Anesthesia Considerations for Laparoscopic Surgery by Dr. Masood Entezariasl

2. Anesthesia for Laparoscopical surgery Dr Masood Entezariasl

3. Laparoscopy • laparoscopy requires the formation of a pneumoperitoneom and carbon dioxide is used as the insufflating gas

5. Three main anesthetic considerations when surgery conducted laparoscopically : - problems from gas insufflation - trauma by veress needle or trochar - anesthetic complications

6. Problems from gas insufflation

7. Problems from gas insufflation • Occurring physiological changes in cardiovascular and respiratory systems • Insufflation pressures of 10-15 mm Hg are well tolerated but pressures greater than 30 mm Hg can result in profound hemodynamic responses • The pneomoperitoneum increasesintra-abdominal and interathoracic pressure • This decreases venous return and so lowers cardiac output

8. Carbon dioxide absorption increases sympathetic activity to augment cardiac contractility and increase heart rate • During anesthesia there is a satisfactory circulation with a normal or raised arterial blood pressure and the tachycardia • Problems arise when hemorrhage occurs, as the usual compensatory cardiovascular responses may be inadequate

9. Diaphragmatic splitting can result in basal atelectasis , increased intrapulmonary shunts , hypoxia, and hypercarbia in spontaneously breathing patients • This changes are minimized by positive pressure ventilation • Cardiac arrhythmias may result from a low cardiac output in the presence of hypercarbia

10. Inadvertent misplacement of the insufflating gas can cause: - subcutaneous emphysema - pneomomediastinum - pneumothorax - pneomopericardium • Carbon dioxide gas embolism is a major complication, as a large embolus will cause outflow obstruction of the pulmonary artery

11. The diagnosis is made by the occurrence of sudden hypotension , hypoxia, and a low expired carbon dioxide tension • Hypothermia may occur in long procedures • A 0.3°C decrease in core temperature has been found for each 50 liters of carbon dioxide insufflation

12. Trauma by veress needle or trochar

13. Trauma by veress needle or trochar • Major damage can occur • Hemorrhage can result from the passage of the trochar or needle through the anterior abdominal wall • Tearing of adhesions from the expanding pneomoperitoneom will also cause bleeding • Traumatic puncture of the major intra-abdominal vessels has been reported • The raised intra-abdominal pressure may tamponade even a large venous hemorrhage may not be obvious during the laparoscopy leading to a delay in a subsequent laparotomy

14. Intestinal perforation occurs • The bowel can be grazed leading to peritonitis ,abscess formation and sepsis • Puncture of the bladder , ureter, and liver has been reported • If an organ is in the peritoneal cavity, then it has been damaged at laparoscopy

15. Anesthetic problems associated with laparoscopy

16. Trendelemberg position and a pneomoperitoneum will lead to an increased risk of passive regurgitation of gastric contents • The lower esophageal sphincter pressure alters little and the risk is low but present • The patient is often in a steep trendelemberge positionfor gynecological surgery, but may be in a head-up position for abdominal surgery • Occasionally, both are employed in the same patient

17. The commonperoneal nerve , femoral nerve and the brachial plexus are at risk • A small number of patients proceed to laparotomy • Postoperative pain can be decreased by infiltrating with local anesthetic the wounds made by trocher • Shoulder tip pain may occur from diaphragmatic irritation by the gas

18. Many anesthetic techniques have been used for laparoscopy • Epidural and spinal anesthesia are not well tolerated because of the discomfort from peritoneal distention and respiratory stimulation • General anesthesia is used frequently • The safest and preferred technique is endotheracheal intubation and ventilation of the patient

19. This allows abdominal wall relaxation and decrease the effects of the diaphragmatic splinting on respiratory function, the risk of gastric aspiration is minimized and , should a laparotomy ensue, you are prepared • Emergency laparoscopic surgery necessitates a rapid sequence induction technique • Adequate venous access is essential for laparoscopic anesthesia as profound hemorrhage can occur