ANESTHESIA IN
LAPAROSCOPIC SURGERY
Lt. Nutnaree Thuncharoon M.D.
Lt. Pasin Charnviboon M.D.
OUTLINES
• Laparoscopic surgery
• Physiology Impact
• Intraoperative management
• Postoperative management
• Special consideration
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LAPAROSCOPIC SURGERY
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INTRODUCTION TO LAPAROSCOPIC SURGERY
Open Surgery Minimally invasive surgery Robotic-assisted surgery
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LAPAROSCOPIC SURGERY
• Minimal invasive surgery
• Pneumoperitoneum is created to allow surgical exposure and manipulation
• Insufflation gas: Carbon dioxide (CO2)***, Helium, Nitrous oxide
• Abdominal wall lift (gasless laparoscopy)
• Maintain the IAP below 15 mmHg
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CARBON DIOXIDE (CO2)
• Advantage • Disadvantage
• Highly blood solubility • Physiologic derangements
• Rapid pulmonary removal
• Minimizing consequences
(Inadverent extraperitoneal,
intravascular insufflation)
• Nonflammable
• Nonoxidizing
• Safe to use with electrocautery
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BENEFITS & DISADVANTAGES OF LAPAROSCOPIC SURGERY
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PATIENT POSITION
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COMMON POSITION
• Trendelenburg (Head down)
• Myomectomy
• Reverse Trendelenburg (Head up)
• Sleeve gastrectomy , Cholecystectomy
• Lithotomy
• Pelvic surgery (radical prostatectomy , hysterectomy)
• Lateral or semilateral position combined with a flexion
• Urological surgery , nephrectomy
• Suprine position
• Colonic surgery , gastric surgery , splenic surgery , hepatic surgery
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RISK AND CONTRAINDICATIONS FOR
LAPAROSCOPIC SURGERY
• High risk for general anesthesia
• Morbid obesity (BMI>40)
• It depends on each type of surgery.
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PHYSIOLOGY IMPACT
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas
2. Pneumoperitoneum
3. Positioning
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1. CO 2 GAS
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 1. CO2 Gas
Hypercarbia (PaCO2 > 45 mmHg)
2. Pneumoperitoneum • Monitor: Capnography
3. Positioning • Increase Catecholomine (Sympathetic >
Parasympathetic)
• Peripheral and Pulmonary vasoconstriction
• Splanchnic & Mesenteric vasodilatation >
Decrease mesenteric blood flow
• Level
• Mild > Respiratory drive,
Oxyhemoglobin dissociation curve shift
to right (Increase tissue oxygenation)
• Severe > Acidosis
• Pulmonary vasoconstriction
(Increase ventricular afterload)
• Impair inotropic effect
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2. PNEUMOPERITONEUM
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 2. Pneumoperitoneum
2. Pneumoperitoneum • Highly innervate by autonomic
3. Positioning nervous system
Peritoneal stretching > Activate
autonomic nervous system
(Sympathetic > Parasympathetic)
• Increase Catecholamine > Systemic
vasoconstriction
➢ Increase MAP + LV afterload
➢ Decrease Splanchnic blood flow
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 2. Pneumoperitoneum
• Increase IAP
2. Pneumoperitoneum ➢ Splanchnic circulation collapse
3. Positioning without IVC compression + Decrease
Splanchnic blood flow > Increase
venous return & cardiac filling
(transient) + Decrease Mesenteric
blood flow
➢ IVC Compression > Decrease Venous
return & cardiac filling
➢ Decrease renal perfusion
➢ Reduce Urine output
➢ Activate Renin-angiotensin
system (RAS) > Oliguria
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3. POSITIONING
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 3. Positioning
2. Pneumoperitoneum • Trendelenburg position
3. Positioning • Reverse Trendelenburg position
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 3. Positioning
2. Pneumoperitoneum • Trendelenburg position
3. Positioning ➢ head declined angle 30°- 45°
➢ Increase Preload:
➢ Increase venous return &
Cardiac filling > Increase EF &
CI + Increase Central venous
pressure (CVP)
➢ Decrease venous outflow
Chapman, 2020
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Trendelenburg position
Head declined
• Cardiovascular Chapman, 2020
• Respiratory
Venous return Venous return
& Cardiac filling outflow
Central venous pressure Preload
Hydrostatic pressure Cardiac output Myocardial oxygen demand
Baroreceptor
reflex
Vasodilatation & Bradycardia Myocardial Infarction
