Anesthesia for laparoscopic surgeries

Anesthesia For Laparoscopic Surgeries

ANESTHESIA FOR LAparoscopic

surgeryPRESENTER- DR SHABBIR

Todays SeminarHistoryWhat is laparoscopy and its applicationsAdv. and disadv.ContraindicationsPhysiological changes Choice of anaesthesiaAnaesthetic management for laparoscopyComplications Laparoscopy for special groups (children, preg, cardiac ds)

HISTORYGeorge Kelling used cystoscope to observe abd organs of dogs CYSTOSCOPYLaparoscopy introduced in 20 th Century 1975 : first laparoscopic salpingectomy 1970 -- 80 : used for gyne procedures1981: Semm, from Germany,1st lap appendectomy 1989: laparoscopic cholecystectomy

HISTORY1980: Patrick Steptoe (UK): started laparoscopic procedures.

1983: Semm (German gynecologist): performed the first laporoscopic appendectomy.

1985: Erich Muhe (Germany): 1st reported lapaorscopic cholecystectomy.

1987: Ger: lap repair of inguinal hernia.

HISTORY1987: Phillipe Mouret (France): 1st Laparoscopic Cholecystectomy using video technique

1988: Harry Reich: laparoscopic lymphadenectomy for t/t of ovarian cancer.

1989: Harry Reich: first laparoscopic hysterectomy using bipolar dissection.

1990: Bailey and Zucker (USA): laparoscopic anterior highly selective vagotomy with posterior truncal vagotomy.

DEFINATIONIt is a minimally access procedure allowing endoscopic access to peritoneal cavity after insufflation of gas to create space between the anterior abd. Wall & viscera for safe manipulation of instruments & organs.TYPESIntraperitonealExtraperitonealAbd wall retraction (gasless laproscopy)Hand assisted (Hassans tech.)

ADVANTAGES

1 Minimal pain & illeus2 Improved cosmesis3 Shorter hospital stay , faster recovery & rapid return to work4 Non muscle splinting incision & less blood loss5 Post op respiratory muscle function returns to normal more quickly6. Wound complications i.e. infection & dehiscence are less7 Lap surgery can be done as day care surgery

DISADVANTAGES

More expensiveMore operating timeDifficult in complicated casesPotential for major complications in inexperienced hand

LAPROSCOPIC PROCEDURESCholecystectomyVagotomyAppendectomyColectomyInguinal hernia repairAdrenalectomyNephrectomyProstatectomyPancreatectomyBariatric surgeryNissen fundoplicationPara-esophageal hernia repairSplenectomyLiver resectionCystectomy with ileal conduit

LAPAROSCOPIC SURGERY [GYNAC]Ectopic pregnancyOvarian cystectomyReversal of ovarian torsionSalpingo-oophorectomyHysterectomyMyomectomySacrocolpopexyLymphadenectomyLymphadenectomy, stagingAblation of endometriosis

LAPROSCOPY EQUIPMENTSCameraLight SourceInsufflatorTV MonitorTelescopesLight Guide Cable Apart from the insufflator the system will work better if all the components are from the same company as one piece talks to another

SURGICAL REQUIRMENTS

Pneumo-peritoneum created by gas insufflation in peritoneal cavity separate abd. wall from viscera

Surgical site accessed by trocars & cannulae inserted through puncture wound in ant. abdominal wall , An endovideo camera attached to primary cannula to displays surgical site

Gas insufflator-can deliver gas at flow rate of4-6l/min. Insufflation pressure and IAP is electronically controlled

IAP of around 15mm of hg is adequate for most proced.

