1. Dr. Ali Bandar, MD, PHD Anesthesia for Laparoscopic Surgery

2. Objectives 2 A.Introdution B.Indications of Laparoscopic surgeries. C.Advantages over laparotomy D.Disadvantages E.Contraindications F.Anesthetic Consideration G.Anesthetic techniques

3. Introduction 3

4.  General surgery: appendix, colon, small bowel, gallbladder, bile ducts, stomach, esophagus, liver, spleen, pancreas, adrenals, hernia repairs, diagnostic laparoscopy, adhesiolysis  Gynecologic procedures: Salpengectomy, Miomectomy, infiltelity…  Thoracoscopic surgery: Sympatectomy…  Cardiac surgery: Coronary artery bypass, valve repair  Orthopedics  Urologic procedures  Neurosurgery  Transplant surgery A.Indications of Laparoscopic surgeries

5. Advantages of laparoscopy over Laparotomy Patient Specific:  More cosmetic  Shortert recovery  Earlier return home  Faster Activity  Less cost Surgoen Specific:  Better Visualization  medical risk  ileus  damage to healthy tissue  wound infection  P/O complications  Better outcomes Anesthetist Sp  Incisional stress response  Opioid requirment  P/O Pain  Fluid shift  P/O Resp Dysfun.

6. Disadvantages :  It needs well-trained surgeons.  There is narrow, two-dimensional visual field on video.  General anesthesia is usually needed.  Higher costs (especially with disposable instruments)

7. Related to Surgery :  Diaphragmatic hernia.  History of extensive surgery.  Large intra-abdominal masses.  Tumor of the abdorninal wall.  Peritonitis.  Coagulopathies.  Surgeon inexperience (is the strongest contraindication). 7 Patient refusal. Related to Anesthesia:  Severe cardiovascular or pulmonary diseases(including bullae).  Increased ICP or space occupying lesions.  Impending renal shutdown.  Hypovolemic shock

8. 8 Anesthetic Considerations Of Laparoscopy:

9. 1.General considerations 2.Considertaions related to positioning. 3.Considerations of gas insuflation 4.Considerations of pneumo-peritoneum 9

10. 10 1. General Considerations 1.Dark Room 2.Trocar Injury(Vascular, Organs) 3.Potential conversion to open 4.Increased risk of PONV

11. Anesthetic Considerations Of Laparoscopy: 1.General considerations 2.Considertaions related to positioning. 3.Considerations of gas insufflation 4.Considerations of pneumo-peritoneum 11

12. 12 Trendelenburg (lower abdominal procedures) - Appendectomy - Hernia repair Anti- Trendelenburg (upper abdominal procedures) -Cholecystectomy - LSG

13. Anti-Trendelenburg: Favorable for Respiration Trendelenburg:  ↓ Pulmonary compliance  ↑ airway pressure  ↓FRC  Atelectasis  Endobronchial intubation 13 Respiratory effect of Positioning:

14. Anti-Trendelenburg:  Blood Pooling  Venous stasis  Thromboembolism  ↓ Venous Return  ↓ CO  ↓↔ BP Trendelenburg:  ↑ CVP, VR  ↑ CO  ↑ Cerebral Perfusion ↑ ICP ↑ IOP 14 Cardiovascular effect of Positioning :

15. Brachial plexus palsy effect of prolonged arm Abduction 15 Position – Nerve Injury:

16. 16 Effect of prolonged positioning:  Head and neck congestion. They become dusky.  Conjunctiva and eyelid edema.  Retinal hemorrhage and detachment with increased intraocular pressure.  Cerebral edema with increased ICP.  Laryngeal, tongue, and airway edema.

17. Anesthetic problems Of Laparoscopy: 1.General considerations 2.Considertaions related to positioning. 3.Considerations of Gas insufflation 4.Considerations of pneumo-peritoneum 17

18. 18 AirN2OO2 Helium Angon CO2 What gases can be used?

