Prof. Panditrao takes you in the detailed discussion about the historical aspects, problems, altered physiology, preparation of and Anesthetic/ peri-operative management of the patients for various laparoscopic surgical procedures

1. PERI-OPERATIVE
MANAGEMENT OF
PATIENTS FOR
LAPAROSCOPY

2. PROF. MRIDUL M. PANDITRAO
Consultant
Department Of Anesthesiology & Critical Care
Rand Memorial Hospital
Freeport
Grand Bahama

3. INTRODUCTION
“LAPAROSCOPIC SURGEON”

 Laparos & scopos
 1970s, 80s & 90s
 Reduction Of
trauma, morbidity/mortality
hospital stay, health care costs
better maintenance of homeostasis
Soper NJ, Barteau JA et al: Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy: Surg Gynecol
Obstet 1992: 174:114
Grace PA, Quereshi A, Coleman J, et al: Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 1991; 78:160.

4. INTRODUCTION
Why Is It so Popular?????
 Day Care Anesthesia/ Surgery
 The majority of patient population: female
 Various pathological conditions
 Various specialties and super specialties
 Smooth Post-operative course
 Less pain and morbidity
 Turns out to be cost-effective

5. INTRODUCTION (CONTD.)
SCOPE OF LAPAROSCOPIC PROCEDURES IN FEMALE PATIENTS
N Specialty Procedure N Specialty Procedure
o o
1 Gynecological Diagnostic laparoscopy 2. General Surgical Laparoscopic cholecystectomy
/ Obstetric Laparoscopic sterilization Nissen’s Funduplication
Laparoscopic assisted vaginal Diaphragmatic or Hiatus hernia repair
hysterectomy Appendectomy
Laparoscopic assisted fertilization Vagotomy
procedures Adrenalectomy
Removal of unruptured ectopic / tubal Inguinal hernia repair
pregnancies Colectomy
Ovarian cyst/rupture of ovarian cyst
3. Urological
Ovarian apoplexy Nephrectomies : Partial / Radical
Torsion of uterine appendages Living donor nephrectomy
Reflux of menstrual blood
Nephro Ureterostomy
Differentiation between gynecological and
Pyeloplasty
surgical pathologies
Pelvic lymph node dissection
Total cystectomy with ileal conduit
formation

6. INTRODUCTION (CONTD.)

7. PROBLEMS????
1. Problems due to pneumoperitoneum & altered/ increased
Intra Abdominal Pressure (IAP) :
V/Q mismatch
Gas in wrong place
Cardiovascular system changes
2. Problems due to improper patient selection/the actual
procedure gone wrong/not performed properly
3. Problems due to positioning of the patients for
laparoscopic procedures
4. Problems of peri-operative period inclusive of the
anaesthetic techniques

8. PROBLEMS DUE TO PNEUMOPERITONEUM
 ‘Pneumoperitoneum’ : defined as an
abnormal presence of air/gas either due to
disease process or iatrogenic intervention,
inside the peritoneal cavity
 Air / gas (CO2) is an unnatural, unwanted
and interfering agent
 Patho physiologic changes
Wahba RW, Tessler MJ, Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominal
surgery. Can J Anaesth 1996; 43:77

9. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Ventilation/Perfusion changes (V/Q)
 Intra abdominal pressure (IAP) > 15 mm Hg-
domes of diaphragm get elevated leading to ↓FRC
 ↓Thoraco-pulmonary compliance (30-50%) in healthy,
obese as well as ASA III/IV
 Increased V/Q mismatches and chances of hypoxia.
 So it is recommended to keep the IAP to <15 mm Hg.
Andersson LE, Baath M, Thorne A, et al: Effect of carbon dioxide pneumoperitoneum on development of atelectasis during anesthesia,
examined by spiral computed tomography. Anesthesiology 2005; 102:293.
Fahy BG, Barnas GM, Nagle SE, et al: Changes in lung and chest wall properties with abdominal insufflation of carbon dioxide are
immediately reversible. Anesth Analg 1996; 82:501.7
Odeberg-Wernerman S: Laparoscopic surgery—effects on circulatory and respiratory physiology: an overview. Eur J Surg
(Suppl) 2000; 585:4.

10. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Gas in Wrong place
“Verress needle”
 Wrong point of insertion
 Wrong plane of insertion
 Wrong direction of insertion
Subcutaneous and retro-peritoneal emphysema
In laparoscopic procedures like inguinal hernia repair (TEPP),
intentional production of extra peritoneal emphysema is
imperative
 Lew JKL, Gin T., Oh TE., Anaesthetic Problems during Laparoscopic cholecystectomy, Anaesth Intensive care,
1992,20, 91

11. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Gas in Wrong place
Pneumothorax
Pneumomediastinum
Pneumopericardium
 Operator related
 Through congenital / potential communications
 Rarely actual rupture of pericardium or dome of diaphragm.
The detection of these, entirely depends upon:
 High degree of suspicion
 Progressively increasing ETCO2 levels in spite of good/adequate controlled
ventilation
 If ABG done: increased PaCO2 – ETCO2 gradient
 Clinically / radiologically evident gas in these areas
Spielman FJ: Laparoscopic surgery. In: Kirby DD, Hood RR, Brown DL, ed. Problems in Anesthesia: Anesthesia in Obstetrics and
Gynecology, Philadelphia: JB Lippincott; 1989:151.
Knos GB, Sung YF, Toledo A: Pneumopericardium associated with laparoscopy. J Clin Anesth 1991; 3:56.
Whiston RJ, Eggers KA, Morris RW, et al: Tension pneumothorax during laparoscopic cholecystectomy. Br J Surg 1991; 78:1325.

12. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Gas in Wrong place
CO2 absorption via peritoneal cavity

 Increased levels of PaCO2 in laparoscopy : from various sites & not
from problems in ventilation or V/Q mismatch
 ASA I-II Patients : not significant , initially
 In patients with pre-existing cardio-respiratory involvement, problem
becomes significant with, increased morbidity & mortality
CO2 embolism 
 Accidental intravascular entry of needle or trocar
 Excessive intra abdominal insufflations leading to puncture of vessel
Fitzgerald SD, Andrus CH, Baudendistel LJ, et al: Hypercarbia during carbon dioxide pneumoperitoneum. Am J Surg 1992; 163:186.
Wulkan ML, Vasudevan SA: Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonates
with cyanotic congenital heart disease?. J Pediatr Surg 2001; 36:1234

13. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Cardiovascular System changes
Etiology:
 Effects of pneumoperitoneum & ↑I A P
 Position of the patient
 Preoperative cardio respiratory status of the patient &
state of intravascular volume
 Levels of CO2 absorption and its effects
 The effects of Anaesthesia / Anaesthetic agents
 Autonomic response of the patient‟s body to these
manipulations

14. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Cardiovascular System changes
Effects
 Increased preload (due to indirect increase in IAP)
 Increased afterload due to increased systemic vascular
resistance & pulmonary vascular resistance
 Decreased myocardial contractility usually as a result of
general anaesthesia
 decreased effective cardiac output, initially decreased MAP,
increased heart rate, and later on increased blood
pressure
Smith I., Benzie RJ, Gordon NLM, et al, Cardiovascular effects of peritoneal insufflations of carbon dioxide for laparoscopy Br.
Med. J. 1971,:3: 410
Joris J, Honore P, Lamy M, Changes in oxygen transport and ventilation during laparoscopic cholecystectomy,
Anesthesiology, 1992, 77, A149

15. PROBLEMS DUE TO PNEUMOPERITONEUM
(CONTD.)
Cardiovascular System changes
How to offset them:
Adequately preloading the patient
Using vasoconstrictors (alpha 2 agonists),p.r.n.
Adequate analgesia / good sedation with Opioids
Rarely drugs like beta blockers : esmolol, metoprolol
vasodilators like Clonidine or glyceryl trinitrate
Rarely, acute hypoxemia, hypotension, cardiac dysrrythmias leading
to cardio-vascular collapse
life threatening ventricular dysrrythmias due to vagal stimulation, or
lighter planes of general anaesthesia
Shifren Jl, Adelstein L, Finkler NJ, Asystolic cardiac arrest: a rare complication of laparoscopy. Obstet. Gynaecol.1992, 79:
840
Beck DH, McQuillon PJ, Fatal carbon Dioxide embolism and severe haemorrhage during laparoscopic cholecystectomy, Br. J.
Anaesth.1994:72: 243

16. PROBLEMS DUE TO IMPROPER PATIENT SELECTION/
INCOMPETENTLY CONDUCTED
PROCEDURE/OPERATOR ORIENTED PROBLEMS
 Conversion of closed to open procedure
 “Improper trocar insertion”
 Trocar site hernia formation
 Implantation of aggressive malignant tumors
 Bile duct injuries, accidental division,
resection and obstruction due to accidental
clamping with haemostatic clamps

17. PROBLEMS DUE TO IMPROPER PATIENT SELECTION/
INCOMPETENTLY CONDUCTED
PROCEDURE/OPERATOR ORIENTED PROBLEMS
Improper trocar insertion
 Haematomas due to injuries to inferior epigastrics, iliac
vessels
 Gastro-intestinal hollow visceral perforations leading sepsis
and mortality.
 Intra abdominal solid organ injuries like hepatic/splenic
tears.
 Major vessel (IVC/ abdominal aorta) injuries.
 Peritoneal/omental/mesenteric injuries.
 Retroperitoneal haematomas especially in post operative
period.
Hasson‟s mini laparotomy technique
Hasson H: A modified instrument and method for laparoscopy. Aus. J. Obste.t Gynecol. 1971:70: 886

