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Anesthesia for Laparoscopic Interventions Peter Biro Department of Anesthesiology University Hospital Zurich

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Presentation on theme: "Anesthesia for Laparoscopic Interventions Peter Biro Department of Anesthesiology University Hospital Zurich"— Presentation transcript:

1 Anesthesia for Laparoscopic Interventions Peter Biro Department of Anesthesiology University Hospital Zurich

2 The „Good“

3 Advantages Better cosmetic results Less pain, less analgesics required Shorter in-hospital stay Less complications (outcome?) Better pulmonary function (in particular in obese patients) Fast recovery, better comfort

4 Cholecystectomies in my Hospital OpenLaparoscopic

5 Cholecystectomies in my Hospital OpenLaparoscopic Open portion 50%

6 Cholecystectomies in my Hospital OpenLaparoscopic Open portion 33%

7 Cholecystectomies in my Hospital OpenLaparoscopic Open portion 13%

8 Surgeon Urologist Gynecologist Diagnostic Intestinal Herniotomy Liver Spleen Fundioplication Cholecystectomy Esophagus Axillar lymphonodes Gastric banding Adrenalectomy Parathyreoidectomy Diagnostic Nephrectomy Kidney cysts Prostatectomy Varicocele Lymphadenectomy Testicular descensus Diagnostic Tubar ligation Adnexectomy Ovarectomy Lymphadenectomy Endometriosis Myomectomy Axillar lymphonodes

9 What about the Anesthetist? General Anesthesia & Perioperative maintenance of vital functions...and comfort

10 The „Bad“

11 Mechanical Effects of Pneumoperitoneum Elevated intra- and retroperitoneal pressure Diaphragma displacement to cranial Elevated intrathoracic pressure Increase of airway pressure Decrease of total respiratory compliance Gas embolism (risk of)

12 Effects on Pulmonary Function Change of FEV 1 (post- vs. preoperative)―55% ―30% Duration till return to baseline FEV days 5 days FRC on 1 st postoperative day―20% ―34% PEF25-75% on 2 nd postoperative day ―50% ―25% Confirmed post operative atelectasis (X-ray) ―90% ―40% Openvs. Laparoscopic Cholecystectomy

13 Other Effects of Pneumoperitoneum Resorption of CO 2 (hypercarbia, acidosis) Increase of PCO 2 (arterial and end-tidal) Acidosis Increase of lactic acid Hormonal changes (catecholamines, vasopressin) Aggravation or improvement of side effects due to posture...but oxygenation remains basically unchanged

14 Hemodynamic Effects of Pneumoperitoneum Increase of atrial filling pressures ( right : CVP, left : wedge pressure) Increase of heart rate Increase of both, systemic and pulmonary vascular resistance Increase of both, arterial and pulmonary blood pressure Cardiac output and intrathoracic blood volume show unconsistent changes in both directions

15 Hormonal Effects of Pneumoperitoneum Increase of...  Vasopressine  Dopamine  Adrenaline  Noradrenaline  Renine  Cortisone ► sympatho-adrenergical stimulation, „stress“ metabolism

16 Example for Overlaping Effects MAPHRSVR BaselinePneumoperitoneum mmHg Beats/min Dyne/s/cm -5 /20

17 CO 2 Homeostasis and Pneumoperitoneum CO 2 uptake in 2 phases:  Initially fast resorption for app. 30 minutes  Followed by equlibration on higher level (>30% of baseline) If spontaneous ventilation possible ►increase of alveolar ventilation V/Q mismatch leads to arterio-alveolar CO 2 difference. ► invasive blood gas measurements mandatory in high risk patients (>ASA III)

18 Patients at Cardial Risk Due to...  acute elevated afterload  and sometimes decreased preload (head up posture) ► one must aplly:  invasive arterial blood pressure measurement  In case of cardial insufficiency / pulmonary hypertension: TEE, Swann-Ganz catheter  IAP not above 10 mmHg or even better...arrangement for or transition to open surgical procedure in neutral horizontal position

19 Patients at Cardial Risk Measures to improve situation (before transition to open surgical approach)...  Reduction of afterload with vasodilators  Carefull fluid replacement (under continuous TEE controll)  Application of positive inotropic and vasodilating agents such as dobutamine or phosphodiesterase inhibitors Immediate measures in case of dramatic cardial deterioration:  reversal of pneumoperitoneum (stop CO 2 inflow, deflate abdomen)  reversal of head down position to neutral or slightly elevated

