Anaesthesia for Laparoscopy

Aims

• to underline the principles of anaesthesia for

laparoscopic surgery
• to point out the dangers of peritoneal insuffl
ation of CO2 and look at alternatives
• to examine claims that laparoscopic procedu
res are less stressful than open procedures
 Objectives

• to increase awareness of the risks and benefi

ts of laparoscopic surgery from the anaesthe
tist’s (and patient’s) point of view
• to stimulate further interest and research in
newer techniques which may reduce the risk
s
 Introduction

• Gynaecological laparoscopy
• Dangers of peritoneal insufflation of CO2
“Though laparoscopy offers advantages to both patients and s
urgeon it involves considerable alteration in respiratory a
nd cardiovascular homeostasis and should not be regarded
as yet another minor investigation”
Hodgson, McClelland and Newton 1970
 Anaesthetic techniques

• The role of endotracheal intubation

• The role of mechanical ventilation
• The role of muscle paralysis
• The role of nitrous oxide
 Anaesthetic techniques
• Capnography
– CO2 absorption through peritoneum, venous channels, ret
roperitoneal and subcutaneous tissues
• Invasive monitoring
• Insufflating gas
– air, nitrous oxide, carbon dioxide
• Helium
– Haemodynamic stability (Fleming et al., Junghans et al. 1
997)
– Inhibition of tumour growth (Neuhauss et al. 1999)
 Pathophysiological effects

Haemodynamic
• head up versus head down position
• bradycardia
• blood loss
• visceral traction
• gas embolus: early versus late
 Pathophysiological effects

Respiratory: Hypercapnoea
• Head down, spontaneous respiration
• CO2 absorption
• Compromised diaphragm function with rais
ed IAP
• Pneumothorax
 Pathophysiological effects
CO2 pneumoperitoneum (Safran and Orlando AJS 1994)

• Hypertension, tachycardia leading to increased myocardial oxygen demand

• Increased noradrenaline levels leads to increased SVR (and decreased Q)
• Hypercarbia and acidosis
• Decrease in urine output and increased plasma renin activity (PRA)
– due to increased intra-abdominal pressure (IAP) and the local compression of renal
vessels
• Intra-abdominal distension leads to a decrease in pulmonary dynamic complia
nce .
• Low compliance, together with an increased minute volume of ventilation, is a
ccompanied by high peak airway pressures .
• head-up positioning and fluid deficit accounts for many of the adverse e
ffects in haemodynamics during laparoscopic cholecystectomy (Hirvone
n et al 2000).
 Pathophysiological effects
Gasless/abdominal wall lift techniques

• abdominal wall lift permits the conduct

of laparoscopic procedures at an intra-
abdominal pressure of only 6-8 mm H
g
• benefits patients with pre-existing card
iac disease and chronic bronchitis, es
pecially for liver surgery (Banting et al.
1993).
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

• .. gasless technique provided inferior exposure and the operatio

n took longer, … value in high-risk patients with cardiorespirator
y disease? (Vezakis et al. 1999, Johnson and Sibert 1997)
• .. using thoracic epidural: no clinically important differences in ca
rdiovascular and systemic response were observed between pat
ients undergoing CO2 or gasless laparoscopy for colonic diseas
e (Schulze et al. 1999).
• .. compromised surgical exposure and thus increased technical
difficulty. Patients realised no benefits from its use in terms of po
stoperative discomfort or return to activity (Goldberg and Maurer 1
997)
• .. gasless laparoscopic cholecystectomy resulted in more uneve
ntful and faster immediate and late postoperative recovery than
conventional carbon dioxide pneumoperitoneum (Koivusalo et al 1
996, 1997).
 Pathophysiological effects
Gasless versus CO2 pneumoperitoneum

Conclusion
• Most studies have shown decreased surgical
access and increased conversion rates
• Cardiorespiratory benefits are limited in mo
st studies
• Side effects are similar overall
• Need a meta-analysis/more studies
 Studies of laparoscopic vs open procedures

• endocrine and metabolic changes during acute e

mergency abdominal surgery performed using eit
her laparoscopy or laparotomy in children. Prolac
tin, cortisol, interleukin-6, glucose, insulin, lactic
acid and epinephrine levels .. No differences were
elicited (Bozkurt et al. 2000)
• stress responses after sigmoid colectomy, in pati
ents undergoing lap. assisted colectomy, are com
parable with open operation (Fukushima et al. 199
6)
• LC produces significant increases in stress horm
one levels … “not physiologically minimally invas
.
ive” (Naude et al. 1997)
 Studies of laparoscopic vs open procedures

• significant lower values of intraoperatively and po

stoperatively measured epinephrine, norepinephri
ne, interleukin-1 beta, and interleukin-6 in patient
s with laparoscopic vs open cholecystectomy (Gl
aser et al. 1995)
• neuroendocrine stress response and inflammator
y response following laparoscopic cholecystecto
my were significantly reduced compared with tho
se after open cholecystectomy (Karayiannakis et
al. 1997)
• activation of stress-related factors during gynaec
ologic laparoscopy seems to be less intense and
 Studies of laparoscopic vs open procedures

Conclusion

More studies and larger patient groups are nee

ded to be certain that laparoscopic procedur
es produce less stress response than open pr
ocedures … especially if the duration of the
operation is longer
 Conclusion

• Laparoscopic procedures are not minimally

invasive physiologically
• The benefits of gasless techniques are yet to
be established