1. Dr Santanu Kumar Dash

2.  to understand the principles of anaesthesia for
laparoscopic surgery
 to increase awareness of the risks of CO2
peritonium
 benefits of laparoscopic surgery from patient’s
point of view
 special considerations in geriatrics, COPD, heart
disease, pregnancy, paediatrics and obese patients

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

4.  Day care surgery
 Shorter hospital stay
 Improved cosmesis
 Less post-op ileus
 Faster recovery
 Rapid return to normal activities
 Minimal pain
 Small scar
 Better preservation of resp fn

5.  More expensive
 More operating time
 Difficult in complicated cases
 Potential for major complications in
inexperianced hand

6.  General Surgery:
▪ Cholecystectomy
▪ Appendicectomy
▪ Varicocoelectomy
▪ Hernioplasty
▪ Diagnostic laparoscopy
▪ Hiatus hernia repair
▪ Adhesiolysis

7.  OBG:
▪ Diagnostic tool for infertility
▪ Ectopic pregnancy
▪ Myomectomy
▪ LAVH
▪ Endometriosis
 Thoracic Surgery:
▪ Sympathectomy
 Mediastinoscopy

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

9. CO2 pneumo peritoneum
Due to patient positioning
Cardiovascular effects
Respiratory effects
Gastro intestinal effects
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR

10. 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.
N2O –bowel distension,risk of explosion,PONV.
He & Argon not available here- embolism)

11. CO2 as Insufflator Gas
▪ More soluble in blood than air
▪ Carriage is high due to bicarbonate buffering
and combination with Hb
▪ Rapidly eliminated by lungs
▪ Inert & not irritant to tissues

12. Cardiovascular effects depends on
▪ Patient’s preexisting cardiopulmonary status
▪ the anesthetic technique
▪ intra-abdominal pressure (IAP)
▪ carbon dioxide (CO2) absorption
▪ patient position
▪ duration of the surgical procedure

13. - There is biphasic response on CO
- If IAP <10mmHg, milking effect on veins CO
- If IAP >15mmHg, 10%-30% reduction in CO
 increase in systemic vascular resistance, mean
arterial pressure, and cardiac filling pressures
 more severe in patients with preexisting cardiac
disease
 significant changes occur at pressures greater
than 12 - 15 mmHg

14.  Increased noradrenalin levels leads to increased
SVR
 increased plasma renin activity (PRA) due to
increased intra-abdominal pressure (IAP) and
the local compression of renal vessels
 Hypertension, tachycardia leading to increased
myocardial oxygen demand
 Hypercarbia and acidosis

15. common during insufflation and during
desufflation
 Volatile anaesthetic agents
 Hypercarbia, hypoxia and gas embolism ppt
tachyarrythmias and VPDs
 Sudden stretching of peritoneum causes vagal
stimulation
 Light planes of anaesthesia

16. Management :
 Adequate preload will improve cardiac output
 Intermittent pneumatic compression to legs will
improve venous return
 Use of alpha 2 agonist such as clonidine or
dexmedetomidine & or beta blocker reduces
haemodynamic changes

17. Exaggerated in obese patients, ASA classII and III patients & in
those with respiratory dysfunction
Intra-abdominal distension leads to a decrease in pulmonary
dynamic compliance
2. increased IAP displaces the diaphragm upward
3. functional residual capacity and total lung compliance
decreases
4. Early closure of smaller airways, basal atelectasis
5. increased peak airway pressures
6. increase in minute ventilation required to maintain
normocarbia
7. Increase in intra pulmonary shunting

19.  Risk factor for Regurgitation
Increased intra-abdominal pressure
Decreased lower esophageal sphincter tone (if
barrier pressure is increased>30cm of H2O)
Head down position
NG tube mandatory

20. Mesentric circulation:
 Reduced bowel circulation resulting in decreased
gastric intra mucosal pH
 Due to IAP, collapse of capillaries and small
veins,
 Reverse Trendelenburg position,
 Release of vasopressin
all lead to decreased mesenteric circulation

21. Porto Hepatic circulation:
Rise in IAP result in decreased total hepatic
blood flow due to splanchnic compression
Hormonal release (catecholamine, Vasopressin & Angiotensin
lead on to overall reduction in splanchnic blood flow except
for Adrenal glands

22.  Increased IAP 
 decreased RBF 
 increased sympathetic activity 
 elevated plasma Renin activity 
 fall in filtration pressure 
 fall in urine output

23.  Increased IAP Increased lumbar spinal pressure
Decreased drainage from lumbar plexus 
Increased ICP
 Hypercapnia, high systemic vascular resistance and
head low position combine to elevate intracranial
pressure.
 The induction of pneumoperitoneum itself
increases middle cerebral artery blood flow

24.  Increased IAP may lead to increased venous
stasis
 causing deep vein thrombosis especially in
prolonged surgery
 deep vein thrombosis prophylaxis
should be done in such patients.