Patient is positioned to produce gravitational displacement of abd viscera away from surgical site

PNEUMOPERITONEUM

Created by insufflations of gas in peritoneal cavity to provide sufficient space to ensure adequate visualization and manipulation

Ideal gas for pneumo-peritoneumLimited systemic absorptionLimited systemic effects if absorbedRapid excretionHigh solubility in bloodShould not support combustionColourless, inert, non-explosiveReadily available, non explosive, nontoxic

Helium Insoluble, gas embolismArgon

N2O: Supports combustion, diffuses into the bowel, PONV

N2

Air

CO2:Safe during electrocauteryCan be easily eliminated through the lungsRapidly absorbed into the bloodstream

CARBON DIOXIDE-Advantagesdoes not support combustionHigh solubility, eliminated by lungslow risk of gas embolism, readily available ,less expensive

-DisadvantagesHypercarbia and acidosisSympathetic stimulation

OTHER GASESNITROUS OXIDEAdvantage-biologically inert,highly soluble,insignificant change in acid base balance,less post operative painDisadvantages-supports combustion,hazardous for operative teamHELIUM-Advantages neither combustible nor support,decreased cardiopulmonary changes,minimal effect on acid base balance.Disadvantages-risk of gas embolism(less soluble),more diffusible, post op emphysema takes days to get absorbedARGON Advantage-non combustible,chemically inert,stable AB balance.Disadvantage-cardiac depressant

CONTRAINDICATIONS

Diaphragmatic herniaAcute or recent MISevere obstructive lung diseaseIncreased ICP Hypovolemia CCF Severe Valvular heart diseases

POSITIONINGLap cholecystectomy rTn & TnUrology Tn,supine & lateral OBG DorsolithotomyUpper GIT & biliary Head upThoracoscopy lateral decubitus Nephrectomy Adrenalectomy

Laparoscopy Anesthetic issues CO2 pneumo peritoneum Due to patient positioningCardiovascular effects Respiratory effects Gastro intestinal effects Unsuspected visceral injuries Difficulty in estimating blood loss Darkness in the OR

Respiratory & Ventilatory ChangesIncreased Intra-abdominal pressure

Upward displacement of diaphragm/Impaired diaphragmatic excursion

Reduced lung compliance, FRCIncreased airway pressure & barotraumaV/Q mismatch with hypoxemia & hypercarbiaCompression of basilar lung segments & atelectasis

CAUSES OF PaCO 2

PHYSIOLOGICAL EFFECTSCardiovascular effects depends on Patients preexisting cardiopulmonary status the anesthetic technique intra-abdominal pressure (IAP) carbon dioxide (CO2) absorption patient position duration of the surgical procedure

HEMODYNAMIC CHANGES IAP

Venous return & SVR

Cardiac Output & Cardiac Index

- There is biphasic response on CO - If IAP 15mmHg, 10%-30% reduction in CO increase in systemic vascular resistance, mean arterial pressure, and cardiac filling pressures more severe in patients with preexisting cardiac disease significant changes occur at pressures greater than 12 - 15 mmHg

RENALDecrease in renal blood flow when IAP >15 mmHgDecrease in GFRDecrease in urine outputDecrease in creatinine clearanceDecrease in sodium excretionPotential for volume overload in the face of excessive fluid administration.

LOWER LIMB

Femoral venous blood flow

Pooling of blood (Reverse Trendelenberg position)

DVT

Effect of Pneumoperitoneum On Pharmacokinetics

Prolonged T1/2 of drugs eliminated by liver (reduction of hepatic perfusion)

Reduced Clearance of drugs eliminated through kidneys (reduced creatinine clearance and urine flow)

Neurohumoral Responses

RAA system activation ( renin, angiotensin, and aldosterone)

Sympathetic system activation ( catecholamines)

1. CO2 s/c emphysemaCause a) accidental extraperit insufflation (malpositioned verris needle) b) deliberate extraperit insufflations- retroperit surg, TEPP, . fundoplication, pelvic lymphadenectomy Diagnosis ETCO2 -cannot be corrected by adjusting ventilation - even after plateau reached ABG, Palpation

Treatment 1. stop CO2 insufflation, interrupt lap temporarily 2. CMV continued till hypercapnia resolves 3. resume lap at low insufflation P thereafter

Pneumothorax / pneumomediastinumCause 1. pleuroperitoneal communications (R>L) 2. Diaph defects( aortic, esophageal, GE jn surg) 3. Rupture of preexisting bullae 4. Perf falciform ligamentDiagnosis airway P, sudden Sp O2 , sudden / ETco2, Abnormal motion of hemidiaph by laparoscopist

