Anesthesia for laparoscopic urological surgery

1. Anesthesia for laparoscopic urological surgery 민진기

2. Anesthesia for laparoscopic urological surgery Laparoscopy for urological surgery relatively recent surgical innovation Perioperative care issues relate to operating positions, the conseguences of carbon dioxide under pressure in the abdomen postoperative analgesia

3. Anesthesia for laparoscopic urological surgery Laparoscopic cholecystectomy experience was used as the foundation for anesthesia and to delineate specific organ system issue and any intervention Significant differences were found in spectrum of urological patient population, notably renal function

4. Back ground Effect of carbon dioxide: 30 years ago they include effects on the cardiovascular system, mechanical consequences of pneumoperitoneum, neurohormonal response, systemic absorption of carbon dioxide, physiologic change associated with pt. Positioning Working practice and insufflation pressure

5. Back ground Potential pitfalls changes in FRC and physiolgical dead space tracheal tube movement complication such as gas embolism There would be other dynamics some due to handling the genitourinary system, some organ specific issue some differences in positions for opertion

6. Back ground Stability of renal function during laparoscopic cholecystectomy limiting inflation pressure and minimizing movement of the kidney Nevertheless..

7. Back ground Required head down position (Trendelenburg) for prostate and bladder surgery additonal carbon dioxide pressure dynamic on the cerebral circulation paradoxical forces act on the cerebral blood flow

8. Patient selection Primary consideration consequence of rise in intra-abdominal pressure How the individual might react to positive pressure ventilation, fluid challenge other mechanisms normally employed to counter rises in intra-abdominal pressure Trendelenburg position시 History of significant cardiovascular comorbidity, cerebrovascular disease or glaucoma

9. Anesthetic technique Premedication: temazepam Induction: propofol Maintenance: remifentanil and sevoflurane Muscle ralaxant: vecuronium and atracurium Ketorolac, ondansetron

10. Monitoring and measuring Routine monitoring ECG, Non-invasive blood pressure, pulse oxymeter, End-tidal gas Paritcular attention End-expired carbon dioxide, central venous pressure change, urine output (when accurate)

11. Monitoring and measuring Summary data for end-expired carbon dioxide centralvenous changes relative to pre-insufflation values No observed evidence of the changes from baseline not being tolerated In several operation (pyeloplasty,nephroureterectomy, prostatectomy) interruptions to the urinary tract and urine flow

12. diuresis Mannitol 10% or 20% at 1-2g/kg to promote urine flow to flush out and maintain urinary tract patency to preserve renal tissue and conserve renal function as a prophylactic against cerebral swelling Furosemide may alse be required

13. Cerebral protection Osmotic diuresis towards the end of procedure Restricted fluid loads and maintenance in the prolonged head-down position Increase in ventilation rate to adjust for rises in end-tidal carbon dioxide

14. complication conversion rate to an open procedure was 4% surgical complication rate was 6% re-exploration for bleeding, hematoma, ileus, diaphragmatic tear, small bowel obstruction, prolonged drain loss, prolonged post-pyeloplasty urine leak, subcutaneous hematoma

15. complication Non-surgical complication rate was 2.7% post-operative hypoxia (previously pneumonectomy and overhydrated), readmission with a chest infection, Clostridium difficile diarrhea

16. Postoperative pain consideration Requirement for strong analgesics, certainly initially, and sometimes on PCA Once in recovery, further dose of opiod for the first postoperative night

17. Postoperative pain consideration Generally, the only indication for epidural-based anesthetic-analgesic technique is cystectomy and ileal conduit  produce easier intestine to handle and reduce the incidence of postoperative ileus

18. Discussion Surgical outcome are impressive blood loss, complication, days in hospital, etc. The range of renal problems faced has been large tansplant recipients need planning with their renal physician before undergoing laparoscopic procedures to remove non-functioning of diseased kidneys

19. Discussion Although laparoscopic cholecystectomy has proved relevant model for process of surgery, measuring effect of anesthetic intervention is handicapped by a lack of robust marker, discriminatory endpoints, presence of confounder

20. Discussion monitoring CVP has proved informative, not least for its ability to detect problems or the risk of a potential fatal complication developing, monitoring the effects of mannitol infusion

21. Discussion In the main, the anesthetic experience is that most of the management and techniques adopted have proved near optimal. Small adjustments for technique, for instance, the fully fit donor nephrectomy, the pregnant patient for nephrectomy, the hepatitis B positive alcoholic, pneumonectomy patient for nephroureterectomy, much of the spectrum of renal morbidity

22. Discussion On the whole, the challenges have been managed safely