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Trendelenburg position
• Cardiovascular Head declined
Endobronchial
intubation
• Respiratory
Functional residual
Total lung volume Pulmonary compliance
capacity (FRC)
Atelectasis
Lung Inflation with a Paw of 40
recruitment cmH2O for 7-8 sec
Chapman, 2020
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
1. CO2 Gas 3. Positioning
2. Pneumoperitoneum • Reverse Trendelenburg position
3. Positioning ➢ Increase SVR
➢ Decrease CI (Minor)
Ebli, 2013
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Reverse Trendelenburg position
Head rising
Ebli, 2013
CARDIOVASCULAR RESPIRATORY
Airway pressure
Venous return Preload
Cardiac output & Pulmonary
Central venous pressure FRC
Cardiac index compliance
Mean arterial pressure Pulmonary artery pressure
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PHYSIOLOGIC IMPACT OF LAPAROSCOPY
• Cardiovascular effect
• Pulmonary effect
• Regional Perfusion effect
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Pneumoperitoneum
IAP
(Cardiovascular effect)
IVC Venous Intrathoracic Peritoneal Vascular
compression resistance pressure stretching resistance of
Intraabdominal
Pooling of blood in Release neurohumoral factor
organ
lower extremities (Vasopressin, Renin-angiotensin, Catecholamine)
Venous
Inotropism Systemic vascular resistance
return
Cardiac Arterial
output pressure
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Pneumoperitoneum
IAP
(Pulmonary effect)
Diaphragm Pleural Airway
Lung volume pressure pressure
elevated
Carina
FRC
displacement
A-a O2 V/Q
Gradient Mismatch
Endobronchial Lung Lung
Hypoxia
intubation Compliance Resistance
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Pneumoperitoneum
IAP
(Regional Perfusion effect)
Systemic CO2 Hemodynamic
Absorption change (SVR, CI)
Splanchnic Renal Cerebral Intraocular Femoral
blood flow blood flow blood flow pressure vein flow
GFR DVT
Pulmonary
Urine output ICP
embolism
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INTRAOPERATIVE MANAGEMENT
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PERIOPERATIVE MANAGEMENT
I. Monitoring
II. Anesthesia Maintenance
III. Ventilation
IV. Circulation and management
V. Intraoperative complication
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I. MONITORING
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I. MONITORING
• Electrocardiography
• Noninvasive Blood pressure
• Capnography
• Pulse oximetry
• Body Temperature
***Invasive or advance monitoring may be considered in
patient with pre-existing cardiopulmonary disease***
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II. ANESTHESIA MAINTENANCE
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II. ANESTHESIA MAINTENANCE
• Inhaled Anesthetics and Propofol
• Nitrous Oxide
• Pharmacologic Adjuncts
• Neuromuscular blockade
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II. ANESTHESIA MAINTENANCE
• Inhaled Anesthetics and - TIVA: Propofol (agent of choice)
Propofol - Predictable pharmacokinetic profile
• Nitrous Oxide - Antiemetic properties > Low incidence
of PONV
• Pharmacologic Adjuncts
- Inhaled anesthetic: Desflurane and
• Neuromuscular blockade Sevoflurane
- Short-acting
- Easily titratable properties
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II. ANESTHESIA MAINTENANCE
• Inhaled Anesthetics and - Risk of PONV (Avoid in patient with
Propofol risk)
• Nitrous Oxide - Mx: antiemetic prophylaxis
• Pharmacologic Adjuncts - Intra-abdominal laparoscopic
surgical fire with N2O (rare)
• Neuromuscular blockade
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II. ANESTHESIA MAINTENANCE
• Inhaled Anesthetics and - Aim: Lower postoperative pain
Propofol - Balanced anesthetic to minimized
• Nitrous Oxide intraoperative sympathetic
• Pharmacologic Adjuncts stimulation and optimizing
postoperative recovery
• Neuromuscular blockade
- ± combination with long-acting local
anesthetic
- : Remifentanil, Dexmedetomidine,
Lidocaine
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II. ANESTHESIA MAINTENANCE
• Inhaled Anesthetics and - Improve surgical exposure
Propofol - Role of NMB in laparoscopic surgery
• Nitrous Oxide still controversy
• Pharmacologic Adjuncts
• Neuromuscular blockade
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III. VENTILATION
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III. VENTILATION
• To handle transient effects of laparoscopy and control minute
ventilation during pneumoperitoneum
• Effect on Tidal volume, peak airway pressure depend on position