19. Why a Carbone Deoxide ??  Non-flammable and does not support combustion.  Readily diffuses through membranes & rapidly removed by lungs  Highly soluble; so, the risk embolization is minimal.  CO2 levels in blood and expired air can be easily measured.  High CO2 concentration of blood can be tolerated. As long as 02 requirements are met.  Medical CO2 gas is readily available and inexpensive. 19

20. 20 3. Considerations of GAS Insufflation  Direct Peritonial irritation  CO2 produces postoperative shoulders pain  HyperCarbia and respiratory Acidosis  Hypothermia  Subcutaneous Emphesyma  Pneumothorax, Pneumomediastinum  Gas Embolism and acute PE  Bronchial Intubation

21. Anesthetic Considerations Of Laparoscopy : 1.General considerations 2.Considertaions related to positioning. 3.Considerations gas insufflation 4.Considerations of pneumo-peritoneum 21

22. Effect Pneumo-peritonium CNS:  The induction of pneumoperitoneum itself increases middle cerebral artery blood flow  Increased ICP: o Increased lumbar spinal pressure → Decreased drainage from lumbar plexus o Hypercapnia, high systemic vascular resistance and head low position combine to elevate intracranial pressure. 22

23. CardioVascular Effect of Pneumo-Peritonium:  ⬆ IAP up to 15-20 mm Hg, ⬆ venous return ⇨ ⬆ CVP, and ⬆CO.  ⬆ IAP >20 mm Hg, compresses the IVC resulting ⬇, ⇨ ⬇ CVP and, CO.  ⬆ IAP ⬇ femoral venous blood flow, which ⬆ the incidence of deep venous thrombosis. 23

24. Respiratory Effect of Pneumo-peritonium:  Limitation of diaphragmatic and anterior abdominal wall movement cause decreased lung volume, atelectasis and dead space ventilation  FRC 20-25%  Respiratory Compliance 30-50%  Respiratory Resistance 24

25. Gastro intestinal effect of Pneumo-peritonium  Risk factor for regurgitation  Decreased mesenteric circulation  Decreased total hepatic blood flow 25

26. Renal Effect of Pneumo-Peritonium: An Increased IAP decreases the GFR and urine output about 50% (renal compartmental syndrome) due to the following causes:  Compression of renal vein and inferior vena cava.  Reduction of renal cortical blood flow up to 60%.  Renal parenchymal compression. 26

27. Anesthetic Management 27

28. 28 Preoperative management: 1-Complete history, examination, and investigations 2- Consent for laparotomy. 3-Complete bowel preparation. 4-Premedications: Anti-emetics e.g., ondansetron (S-HT3 receptor antagonists). Antacids and H2 antagonists to decrease aspiration effects. Anticholinergics may be given to decrease the possibility of bradycardia 5- Pharmacological DVT prophylaxis ( as per surgeon )

29. 29 Intraoperative management:  Monitoring as ASA standards  Mechanical DVT prophylaxis  General Anaesthsia: conducted by intubation, volatile agents, opioids, and controlled ventilation.  Good muscle relaxation  Positioning  Naso-or orogastric tube  Extubation : In addition to the usual criteria of extubation, extubation should be delayed if venous congestion and edema are observed in the head, neck, upper chest, eye, tongue...etc.

30. 30 Post-operative management: Postoperative nausea and vomiting: There is an increased incidence of postoperative nausea and vomiting (the incidence is 42%). Postoperative pain: postoperative pain (Multi-modal) - local anesthetic infiltration of port site -Paracetamol -NSAIDs -Opioids (+/-) Respiratory distress: It may occur if pneumothorax is not detected intraoperatively. NB. Don`t under-estimate surgical emphysema

31. Take Home Message  Pt. selection  Considerations General Positioning Pneumoperitoneum Gas insufflation  Post op. pain management  Post op. N&V 31

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