20 Organ Perfusion and Pneumoperitoneum Decrease of...  gastrointestinal blood flow (in particular with IAP > 15 mmHg)  renal blood flow Increase of...  cerebral blood flow (cave: patients with elevated intracranial pressure)

21 Pneumoperitoneum and Pregnancy Increase of intrauterine pressure Decrease of uterine blood flow Decrease of fetal blood pressure Consequences have to be evaluated on an individuall scale. Eventually consideration of open surgical procedure in neutral horizontal position

22 Pneumoperitoneum and Pregnancy Cholecystectomy is the most often perfomed non-obstetric surgical intervention in pregnancy Meanwhile 50% are performed in laparoscopic mode However,...  surgery before 20th week of gestation bears elevated risk for preterm birth  No evidence for difference in malformation frequency in open vs. laparoscopic surgery Actually there is no general contraindication for laparoscopic surgery in pregnancy

23 Pediatric Surgery Since the nineties laparoscopy usual for neonates and toddlers Hemodynamic effects are more pronounced ►Therefore...  ► limit IAP to < 8 mmHg  ► table positioning angle not exceeding ±15°  ► avoid vagal reflexe (bradycardia)  ► not recommended for emergency operations

24 Morbid Obesity Higher rate of complications (+18%) Longer in-hospital stay (4-5 days more) However, laparoscopic procedures have strong advantages...  less problems with wound healing  less tendency for burst abdomen  early mobilization

25 CO 2 Homeostasis and Pneumoperitoneum Amount of CO 2 uptake is dependent on intraabdominal pressure (IAP) and duration of pneumoperitoneum With IAP < 10 mmHg hyperkapnia is unlikely After discontinuation of pneumoperitoneum fast reversal of hypercarbia even without forced hyperventilation

26 Complications Aspiration of gastric content  Intraoperative occurrence up to 6%  in 50% of cases reflux of gastric acid Consequences  ► gastric tubing  ► tracheal intubation (no laryngeal mask or similar supraglottic devices)

27 Complications Secondary unilateral bronchial ETT displacement Etiology  diaphragma elevation  airway shifts upwards while ETT is fixed at teeth level Consequences  ► ETT advancement not deeper than 20 cm  ► carefull checking and ►re-checking of bilateral ventilation (in case of doubt fiberbronchoscopy)

28 Complications Hypothermia  not less than in open surgery ► use patient warming devices as usual Smoke resorption  carbon monoxide (CO) poisoning possible ►check blood gases regularly Surgical emphysema  due to improper CO 2 insuflation ►check for airway obstruction Vascular injury and bleeding  may occurr during insertion of scope ►avoidance by muscular relaxation

29 Complications Pneumothorax  ► stop CO 2 inflow, ► deflate abdomen, ► insert thoracic drainage Pneumomediastinum  typical for surgery of diaphragma or esophagus  differencial diagnosis to pneumothorax or gas embolism necessary  risk of pericardial tamponade  ► diagnosis to be made with echoecardiography

30 Complications Gas (CO 2 ) embolism Etiology  intravasal gas insufflation (CO 2 voulme 5x larger than for air) Symptoms  fast decrease of PetCO 2  decrease of oxygen saturation (SpO 2 ) without change of airway pressure  Hypotension  Cardiac arrhytmia  Precordial „mill wheel sound“ ► Measures  stop CO 2 inflow, ► deflate abdomen, ► left tilt position, ► aspiration of gas via central venous line

31 Side Effects Postoperative pain  positive correlation to level and duration of IAP and intraabdominal pH  projection into the shoulder due to irritation of diaphragm  sometimes free interval up to 24 hours  duration up to 3-4 days ► Therapy  multi modal analgesia (combination of different drugs and application modalities according to standardized protocolls)

32 Side Effects Postoperative Nausea and Vomiting (PONV)  more in laparoscopic than in open surgery (in particular gynecology)  young females < 30 years  non smokers  early pregnancy  first phase of menstruation  amount of CO 2 uptake Therapy  corticoids, 5-HT 3 antagonists, dehydrobenzperidol Schulte Steinberg H., Euchner Wamser I., Zalunardo M.P. Anästhesie für laparoskopische Eingriffe. Anaesthesist 1999, 48:

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