18. PROBLEMS DUE TO POSITIONING OF
PATIENTS FOR LAPAROSCOPIC PROCEDURES
 Trendelenberg/head down for pelvic/lower
abdominal surgeries,
 While reverse or rT/ head up for upper
abdominal quadrant surgeries eg.
Cholecystectomy, Nissen‟s funduplication….
 In addition lithotomy in Gynecological
 lateral posture for Cholecystectomies

20. PROBLEMS DUE TO POSITIONING OF
PATIENTS FOR LAPAROSCOPIC PROCEDURES
Respiratory system
 Head down tilt: respiratory embarrassment, rarely
endo bronchial intubation
 Head up tilt/lateral tilt: may increase the dead
space & V/Q mismatch
 compromising an already compromised patient.

21. PROBLEMS DUE TO POSITIONING OF
PATIENTS FOR LAPAROSCOPIC PROCEDURES
Cardiovascular system
 Head up tilt:
fall in preload due to peripheral pooling of blood
increased systemic vascular resistance
Isoflurane offsets this effect in healthy patients
 Head down tilt:
congestion to head, neck, face leading to intracranial
congestion increased ICP, increased IOP
Odeberg S, Ljungqvist O, Svenberg T, et al: Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia
for laparoscopic surgery. Acta Anaesthesiol Scand 1994; 38:276.
Batra MS, Driscoll JJ, Coburn WA, et al: Evanescent nitrous oxide pneumothorax after laparoscopy. Anesth Analg 1983; 62:1121.

22. PROBLEMS DUE TO POSITIONING OF
PATIENTS FOR LAPAROSCOPIC PROCEDURES
Hepato/Renal and splanchnic blood flow
 decreased RBF, GFR, urinary output by nearly 50%
 Similarly elevated hepatic enzymes and bilirubin levels
 Peripheral problems
 femoro-popliteal venous stasis, deep venous
thrombosis and thrombo-embolization
 Peripheral nerve/Plexus injuries in „head down, arm
over extended,
 Common peroneal nerve injury due to improperly
padded lithotomic positions.

23. PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE OF
THE ANAESTHETIC TECHNIQUES
Related to nitrous oxide administration
Related to intravenous drugs
especially opioids
Related to anaesthetic technique
specifically.

24. ANAESTHETIC PROBLEMS????
Role of nitrous oxide

 Riddled with controversies?!?!?!
Available evidence: Does not interfere!!!!!
Krogh B, Jensen PJ, Henneberg Sw, et al. Nitrous Oxide does not influence operating conditions or
post operative course in colonic surgery. Br. J. Anaesth. 1994; 72:55.
Taylor E, Feinstein R, White PF, Sopor N. Anesthesia for laparoscopic cholecystectomy: is nitrous
oxide contraindicated? Anesthesiology; 1992: 76:541
Lemaire BM, van Erp WF: Laparoscopic surgery during pregnancy. Surg Endosc 1997; 11:15.
Sukhani R, Lurie J, Jabamoni R: Propofol for ambulatory gynecologic laparoscopy: Does omission
of nitrous oxide alter postoperative emetic sequelae and recovery?. Anesth Analg 1994; 78:831.

25. ANAESTHETIC PROBLEMS????
 Intravenous anaesthetics
 Propofol as TIVA and its cardio inhibitory effects
 Fentanyl and the spasm of sphincter of Oddi/PONV
 Addition of isoflurane improves overall outcome
 Nalbuphine with minimal biliary stasis activity
 Parenteral NSAIDs may actually make the
use of opioids redundant.
Humphrey HK, Fleming NW. Opioid induced spasm of the Sphincter of Oddi apparently reversed by nalbuphine.
Anesth analg 1992; 74: 308

26. ANAESTHETIC PROBLEMS????
 Anaesthetic techniques
Which technique to use:
 General
 regional
 combination
 local
Choice is yours!

27. ANAESTHETIC TECHNIQUE OF CHOICE
Balanced General Anaesthesia
intravenous/inhalational induction
oxygen, nitrous oxide,
muscle relaxant, endo tracheal
intubation and an opioid!

