1. Laparoscopy- anaesthetic concerns Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute, puducherry – India

2. What is it ?? Laparoscopy (or peritoneoscopy) is a “minimally invasive” procedure allowing endoscopic access to the peritoneal cavity after insufflation of a gas (CO2) to create space between the anterior abdominal wall and the viscera. Laparoscopic surgery can also be extraperitoneal. It can also be gasless with abdominal wall retraction, Hand assisted

4. Some history Laparoscopy introduced in 20 th Century 1975 : first laparoscopic salpingectomy 1970 -- 80 : used for gyne procedures 1981: Semm, from Germany,1 st lap appendectomy 1989: laparoscopic cholecystectomy

5. All surgeries including laparoscopic autopsies

6. Why ??

7. major benefits Small incision reduced postoperative discomfort, shortened recovery rates, lower incidence of post operative wound infections Less post op pulmonary complications shorter in-patient stay

8. Advantages Obesity and bariatric surgery Pulmonary diseases

9. There are some disadvantages also

10. Disadvantages Higher equipment costs May be longer time of surgery Cannot do Positioning and Pneumoperitoneum cardiopulmonary effects

11. Contraindications – Diaphragmatic hernia – Acute or recent MI – Severe obstructive lung disease – Increased ICP – V – P shunt – Hypovolemia – CCF – Valvular heart diseases – CHAVI

12. Three specific problems Positioning Pneumoperitoneum CO2 insufflation

13. Positioning Trendelenberg and reverse Trendelenberg and its effects ‘well leg compartment syndrome’ induced by the combination of impaired arterial perfusion to raised lower limbs, compression of venous vessels by lower limbs supports, reduced femoral venous drainage due to pneumo peritoneum.

14. Risk factors Risk factors include surgery > 4 h duration, muscular lower limbs, obesity, peripheral vascular disease, hypotension, and steep Trendelenburg positioning Get up after two hours and go back again

15. pneumoperitoneum CO2 insufflation --- intra-abdominal pressure (IAP) climbs. Normal IAP = 0 – 5 mmHg Upto 10 – ok More than 15 – problems start Individual systems affected

16. Cardiovascular effects systemic vascular resistance (SVR) is increased 1. Mechanical compression of the abdominal aorta 2.Production of neurohumoral factors such as vasopressin 3.activation of the renin–angiotensin–aldosterone axis. IVC compressed Positioning can exacerbate

18. Steps to decrease CVS effects Healthy patients appear to tolerate these hemodynamic effects well What will decrease?? the lowest insufflation pressure vasodilating agents, centrally acting alpha-2 agonists. appropriate intravenous fluid loading

19. RS The upward pressure elevates the diaphragm, compresses the lungs, and impedes expansion of the lungs and chest cavity decreased functional residual capacity – atelectasis – V/Q mismatch Thoracopulmonary compliance may be decreased by up to 50% during pneumo peritoneum. Exacerbated by positioning The changes with anesthesia and laparoscopy can be partly offset by applying PEEP – but hemodynamics ??

21. Why should carbon dioxide ?? Noninflammable Rapidly excreted via the lungs CO2 embolization is less (200 ml Vs 20 ml for air ) medical grade CO2 is readily available inexpensive. CO2 levels can be measured

22. But CO2 is not inert It gets converted to carbonic acid in moist peritoneum – local pain it can remain in gaseous form intra peritoneal after laparoscopy, causing referred shoulder pain. Blood - Hypercarbia -- hypertension, tachycardia, cerebral vasodilation, and respiratory acidosis. Insufflations flow rate should be low, initially 1-1.5 Ltr/min of CO2

23. Back to increased IAP

24. Splanchnic effects Blood flow to the kidney and liver is significantly compromised with increasing IAP 20 mm Hg ---- 25 % GFR decrease

25. Neurological effects An elevated IAP causes an increase in intra- cerebral pressure (ICP) by limiting cerebral venous drainage as a consequence of raised intra-thoracic pressure CPP ?? On cardiac output POCD !!

26. Be awake like her

27. Preanaesthetic preparation Consent and readiness for laparotomy The cardiac and pulmonary status of all patients should be carefully assessed Premedication is usually not necessary except in anxious patients. Atropine can be used for premedication to prevent vagally mediated brady arrhythmias PONV prophylaxis PONV

28. Monitoring Pulse rate Continuous ECG Intermittent NIBP Pulse oximetry (SpO2) Capnography (EtCO2) Temperature Intra abdominal pressure Pulmonary airway pressure Others --- be vigilant like

29. Controlled GA with ETT – WHY ?? Less gastric acid aspiration, allows optimal control of CO2 facilitates surgical access ---------------------------------------- No mask ventilation Ryles tube – gastric distension for view, prevention of gastric injuries

