P. (2007). Clinical anesthesia procedures of the
Massachusetts general hospital. Philadelphia: Lippincott
Williams & Wilkins.
Egar, E., Saidman, I. (1965). Hazards of nitrous oxide
anesthesia in bowel obstruction and pneumothorax.
Anesthesiology, 26, 61-66.
Joshi, G. (2002) Anesthesia for laparoscopic surgery.
Canadian Journal of Anesthesia, 49, 45-49
Kaba, A. & Joris, J. (2001) Anesthesia for laparoscopic
surgery. Current Anesthesia and Critical Care, 12(3),
159-165. Retrieved August 22, 2009 from
http://www.currentanaesthesia.com/article/S0953-
7112%2800%2990309-0/abstract.

Mullet, C., Viale J., Sagnard, P., et al. (1993). Pulmonary
CO2 elimination during surgical procedures using intra-
or extraperitoneal CO2 insufflation. Anesthesia &
Analgesia, 76, 622-6.
Stoelting, R., & Miller, R. (2007). Basics of anesthesia.
Philadelphia: Churchill Livingstone
Taylor, E., Feinstein, R., White, P., & Soper, N. (1992).
Anesthesia for laparoscopic cholecystectomy: is nitrous
oxide contraindicated? Anesthesiology, 76, 541-3
Tramer, M., Moore, A., & McQuay, H. (1996). Omitting
nitrous oxide in general anesthesia: meta-analysis of
interoperative awareness and postoperative emesis in
randomized controlled trials. British Journal of
Anesthesiology, 76, 186-93.