• Mode of Ventilator: Volume control (VC), Pressure control (PC)
Volume control (VC) Pressure control (PC)
Reverse Reverse
Trendelenburg Trendelenburg
Trendelenburg Trendelenburg
Tidal volume
Peak airway
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III. VENTILATION
• Prevent ventilator induced lung injury
• Low tidal volumes (6-8 cc/kg IBW)
• Optimized PEEP (5-10 cm H2O)
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IV. CIRCULATION MANAGEMENT
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IV. CIRCULATION AND FLUID MANAGEMENT
• Pneumoperitoneum and positioning impact intravascular volume
status and alter fluid management
• Healthy patient-benefit to high volume loading
• Geriatric patient (age > 70) who received more volume showed
higher rates of anastomotic leaks and longer hospital stay
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V. INTRAOPERATIVE COMPLICATION
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V. INTRAOPERATIVE COMPLICATION
• Intraoperative life-threatening complication should result in
immediate termination of laparoscopy and serious consideration
to convert to an open laparotomy
• Intraoperative complications:
• Intra-abdominal injuries
• Cardiopulmonary
• CO2 Extravasation
• Patient shifting and Falls
• Ocular injuries
• Peripheral nerve and Brachial plexus injuries
• Airway edema
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Vascular
• Cardiopulmonary - GI and Urological structure
• CO2 Extravasation - Bowel injury
- Rare but major cause of morbidity and
• Patient shifting and Falls mortality
- Postoperative sepsis
• Ocular injuries - NG
• Peripheral nerve and - Bladder perforation and ureter ligation
Brachial plexus injuries - low urine output, hematuria, pneumaturia
(rare)
• Airway edema
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries Cardiovascular complication
- Hypertension
• Cardiopulmonary - often transient
• CO2 Extravasation - Adjust depth of anesthesia
- Short-acting vasoactive agents
• Patient shifting and Falls - Hypotension
• Ocular injuries - decreasing depth of anesthesia
- volume expansion
• Peripheral nerve and - lower IAP insufflation
Brachial plexus injuries - short-acting vasopressors
- slow re-insufflation with lower IAP
• Airway edema - Dysrhythmias (Tachy/Bradyarrhythmia)
- Cardiac arrest
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries Pulmonary complication
• Cardiopulmonary - Hypercarbia
- In patient with refractory Hypercarbia
• CO2 Extravasation - cessation of insufflation
• Patient shifting and Falls - persistent ventilator support
• Ocular injuries - Hypoxia
- confirming O2 delivery and endotracheal
• Peripheral nerve and tube positioning
Brachial plexus injuries - In patient with refractory hypoxia
• Airway edema - pneumoperitoneum release
- 100% O2 ventilation
- neutral positioning
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CAPNOGRAPHY AND COMPLICATION
Capnography Increase PETco2 Decrease PETco2
No Yes Yes Yes Yes
Pulse oximetry Desaturation No change Desaturation Desaturation Desaturation
Airway pressure Increase Paw No change Increase Paw Increase Paw No change
Clinical examination
a. Reduce air entry Yes No Yes Yes Murmur
b. Hyperresonance No No Yes Yes Hypotension
c. Swelling and crepitus No Yes Possibly Possibly ECG changes
Presumptive diagnosis Endobronchial Subcutaneous Capnothorax Pneumothorax Massive CO2
intubation emphysema
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Subcutaneous Emphysema
• Cardiopulmonary - resolves within 24 hr
- Mx: peritoneal deinsufflation ±
• CO2 Extravasation reinsufflation at a lower IAP
• Patient shifting and Falls - Capnothorax/ Tension capnothorax
• Ocular injuries - Postoperative CxR
• Peripheral nerve and - Early detection of Tension capnothorax
(life-threatening condition)
Brachial plexus injuries
- Mx: immediate peritoneal deinsufflation.,
• Airway edema hyperventilation, addition of PEEP,
emergent needle decompression or chest
tube insertion (in severe cases)
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Venous Gas Embolism (Fatal complication)
• Cardiopulmonary - Signs:
- Cyanosis
• CO2 Extravasation - “Mill wheel” murmur
• Patient shifting and Falls - Acute tachycardia
• Ocular injuries - Cardiac arrhythmias
- QRS complex widening
• Peripheral nerve and
- Hypotension
Brachial plexus injuries
- Hypoxemia
• Airway edema - Low end-tidal CO2
- Mx: Deinsufflation, ACLS/ IV Fluid/
Hyperventilation/ Oxygen therapy as need