30. zone 4 opened, zone 3 increased, zone 2 becomes three in increased IAP. The application of PEEP prior to Pneumo peritoneum is supposed to stop the lung changes All so called changes due to PEEP will be acceptable if we have adequate intravascular status

31. laryngeal mask airway (LMA) controversial due to the increased risk of aspiration difficulties encountered when trying to maintain effective gas transfer while delivering the higher airway pressures Still a lot of RCT s prove the use of proseal LMAs in lap surgeries

32. nitrous oxide The use of nitrous oxide- controversial produce bowel distension during surgery increase in PONV Halothane increases the incidence of arrhythmia during laparoscopic surgery, especially in the presence of hypercarbia

33. Remifentanyl – PCV Extremely painful - insufflation But surgery is short hence remifentanyl is ideal. Pressure controlled modalities affords higher instantaneous flow peaks, minimizing peak pressures, improved alveolar recruitment and oxygenation in laparoscopic surgery for obese patients

34. Combined spinal epidural anesthesia for laparoscopic appendectomy in adults: A case series management of pneumo peritoneum, achieving adequate level of analgesia Problem of shoulder tip pain, provision of postoperative pain relief prevent deterioration of respiratory mechanics, ambulation as early as possible. Possible with GA ??

35. CSEA

36. Spinal Spinal anaesthesia with Hyperbaric Bupivacaine and Fentanyl is adequate and safe for elective laparoscopic appendectomy in healthy patients but careful evaluation of the method is needed particularly in cardio respiratory conditions. Saudi Journal of Anaesthesia Vol. 6, Issue 1, January- March 2012

37. M RavishankarM Ravishankar et al In a conscious patient undergoing laparoscopy with pneumoperitoneum, under spinal anaesthesia, the preserved inspiratory diaphragmatic activity maintains ventilation and, the gas exchange within physiological limits. Hence it is a safe alternative to general anaesthesia. Who said this ?? J Anaesthesiol Clin Pharmacol. 2010 Oct-Dec; 26(4): 475–479. Respiratory Changes During Spinal Anaesthesia for Gynaecological Laparoscopic Surgery

38. Yes we can do it !!

39. Single shot epidural + GA

40. Previous slide and concepts 1Mechanical compression of the abdominal aorta 2.Production of neurohumoral factors such as vasopressin 3.activation of the renin–angiotensin– aldosterone axis. Using epidural and cutting off all symp. Afferents will correct all the above instead of using separate hypotensives

41. Ephedrine ok Phenylephrine ??

42. Complications CO2 emphysema Capnothorax CO2 embolism Trochar may cause abdominal vessel injury, GIT perforation, hepatic and splenic tear and omental injury. Extraperitoneal insufflation of CO2 Pneumothorax pneumomediastinum and pneumopericardium IPEEP

43. Treatment Most of these cases – 100 % oxygen., Cut off nitrous IVF and supportive measures

44. Other complications

45. Endobronchial intubation Cephalad displacement of the diaphragm during pneumoperitoneum result in cephalad movement of carina leading to endobronchial intubation

46. GAS EMBOLISM Direct insufflation of gas into a vessel by misplaced trochar or veress needle. Small bubble of gas carried through injured vein at operative site Large gas absorption into portal circulation may be caused by very fast rate of gas flow and very high intra abdominal pressure

47. CARDIAC ARYHTHMIAS Patient undergoing laparoscopy are prone to develop cardiac arrythmias due to high PCO2 and raised vagal tone. Other complications Darkness in the OR Regurgitation DARE – IPEEP

49. Insufflator Gas used N2O /CO2 /Argon /He/ Air Preferred gas : CO2 Working pressure : 12 to 14 mm Hg Slow inflation of 1 liter / minute (Air & O2 –risk of embolism high. N 2 O –bowel distension,risk of explosion,PONV. He & Argon not available here- embolism)

50. Post op management O2 administration for couple of hours to prevent alveolar hypoxia as CO2 excretion continues Energetic care for prevention of sickness must be taken as PONV can jeopardize all the benefits of laparoscopy and anesthesiologist gets total blame. Proper warming of patient. Attention must be paid for pain relief.

51. Post op pain – same on day 1 instillation of bupivacaine into the peritoneum interpleural injection of bupivacaine. Rigorous surgical washout at the end of the procedure. Nonsteroidal anti-inflammatory drugs When used in combination with a regular paracetamol, there is a considerable reduction in the requirement for opioid analgesia

52. Post op pain Local infiltration of the incision Expel as gas as possible TAP block Epidural Pre op dexa – pain and PONV

53. Summary Definition, advantages, disadvantages, CI Surgeries Three musketeers Premed Technique – monitoring Complications Postop

54. Thank you all