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

2. Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View

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

4. 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

5. 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

6. 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 

7. 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 

8. Optimising Surgical Conditions for Laparoscopis Surgeries, Surgeon’s View
Kirchhoff et al. Patient Safety in Surgery :5   doi: /

9. 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.

10. 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

11. 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.

12. 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): , August 2008.DOI: /SLA.0b013e31817bbe3a

13. 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.

14. 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

15. 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.

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

17. 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:

18. 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

19. 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:

20. 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

21. Relaxation

22. 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:

23. 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 Apr 15;(2):CD

24. 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, Prospective Randomized Trial of Low-Pressure Pneumoperitoneum for Reduction of
Shoulder-Tip Pain Following Laparoscopy.

25. 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:

26. 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

27. 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

28. 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

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

31. 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.

32. 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

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

34. 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.

35. 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.

36. 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.