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Extreme positioning
• Cardiopulmonary
• CO2 Extravasation
• Patient shifting and Falls
• Ocular injuries
• Peripheral nerve and
Brachial plexus injuries
• Airway edema
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Steep Trendelenburg positioning
• Cardiopulmonary - Corneal abrasion
• CO2 Extravasation - direct ocular trauma, corneal exposure,
and corneal dehydration
• Patient shifting and Falls - Mx: Eye patches
• Ocular injuries - Ischemic optic neuropathy
• Peripheral nerve and - Associate with blindness
Brachial plexus injuries - Prolonged steep Trendelenburg position +
large volume fluid therapy > increase IOP
• Airway edema + venous congestion > optic canal
ischemia
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Compression, stretch, and ischemia
• Cardiopulmonary - shoulder displacement
• CO2 Extravasation - Risk factors:
• Patient shifting and Falls - Prolonged operative times
- High BMI
• Ocular injuries - Inadequate padding
• Peripheral nerve and - Arm tucking
Brachial plexus injuries - Steep Trendelenburg positioning
• Airway edema
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V. INTRAOPERATIVE COMPLICATION
• Intra-abdominal injuries - Risk factor:
• Cardiopulmonary - Prolonged steep Trendelenburg position
- Large volume fluid resuscitation
• CO2 Extravasation
- Facial and pharyngo-laryngeal edema
• Patient shifting and Falls > postoperative airway compromise
• Ocular injuries - Mx:
• Peripheral nerve and - Cuff leak test before extubation
Brachial plexus injuries - Recumbent sitting position
• Airway edema - Continue ETT and ventilatory support in
severe airway edema patient
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POSTOPERATIVE MANAGEMENT
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POSTOPERATIVE MANAGEMENT
Supplement • Oxygen support
Pain control • Multimodal analgesia and adequate pain control
Post operative • Aggressive multimodal antiemetic prophylaxis
nausea and vomitng
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POSTOPERATIVE MANAGEMENT
Pain Prevention
• Adequate pain control is critical to hasten postoperative
recovery and ambulation
• Optimal pain therapy includes the use of multimodal
analgesia techniques
• Factors that could influence postoperative pain include :
• Duration of procedure
• Degree of IAP
• The volume of residual sub-diaphragmatic gas after
surgery
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POSTOPERATIVE MANAGEMENT
Pain Prevention
• Use of multimodal analgesia techniques
• Conventional NSAIDs or COX-2inh with acetaminophen
• Weak or strong opioids if inadequate pain relief
• Parenteral glucocorticoids (e.g. Dexamethasone)
• Ketamine is controversy
• The transversus abdominis plane (TAP) block
• Intraperitoneal instillation (e.g. ropivacaine)
• Intravenous Lidocaine infusion
• Epidural analgesia , intrathecal morphine , neuraxial
analgesia
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POSTOPERATIVE MANAGEMENT
Nausea and vomiting Prevention
• Greater risk for PONV due to intraperitoneal insufflation and bowel
manipulation
• Aggressive multimodal antiemetic prophylaxis is necessary for
minimizing prolonged postanesthesia recovery
• Dexamethasone , 4-8 mg after induction
• 5-HT3 antagonists (eg.ondansetron 4 mg ) at the end of surgery
• Aggresive hydration
• Minimal opioid use
• Aggresive pain control
• Scopolamin patch, prior to surgery
• Neurokinin-1 receptor antogonist,preoperatively
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SPECIAL CONSIDERATION
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PEDIATRIC LAPAROSCOPY
• Laparoscopy in the infant and young child requires specialized
instrumentation
• General anesthesia is typically utilized for most laparoscopic
surgery
• IAP < 15 mmHg appears to be tolerated in Children who BW > 5 kg
• Neonates should be limited to an IAP of <= 12 mmHg
• IAP of 8 mmHg can provide adequate exposure
• DVT is rare so prophylaxis is unnecessary
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LAPAROSCOPY IN PREGNANCY
• The operation should be performed during the second trimester of
preganancy
• Most surgeons feel that the open Hasson approach should be used
• Patient should be positioned slightly on the left side,to avoid
compression to IVC by uterus
• Sequential compression devices should be used to prevent
thromboembolism
• Fetal acidosis may be prevented by avoiding a respiratory acidosis
in the mother
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THANK YOU