25.  Continuous flow of dry gases into peritoneal cavity
under pressure can lead to fall in body temperature.
 (sudden expansion of gas produces hypothermia
due to Joule Thompson effect)
 0.30 C fall in core temperature/50 Lit flow of CO2

26.  Activation of Hypo thalamo pituitary Adreno
cortical Axis 
 Rise in ACTH, Cortisol and Glucogon 
 Altered glucose metabolism
Laparoscpic surgery is as stressful as
conventional surgery

27.  Head Down tilt - for pelvic and sub meso-colic
surgery
 HeadUp tilt - for supra mesocolic surgery
 Lithotomy position - for gynecological
procedures

28.  Head-down position
▪ Endo-bronchial intubation
▪ Promotes atelectasis
▪ Decreases FRC
▪ Decreases TLC
▪ Decreases pulmonary compliance
 Head-Up position: favorable for respiration

29.  Head up tilt----- Blood pooling
Venous stasis
Thrombo-embolism
↓ venous return
↓cardiac output
→ ↓ Blood Pressure

30.  Head down Position:
▪ Increases CVP
▪ Increases cardiac output
▪ Increases cerebral circulation
▪ Increased ICP
▪ Increased intra-ocular pressure

31.  Hyper extension of arm --- brachial plexus injury
 Lithotomy position --- common peroneal injury

32.  Due to trochar injury
 Positioning and compression effect
 CVS and RS complications
 Thermal injuries
 Gas embolism

33.  Subcutaneous emphysema
▪ occur if the tip of the Veress needle does not
penetrate the peritoneal cavity prior to insufflation of
gas.
▪ Occur in inguinal hernia repair, renal surgery
▪ During fundoplication for hiatus hernia repair
Extraperitoneal insufflation, which is associated with
higher levels of CO2 absorption than intraperitoneal
insufflation, is reflected by a sudden rise in the EtCO2,
excessive changes in airway pressure and respiratory
acidosis
CO2 subcutaneous emphysema readily resolves after
insufflation has ceased

34. Pneumothorax, Pneumomediastinum and
Pneumopericardium
 Patent pleuro-peritoneal channels
 Pleural injuries
 Ruptured emphysematous bullae

35. Pneumothorax, Pneumomediastinum and
Pneumopericardium
 Sudden hypoxia, rise in peak airway pressure,
hypercarbia, haemodynamic alterations and
 abnormal movement of the hemidiaphragm on
laparoscopic view should raise a suspicion of
pneumothorax

36.  Recommended Guidelines
 Stop N2O
 Adjust ventilator settings to correct hypoxemia
 If due to pleuro peritoneal channel route
Apply PEEP
 Reduce intra-abdominal pressure
 Communicate with surgeon
 Avoid thoracocentesis unless necessary
 Avoid PEEP if there is rupture of emphysematous bulla
and thoracocentesis is mandatory

37.  Most feared & fatal complication
 Seen frequently when laparoscopy is associated with hysteroscopy
 Intra vascular injection of gas following direct trocar placement into
vessel
 Gas insufflation into abdominal organ
 Suspicion of Gas Embolism
 Blood on aspiration from Vere’s needle
 Pulsation of flow meter pressure gauge
 Disappearance of abdominal distention despite sufficient volume of
gas

38.  Depends on volume of air and rate of iv entry
 Rapid insufflation of gas into blood (2ml/kg)
 -> larger bubbles -Gas lock in RA & venacava
 -> Fall in cardiac output
 ->High pressure in RA
 -> Open foramen ovale
 ->Embolus in cerebral & coronary beds
 -> Paradoxical embolism

39.  Detection of gas in right side of Heart –foamy blood aspirated in the
central venous catheter
 Recognition of physiological changes secondary to emboli:
▪ Tachycardia
▪ Cardiac arrhythmia
▪ Hypotension
▪ CVP rise
▪ Mill-wheel murmur
▪ Cyanosis
▪ Right heart strain pattern in ECG
▪ Pulmonary edema
 Doppler & TEE ---- very sensitive (0.5ml/kg)

