1 Anesthesia Anesthesia management of management of Laparoscopic Assisted Laparoscopic Assisted Surgery. Surgery. Dr. Mohammed Mahdy Dr. Mohammed Mahdy Consultant in Consultant in Anaesthesiology Anaesthesiology Al Bukariya general Al Bukariya general hospital hospital
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AnesthesiaAnesthesia management of management of Laparoscopic Assisted Laparoscopic Assisted
Surgery.Surgery.
Dr. Mohammed MahdyDr. Mohammed Mahdy
Consultant in Consultant in AnaesthesiologyAnaesthesiology
Al Bukariya general Al Bukariya general hospitalhospital
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IntroductionIntroduction
Laparoscopy introduced in 20Laparoscopy introduced in 20thth CenturyCentury
1962 : first laparoscopic tubal 1962 : first laparoscopic tubal ligation ligation
1970 -- 80 : used for gyne 1970 -- 80 : used for gyne proceduresprocedures
Advantages of LaparoscopyAdvantages of Laparoscopy
Shorter hospital stayShorter hospital stay Faster recoveryFaster recovery Rapid return to normal activitiesRapid return to normal activities Minimal painMinimal pain Small scarSmall scar Less post-op ileusLess post-op ileus
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Contraindications for Contraindications for LaparoscopyLaparoscopy
Increased ICPIncreased ICP
V – P shuntV – P shunt
HypovolemiaHypovolemia
CCF CCF
Valvular heart diseasesValvular heart diseases
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Anaesthetic PlanAnaesthetic Plan Pre-operative assessmentPre-operative assessment Pre-medicationPre-medication
Reversal of NM blockadeReversal of NM blockade Recovery roomRecovery room
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Anesthetic Problems of Anesthetic Problems of LaparoscopyLaparoscopy
Due to pneumo peritoneumDue to pneumo peritoneum Due to patient positioningDue to patient positioning Cardiovascular effectsCardiovascular effects Respiratory effectsRespiratory effects Gastro intestinal effectsGastro intestinal effects Unsuspected viseral injuriesUnsuspected viseral injuries Difficulty in estimating blood lossDifficulty in estimating blood loss Darkness in the ORDarkness in the OR
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Pneumo PeritoniumPneumo Peritonium
Preferred gas : CO2 Preferred gas : CO2
Working pressure : 12 to 14 mm Working pressure : 12 to 14 mm HgHg
Slow inflation of 1 litre / minuteSlow inflation of 1 litre / minute
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CO2 as Insufflator GasCO2 as Insufflator Gas
More soluble in blood than airMore soluble in blood than air
Carriage is high due to Carriage is high due to bicarbonate buffering and bicarbonate buffering and combination with Hbcombination with Hb
Rapidly eliminated by lungsRapidly eliminated by lungs
Inert & not irritant to tissuesInert & not irritant to tissues
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Ventilatory problems during Ventilatory problems during LaparoscopyLaparoscopy
Increase in PaCO2Increase in PaCO2
PneumothoraxPneumothorax
Gas-embolismGas-embolism
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Causes for Increased PaCO2Causes for Increased PaCO2
Absorption of PaCO2 –peritoneal Absorption of PaCO2 –peritoneal cavitycavity
V/Q mismatchV/Q mismatch• Increased physiological dead Increased physiological dead
Management of PneumothoraxManagement of PneumothoraxRecommended GuidelinesRecommended Guidelines
Stop N2OStop N2O Adjust vent settings to correct Adjust vent settings to correct
hypoxemiahypoxemia Apply PEEPApply PEEP Reduce intra-abdominal Reduce intra-abdominal
pressurepressure Communicate with surgeonCommunicate with surgeon Avoid thoracocentesisAvoid thoracocentesis
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Gas EmbolismGas Embolism
Most feared & fatal complicationMost feared & fatal complication
Seen frequently when Seen frequently when laparoscopy is associated with laparoscopy is associated with hysteroscopyhysteroscopy
Intra vascular injection of gas Intra vascular injection of gas following direct trocar placement following direct trocar placement into vesselinto vessel
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Suspicion of Gas EmbolismSuspicion of Gas Embolism
Blood on aspiration from Vere’s Blood on aspiration from Vere’s needleneedle
Pulsation of flow meter pressure Pulsation of flow meter pressure gaugegauge
Disappearance of abdominal Disappearance of abdominal distention despite sufficient distention despite sufficient volume of gasvolume of gas
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Effects of Massive Air EmbolismEffects of Massive Air Embolism Rapid insufflation of gas into bloodRapid insufflation of gas into blood Gas lock in RA & venacavaGas lock in RA & venacava Fall in cardiac outputFall in cardiac output High pressure in RAHigh pressure in RA Open foramen ovaleOpen foramen ovale Embolus in cerebral & coronary bedsEmbolus in cerebral & coronary beds Paradoxical embolismParadoxical embolism
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Diagnosis of Gas-embolismDiagnosis of Gas-embolism Detection of gas in right side of HeartDetection of gas in right side of Heart Recognition of physiological changes Recognition of physiological changes
secondary to emboli:secondary to emboli:• TachycardiaTachycardia• Cardiac arrhythmiaCardiac arrhythmia• HypotensionHypotension• CVP riseCVP rise• Mill-wheel murmurMill-wheel murmur• CyanosisCyanosis• Right heart strain pattern in ECGRight heart strain pattern in ECG• Pulmonary edemaPulmonary edema
Doppler & TEE ---- very sensitiveDoppler & TEE ---- very sensitive
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Treatment of Gas EmbolismTreatment of Gas Embolism
Immediate cessation of Immediate cessation of insufflationinsufflation
Release of pneumo-peritoneumRelease of pneumo-peritoneum Patient in Durrent’s positionPatient in Durrent’s position Cessation of N2O Cessation of N2O Give 100% oxygenGive 100% oxygen CVP insertion and aspiration of CVP insertion and aspiration of
gasgas
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Risk factor for RegurgitationRisk factor for Regurgitation