CO2 embolism (rare but potentially fatal)Risk factors - hysteroscopies, previous abd surg, needle/Trocar in vslConsequences- GAS LOCK in vena cava ,RA VR collapse - Ac RV HTN opens foramen ovale paradoxical gas embolismDiagnosis HR, BP, CVP, hypoxia, cyanosis,ET CO2 biphasic change, a ETco2 ECG- Rt heart strain, TEE, pulm art. aspiration of gas/ foamy bld from CVP line

Treatment1. Release source (stop co2 + release pneumoperit)2. position steep head low + durant position 3. stop N2O + 100%O24. Hyperventilation5. CVP/PA catheter to aspirate CO26. Cardiac massage may break embolus- rapid absorption7. Hyperbaric o2 - cerebral embolism

Endobronchial intubationDue to cephalad movement of diaph with head down tilt and IAP

Diagnosis - Sp O2 airway P

Treatment Repositioning of ETT

AspirationMendelson syndromeAt IAP>20 mmHg

Changes in LES due to IAP that maintain transsphincteric Pgradient + head down position protect against entry of gastriccontent in airways

Nerve injuriesPrevented byavoid overextension of armspadding at P points

ARRHYTHMIAS IN LAPAROSCOPIC SURGERYHypercapnia is the major causehypoxia , hemodynamic changesVagal reflexes [ stretching of peritoneum and fallopian tube clamping ]Depth of anesthesia HalothaneArrythmia may be first sign of gas embolism

LAPROSCOPY IN CHILDRENPhysiological changes = adultsPaco2 ETco2 increase but ETco2 overestimates Paco2Co2 abs more rapid and intense due to larger peritoneal SA / body wt.More chances of trauma to liver during trocar insertionMore chances of bradycardia , maintain IAP to as low as possible

LAPROSCOPY IN PREGNANCYIndications- appendicectomy cholecystectomyRisk preterm labour, miscarriage, fetal acidosisTiming II trimester (< 23 wk)Lap technique HASSANS techSpecial considerations 1.prophylactic- antithrombolytic measures + tocolytics2.operating time to be minimised3.IAP as low as possible4.Continous fetal monitoring (TVS)5.Lead shield to protect foetus if intraop cholangiography needed

Trendelenberg

Rev Trendelenberg15-20 head down VR,CBV,CO,MAPVC,FRC,Compliance Paw (atelectasis)Endobronchial intubation

20-30 head up VR,CBV,CO,MAPImproves diaph function

Predisposition to DVT

ANESTHESIA IN LAPPAEDone in usual manner with special attention tocardiac & pulmonary systemInvestigations Complete hemogramRBSNa, KBUN, CreatinineCoagulation profileCXR, ECGBG, CMSpecial investigations 1. ECHO2. PFT

PREMEDICATION1. NPO 2. Complete bowel preparation3. Antibiotics as per surgical team4. Awareness about post op shoulder tip pain5. Written informed consent for laparotomy6. Anxiolytics/antiemetics/H2 receptor antagonist/analgesic7. Antisialagogue (glyco-P) and vagolytic may be administered at induction of anaes.8. DVT prophylaxis (rTn, pelvic Sx, long duration, malignancy, obesity)9. clonidine/ dexmetetomidine to decrease stress response

MONITORINGHRNIBPContinous ECGPulse oximetryCapnographyTemperatureAirway pressureIAPIf required, ABG, precordial doppler,TEE may be instituted.

ANESTHESIA FOR LAP GAPreloading- 5-10 ml/kg to prevent hemodynamic changes during pneumoperitoneumInduction- propofol, thiopentone Na, TIVA (propofol+fentanyl)3. Msl relaxation Scoline (RSI) for antireflux surg. NDMR4. Maintainence O2 +? N2O + sevo/iso

4. Folleys catheter and NG tube insertion to avoid bladder/bowel injury (PONV, improve surgical view)Ventilatory settings- To maintain normocarbia (ETco2 34-38 mm Hg)- RR rather than TV as the lung compliance is low.6. Positioning gradually, tilt < 15-20, check ETT position, padding at pressure points.7. Gas insufflation slow (1-1.5 1-2.5 L/min) IAP