40.  Immediate cessation of insufflation
 Release of pneumo-peritoneum
 Patient in head down and left lateral decubitus
(Durant’s) position
 Cessation of N2O
 Give 100% oxygen
 CVP insertion and aspiration of gas
 CPR help to fragment CO2 emboli into small bubbles

41.  Postoperative Pain
 abdominal and shoulder tip pain after
laparoscopic surgery
 Complete removal of the insufflating gas is
essential
 Infiltration of the portal sites with a local
anaesthetic reduces pain
 right-sided subdiaphragmatic instillation with a
local anaesthetic reduces shoulder tip pain

42.  Post Operative Nausea & Vomiting (PONV)
 Peritoneal insufflation, bowel manipulation and
pelvic surgery are some of the causative factors
 A meticulous anaesthetic technique along with
antiemetics is helpful in reducing the incidence
of PONV

43. J Emerg Trauma Shock. 2011 Apr;4(2):168-72.
Comparison of ondansetron and combination of ondansetron(4mg)
and dexamethasone(4mg) as a prophylaxis for postoperative nausea
and vomiting in adults undergoing elective laparoscopic surgery.
Bhattarai B, Shrestha S, Singh J.
Source
Department of Anesthesiology, Dhulikhel Hospital, Kathmandu
University Hospital, Dhulikhel; Kavre, Nepal.
Conclusion: Combination of ondanserton and dexamethasone is more
effective in preventing post operative nausea vomiting in patients
undergoing laparoscopic surgerythan ondansetron alone.

44. Am J Ther. 2011 Apr 23. [Epub ahead of print]
A Randomized Double Blind Study to Evaluate Efficacy of
Palonosetron(0.075mg) With Dexamethasone(8mg) Versus
Palonosetron Alone for Prevention of Postoperative and
Postdischarge Nausea and Vomiting in Subjects
Undergoing Laparoscopic Surgeries with High Emetogenic Risk.
Blitz JD, Haile M, Kline R, Franco L, Didehvar S, Pachter HL, Newman E
, Bekker A.
Source
Department of Anesthesiology, New York Uiversity Langone Medical
Center, New York, NY.
Conclusion: There was no change in comparative efficacy over 72
hours, most likely due to the low incidence of PDNV in both groups.

45.  Peritoneal cavity is expanded using
abdominal wall lifter.
 This avoids haemodynamic & respiratory
repercussions of increased IAP
 It increases technical difficulty

46. Anaesthetic Goals
 Accommodate surgical requirements and allow
for physiological changes during surgery.
 Monitoring devices available for the early
detection of complications.
 Recovery from anaesthesia should be rapid with
minimal residual effects.
 The possibility of the procedures being
converted to open laparotomy to be considered

47.  Pre-operative assessment
 The cardiac and pulmonary status of all patients
should be carefully assessed
 Pre-medication
▪ Anxiolytics
▪ antiemetic
▪ H2 receptor blockers
▪ Gastro-kinetic drugs
▪ Preemptive analgesia with NSAIDs
▪ Atropine to prevent vagally mediated
bradyarrhythmias

48. 1.Routine Patient Monitoring Include
 Continuous ECG
 Intermittent NIBP
 Pulse oximetry (SpO2)
 Capnography (EtCO2)
 Temperature
 Intraabdominal pressure
2. Optional Monitoring Include
 Pulmonary airway pressure
 Oesophageal stethoscope
 Precordial doppler
 Transoesophageal echocardiography
VIGILANT ANAESTHESIOLOGIST

49.  General anaesthesia
 Preloading with crystalloid solution is recommended
 Preoxygenation
 During induction of Anaesthesia, avoid stomach
inflation
 tracheal intubation – mandatory
 PLMA should only be used by experienced LMA users
 NG tube placement for Stomach decompression
 Catheterisation to empty the urinary bladder

50. Maintenance of Anaesthesia
▪ intermittent positive pressure ventilation (IPPV) .
▪ Normocarbia (34-38mmHg) to be maintained by adjusting the
minute volume
▪ The use of nitrous oxide during laparoscopic surgery is
controversial (bowel distension during surgery and the increase in
postoperative nausea) .
▪ Halothane increases the incidence of arrhythmia
▪ Isoflurane / sevoflurane comparatively better
 Reversal of NM blockade

