Tadeja Pintar UMC Ljubljana, Abdominal Surgery Optimising Surgical Conditions for Laparoscopic Surgeries, Surgeon’s View Tadeja Pintar UMC Ljubljana, Abdominal Surgery

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View

Surgeon-Anesthetist Collaborative Question and Answer Session Surgeon’s Goals Anaesthetist’s Goals Deep NMB

Surgeon-Anesthetist Collaborative Question and Answer Session Optimize patient safety and surgical outcomes Minimize residual blockade Ensure reasonable OR turnover Surgeon’s Goals Anaesthetist’s Goals

Surgeon-Anesthetist Collaborative Question and Answer Session Optimize patient safety and surgical outcomes Maximize surgical view Maximize access Surgeon’s Goals Anaesthetist’s Goals Optimize patient safety and surgical outcomes Maximize surgical view Maximize access

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View To identify and minimize intra- and postoperative complications an overview of different work has to be performed. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Philipp Kirchhoff, Pierre-Alain Clavien and Dieter Hahnloser*: Complications in colorectal surgery: risk factors and preventive strategies. Patient Safety in Surgery 2010, 4:5 

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications. Philipp Kirchhoff, Pierre-Alain Clavien and Dieter Hahnloser*: Complications in colorectal surgery: risk factors and preventive strategies. Patient Safety in Surgery 2010, 4:5 

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View Kirchhoff et al. Patient Safety in Surgery 2010 4:5   doi:10.1186/1754-9493-4-5

The risk related to surgery is a function of many factors. Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View The risk related to surgery is a function of many factors. Scoring systems to predict morbidity and mortality of various surgeries are important tools for the surgeon and for the patient. These systems generally use data acquired during pre-hospital and in-hospital care, and some supplement this with components measuring the operative severity.

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View Deep NMB and the Surgeon It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it. Sir William Osler

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient’s outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. Optimizing patient outcomes in laparoscopic surgery.B. F. Levy,M. J. P. Scott, W. J. Fawcett,A. Day,T. A.Rockall.Colorectral disease.

A Multivariate Analysis of Potential Risk Factors for Intra- and Postoperative Complications in 1316 Elective Laparoscopic Colorectal Procedures..Kirchhoff, Philipp; Dincler, Selim; Buchmann, Peter. Annals of Surgery. 248(2):259-265, August 2008.DOI: 10.1097/SLA.0b013e31817bbe3a

Analgesia and fluid therapy, together with the remaining enhanced Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View 1  Analgesia – The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2  Individualised goal directed therapy – It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach. Optimizing patient outcomes in laparoscopic surgery.B. F. Levy,M. J. P. Scott, W. J. Fawcett,A. Day, T. A. Rockall.Colorectral disease.

The existing scoring systems in colorectal surgery are: Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View Scoring systems to predict morbidity and mortality from surgery are important tools used to give information to the surgeon and patient. The existing scoring systems in colorectal surgery are: CR-POSSUM (colorectal physiologic and operative severity score for enumeration of mortality and morbidity), AFC (4-item predictive score of mortality after colorectal surgery), and the Cleveland Clinic Foundation colorectal cancer model. Most of these scoring systems are lacking in feasibility, accuracy, and predict only mortality, not morbidity. A Multivariate Analysis of Potential Risk Factors for Intra- and Postoperative Complications in 1316 Elective Laparoscopic Colorectal Procedures. Kirchhoff, Philipp MD; Dincler, Selim MD; Buchmann, Peter MD.Annals of Surgery. Volume 248(2), August 2008, pp 259-265.

Other scoring sistems used are: Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View Other scoring sistems used are: the American Society of Anaesthesiologists (ASA), the APACHE scoring system (Acute Physiology and chronic Health Evaluation), POSSUM (Physiological and operative severity score for enumeration of mortality and morbidity), AFC (4-item predictive score of mortality after colorectal surgery) and the Cleveland Clinic Foundation colorectal cancer model.

Optimized Surgical Conditions: A Surgeon’s Perspective Decreased suture tension upon closure Improved field of view/visualization Better access Decreased CO2 insufflation pressure.

Creating a pneumoperitoneum provides a safe A Prospective Randomized, Controlled Study Comparing Low Pressure Versus High Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy Creating a pneumoperitoneum provides a safe space for dissection between the abdominal wall and the viscera. Lower intra-abdominal pressure [LIAP] is associated with less safe space for dissection. Surgeons who were blinded to pressure felt more difficulty in getting space for dissection. Joshipur VP, et al. Surg Laparosc Endosc Percutan Tech. 2009; 19: 234-40

The effects of retroperitoneal carbon dioxide insufflation on hemodynamics and arterial carbon dioxide.Jennifer E Baird, MDa (CM), Robert Granger, MDaRael Klein, MDa, C.Brian Warriner, MDa, P.Terry Phang, MDa. The American Journal of Surgery Volume 177, Issue 2, February 1999, Pages 164–166

Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were improved by low pressure pneumoperitoneum. However, the technical difficulties were graded higher with low pressure pneumoperitoneum. A Prospective Randomized, Controlled Study Comparing Low Pressure Versus High Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy. Joshipur VP, Joshipur VP, et al. Surg Laparosc Endosc Percutan Tech. 2009; 19: 234-40.