51.  Recovery room -Post-op Period
1.Continue monitoring
2.Post-op pain relief
3.Post-op shivering
4.O2 thru’ Mask
5.Measures to Prevent pulmonary atelectasis
6.DVT prophylaxis

52. ▪ Epidural anaesthesia for outpatient gynaecological
laparoscopic procedures to reduce complications and
shorten recovery time after anaesthesia .
▪ not been reported for laparoscopic cholecystectomy or
other upper abdominal surgical procedures except in
patients with cystic fibrosis .
▪ The high block produces myocardial depression and
reduction in venous return, aggravating the
haemodynamic effects of tension pneumoperitoneum

53.  Local anesthesia with IV sedation
 Quick recovery
 less PONV
 Less haemodynamic changes
 Early diagnosis of complications

54.  Peripheral nerve blocks
Rectus sheath block
Inguinal block
Para vertebral block
 Pre requisites:
relaxed cooperative patient
low IAP
reduced tilt
precise gentle surgical technique

56.  Risk for post operative pulmonary complications can be
minimised by meticulous pre op.preparation.
 Procedure time should be minimized to less than 2hrs
 PFT,CXR,ABG, SpO2 in addition to history and physical
examination
 Cessation of smoking, adequate bronchodilators, steroids
and chest physiotherapy with incentive spirometry help to
reduce post op pul c/o

57.  Standard monitoring
 IAP less than 12mmHg
 GA with controlled ventilation
 Helium for pneumo peritonium
 Monitor peak airway pressure to avoid barotraumas
 Minimal tilt
 Multimodal approach for P.O.analgesia to avoid
respiratory depression

58.  Obesity is associated with
 Diabetes Mellitus,
 hypertension and hypercholesterolemia,
 angina and sudden death.
 Life expectancy in obese patients is
shortened by as much as eight years.

59.  Obesity is defined as a body mass index (BMI)
>30kg/m2.
 Laparoscopy is not contraindicated in healthy
obese patients who experience reduced pain,
faster recovery and fewer postoperative
problems compared to laparotomy

60.  Detrimental effect in respiratory mechanics is due to supine
position and increased weight
 Carbon dioxide production and oxygen consumption are
increased.
 Reduced chest wall compliance & decreased lung
compliance.
 Functional residual capacity (FRC) will be reduced 25 per
cent in the supine position, with a further reduction of 20 per
cent with Anaesthesia.
 airway closure and hypoxemia,
 Increase in intrapulmonary shunting.
 Alterations to gastric function and drug distribution.

61.  Potential airway and intubation problems
 Difficulties may be encountered during intravenous
access, positioning, pneumoperitoneum induction,
trocar access
 In obese patients, the umbilicus is located 3-6cm caudal
to the aortic bifurcation, making trocar placement more
difficult.
 .

62.  Two tables may be necessary. Mechanical lifting devices,
with extra padding should be available.
 Monitoring equipment such as a large blood pressure cuff,
compression lower extremity stockings and pneumatic boots
should be available.
 Intravenous access may need to be central rather than
peripheral in some cases.
 Positioning should include padded stirrups with extra
padding, compression devices
 Towels behind shoulder blades to elevate the head,
facilitating intubation and airway access .

63.  complications may be reduced by filling the peritoneal cavity with
carbon dioxide (CO2) to a predetermined pressure level rather
than to a preset volume
 Tilt Test:
 Placing the patient in steep Trendelenburg for two to five minutes
following intubation and positioning, observing the patient’s
cardiac and respiratory indices. Patients who remain
Normotensive and maintain peak airway pressures at <
30-40mmHg during the Tilt Test before and after insufflation , the
surgery is relatively straightforward, producing excellent results.

64.  Postoperative Care:
 Early mobilisation and avoidance of the supine position will
facilitate early recovery.
 oxygen therapy
 Aggressive pulmonary care and positioning.
 Abdominal pain may restrict ventilation and ambulation.
analgesia is paramount.
 Obese patients must have sequential compression devices
on their lower extremities or
 Prophylactic anticoagulation to prevent pulmonary emboli
(five to 12 per cent obese patients)7.

65.  Age related physiological and pathological changes
and age related concomitant diseases
 Narrow margin of safety
 decrease in organ reserve
 Lead to high incidence of Peri operative
complications

66.  Positioning the patient:
1.Fragile osteoporotic & spondylytic
changes in vertebrae
2.Protect from nerve injury
3.Prevention of venous stasis
4.Careful tilting (increment of 5° )

67.  During intra-op period:
-CV to maintain EtCO2 – 35mm.Hg.
- Isoflurane less arrhythmogenic
- IAP maintained below 15mm.Hg
- Atropine to counteract ref.vagal tone
- Monitor urine out put & Electrolytes
- Careful titration of all anaesthetic agents
-

68.  -During recovery—
-Exaggerated hypotension on correcting
lithotomy
- Expected delay in recovery
Inc.sensitivity to drugs.
Imp.metabolism
Delayed excretion

69. Indications:
 Appendicectomy
 Cholecystectomy
 Ovarian cystecomy

70.  Increased risk of acid aspiration
 Increased risk of abortion/ miscarriage /
premature labor
 Greater distribution volume due to increase
in blood volume
 More prone to hypoxemia due to decrease in
FRC and increase in O2 consumption

71.  Difficult airway due to wt. gain, soft tissue in
the neck, breast enlargement, and laryngeal
edema
 Relatively safe in 8-24 wks of pregnancy.
 Chances for damage to gravid uterus by
Verees needle
 Fetal acidosis common

72.  Operation in 2nd trimester before 24 wks
 Tocolytics therapy if risk of preterm labor
 Open laparoscopy for abdominal access (HASSON’S TECH)
to avoid damage to gravid uterus
 IAP less than 12mmHg
 Continuous Fetal heart monitoring with trans vaginal USG
 PaCO2 to be maintained at normal levels with the help of
EtCO2 monitor/ABG
 Mechanical ventilation to maintain physiologic maternal
alkalosis (pH7.44)
 Pneumatic compression devices to calf muscles to prevent
DVT

73.  Small abdominal surface and organs demand small
telescopes for laparoscopy.
 The abdominal surface / cavity ratio in infants and
children is less than that of adults.
 The abdominal wall in children is pliable and attention is
needed while placing the cannulas and trocars to prevent
intraabdominal injuries.
 The trans umbilical open laparoscopic technique for
insufflation under direct vision is recommended to
prevent complications with veress-needle
 Gasless laparoscopic surgery can now be performed in
these children and smaller infants .

74.  In infants less than 5 kg weight, peri umbilical area should
not be used for port access because of risk of puncture of
umbilical vessels.
 Cold, non-humidified CO2 directly in to the abdominal cavity
also contributes to a major risk of hypothermia
 A fluid bolus of 20 ml.kg-1 can be used to offset
hemodynamic effects

75.  In neonates, the foramen ovale or the ductus arteriosus is
potentially patent and may reopen during the procedure.
 The pulmonary arterial resistance is relatively high, predisposing
to reverse flow through a patent ductus arteriosus or foramen
ovale.
 There is a risk of reopening of right-to-left shunts, cardiac
insufficiency and gas embolism into the systemic circulation
which may result in cardiac ischemia and neurological damage.

76.  CO2 absorption is more intense and faster in infants
 Volume of gas for creation of pneumo peritoneum
is less
 IAP should be limited to 5 – 10 mm Hg in neonates
 and infants and 10 – 12 mm Hg in older children.
 risk of injuries to vitals is higher, so care is must.
 Prone for hypothermia & PONV

77.  CO2 peritoneum results in ventilatory /respiratory changes
 PaCO2 rise will aggravate cardio respiratory disturbances
 Increase in EtCO2 >25% later than 30mts after beginning, suspect CO2
sub.cut.emphysema
 Haemodynamic changes decrease CO and this is more in haemo
dynamically compromised patients
 Preload augmentation, use of vaso dilators, clonidine and
Dexmedetomedine, high dose opioids, & beta blockers – will attenuate
pathophysiologic hemodynamic changes

78.  In pregnancy, lap surgery can be safely performed before23 wks (avoid
hypercarbia) & open laparoscopic approach to avoid injury to gravid uterus.
 Gasless laparoscopy may be helpful but technical difficulty is more
 Laparoscopy has proven benefits allowing quick recovery, shorter hospital stay,
less p.o.pain
 General anesthesia with controlled ventilation has proved to be clinically superior
anesthetic technique
 Improved knowledge of pathophysiology and good perimoperative monitoring
permit safe management in patient with severe cardio respiratory disease

79.  Laparoscopy surgery presents new challenges to
the anaesthesiologist.
 A thorough knowledge of the patho physiological
changes during laparoscopy along with vigilant
monitoring is the backbone for an uneventful and
complete success.