Potential Clinical Consequences and Risks of Suboptimal Block Limited field of view increases: Error rate Operative time Post-op discomfort Risks of increased CO2 insufflation pressure Decreased cardiac output Increased risk of thromboembolism Increased CO2 embolism Increased risk pneumothorax Post-op pain Increased suture tension required at closure Impaired wound healing

Relaxation

Creating a pneumoperitoneum provides a safe A Prospective Randomized, Controlled Study Comparing Low Pressure Versus High Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy Creating a pneumoperitoneum provides a safe space for dissection between the abdominal wall and the viscera. Lower intra-abdominal pressure [LIAP] is associated with less safe space for dissection. Surgeons who were blinded to pressure felt more difficulty in getting space for dissection. Joshipur VP, et al. Surg Laparosc Endosc Percutan Tech. 2009; 19: 234-40.

A pneumoperitoneum of 12 to 16 mmHg is used for laparoscopic cholecystectomy. Lower pressures are claimed to be safe and effective in decreasing cardiopulmonary complications and pain. AUTHORS' CONCLUSIONS: Low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established. Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Gurusamy KS, Samraj K, Davidson BR. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006930.

Post-op Shoulder Pain Reducing pneumoperitoneum pressure to 9mm Hg results in a significant reduction in both the intensity.... and frequency with which it [pain] is reported.” Sarli L, BJS 2000, 87,1161-1165. Prospective Randomized Trial of Low-Pressure Pneumoperitoneum for Reduction of Shoulder-Tip Pain Following Laparoscopy.

Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were improved by low pressure pneumoperitoneum. However, the technical difficulties were graded higher with low pressure pneumoperitoneum. Joshipur VP, et al. Surg Laparosc Endosc Percutan Tech. 2009; 19: 234-40.

Improved Surgical Conditions Through Sustained Deep NMB Throughout the Procedure A new neuromuscular management strategy is needed:ideal relaxant and optimal reversal.ideal relaxant and optimal reversal End of surgery Deep blockade could remain in place for duration of procedure Together with blockade reversing / wearing off predictably and rapidly at end procedure Current practice Ideal practice Increasing Depth of blockade Time A new neuromuscular management strategy is needed: ideal relaxant and optimal reversal

Surgeon’s Perspective on Deep NMB Immobility of the patient Neurosurgery, cardiac surgery, microsurgery Decrease of the tone of the abdominal muscles GI surgery, gynaecological, thoracic surgery Prevention of complications Coughing, increase in intra-abdominal and intrathoracic pressures Abdulatif, et al. Can J Anaesth. 1995,42:96

Potential Clinical Consequences and Risks of Suboptimal Block Limited field of view increases: Error rate Operative time Post-op discomfort Risks of increased CO2 insufflation pressure Decreased cardiac output Increased risk of thromboembolism Increased CO2 embolism Increased risk pneumothorax Post-op pain Increased suture tension required at closure Impaired wound healing

Reducing Intra-abdominal Pressure Increases perfusion of critical organs inferior vena cava flow refilling of the right atrium Reduces pressure on the diaphragm

Laparoscopic Field of View Space at 15 mm Hg is reduced without deep NMB. Increased peritoneal depth allows improved viewing angle. Changes in muscle tone produce variations in the intra abdominal space resulting in changes in visualisation. Gradual changes may not be noticed till errors and lack of operative efficiency have arisen.

Surgeon-Controlled Relaxation Interval Between Initial Bolus and First Surgeon On-demand Dose (Min) Interval Between Surgeon On-demand Doses (Min) Number of Surgeon On-demand Doses 23 ± 10 (13 – 37) 24 ± 2 (22 – 26) 1.5 ± 0.9 (0 – 3) Caesarean section; multiparity patients Caesarean section; multiparity patients Abdulatif, et al. Can J Anaesth. 1995,42:96. Abdulatif, et al. Can J Anaesth. 1995,42:96. 32

Conclusions Patients (%) Frequency of Treatment Failure P<0.001 King M. Anesthesiology. 2000;93:1392. Radical prostatectomy 33

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient’s outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. Optimizing patient outcomes in laparoscopic surgery.B. F. Levy,M. J. P. Scott, W. J. Fawcett,A. Day,T. A.Rockall.Colorectral disease.

Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View 1  Analgesia – The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. 2  Individualised goal directed therapy – It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. In addition, standardization of perioperative care is essential to minimize postoperative complications. Analgesia and fluid therapy, standardisation of perioperative care all together with the remaining enhanced recovery criteria have led to the development of the trimodal approach. Optimizing patient outcomes in laparoscopic surgery.B. F. Levy,M. J. P. Scott, W. J. Fawcett,A. Day, T. A. Rockall.Colorectral disease.

Analgesia and fluid therapy, standardisation of perioperative care all together with the remaining enhanced recovery criteria have led to the development of the multimodal approach. Optimizing patient outcomes in laparoscopic surgery.B. F. Levy,M. J. P. Scott, W. J. Fawcett,A. Day, T. A. Rockall.Colorectral disease.