28. PROBLEMS OF PERI-OPERATIVE PERIOD
INCLUSIVE OF THE ANAESTHETIC TECHNIQUES
Inclusion Criteria
 Before opening abdomen
 Female patients in reproductive age group
 ASA I- II grade
 Upper abdominal procedures
 Pelvic surgical procedures
 Moderate Obesity
 Adequate infra structure and surgical skill
level

29. PROBLEMS OF PERI-OPERATIVE PERIOD INCLUSIVE
OF THE ANAESTHETIC TECHNIQUES
Exclusion Criteria
 Emergent, suspected coagulopathy/Sepsis
 Cardiopulmonary disorders:IHD, Asthma, COPD
 H/O Old surgical operations in the lower part of
the abdominal cavity/ Total adhesive process in
abdominal cavity
 Third trimester of pregnancy
 Sizeable pathological formation
 Decompensated internal hemorrhage

30. PRE-OPERATIVE PREPARATION
 Detailed History
 Thorough Examination/Clinical Assessment
 Routine Investigations
 Special Investigations
 Intravenous Access
 Pre-Anaesthetic Medications
 Monitoring

31. INTRA-OPERATIVE MANAGEMENT
 Preoperative evaluation
 ASA I and II patients - routine
 In IHD or COPD- proper evaluation with 2D ECHO and
dynamic pulmonary function tests; minimal requirement of
LVEF in IHD patients is < 30%
 Hepato renal compromising drugs- avoided: halothane, anti-
biotics…
 Precautions for prevention of venous stasis, nerve injury :
deep vein thrombosis prophylaxis, padding with elastic
bandages
 Monitoring: Routine ---- to ---- TEE,
 Pre-induction oxygenation: To avoid need of mask ventilation
inadvertent stomach inflation & accidental puncture during
trocar placement & to reduce incidence of PONV

32. TECHNIQUE OF CHOICE
 Induction with intravenous agent
 in compromised patients sevoflurane
 Cuffed ET tube: using newer non depolarizing
muscle relaxants like rocuronium
 Controlled ventilation, ETCO2 , NMBD and
Isoflurane/ Desflurane
 Preemptive preloading with a suitable
crystalloid or colloid

33. TECHNIQUE OF CHOICE
 Nasogastric tube, urinary catheter which decrease:
the problems of bladder puncture, GI puncture
improved visualization
post operative gastric distension and PONV.
 Positioning of patient requires meticulousness
 Reconfirmation of endotracheal tube position
 insertion of needle, production of
pneumoperitoneum: gentle and gradual
 Trocar placement :professionally perfect

34. TECHNIQUE OF CHOICE
 IPPV adjusted to avoid hyperventilation & paradoxical
pressure increase: to increase the rate than tidal
volume
 The ETCO2 to be maintained between 35-40 mm Hg
 intravenous fluids, colloids, dobutamine/ inotropic
support, Isoflurane will help in decreasing SVR
 If required glyceryl trinitrate infusion to be used
 arrhythmias due to peritoneal stretching :
stoppage of insufflations
atropine or glycopyrrolate
deepening the plane of anaesthesia
Continuous monitoring of IAP

35. TECHNIQUE OF CHOICE
 Complications like subcutaneous emphysema,
pneumothorax or pneumomediastinum must be kept in mind
 If not possible to monitor PaCO2 with Serial ABG: signs of
hypercapnia: unexplained tachycardia, hypertension,
dysrrythmias, without significant rise in ETCO2, : high
degree of suspicion.
 Multimodal analgesia : preoperative / intraoperative opioids
like Butorphanol / Nalbuphine,
intramuscular/ intravenous parenteral NSAIDs/paracetamol
at the end of surgery local infilteration using Bupivacaine
 Extubation
Michaloliakou C, Chung F, Sharma S. Pre-operative multimodal analgesia facilitates recovery after
ambulatory laparoscopic cholecystectomy. Anesth analg; 1996: 82: 44-51.

36. INTRA-OPERATIVE MANAGEMENT
laparoscopy in its true sense is a team approach
Respect for each member specialty of the team!
Absolutely essential!!!!!

37. POST-OPERATIVE MANAGEMENT
 Monitoring
 Pain Management is easier
 Road worthiness of Day cases
 Follow up
or
 Decision to admission and inpatient care

38. RECENT ADVANCES
Laparoscopy & it’s anaesthesia have not yet
matured !
Surgical techniques:
 Robotic laparoscopy
 Noble gases for insufflations: Inert gases like helium
and argon
 Laplift / Gasless laparoscopy
 Combination of laplift with low IAP< 5 mm Hg with CO2

41. RECENT ADVANCES
Anaesthetic management:
 Suitable number of young healthy patients : laryngeal mask
airway, spontaneous respiration
 Local analgesic solutions infusion: intra-peritoneal, port site
or in abdomen layers
 Local / regional techniques; patient discomfort, shoulder
pain, high level & CVS instabilty
 Local / regional techniques: Combination of spinal
bupivacane 0.75%+ I V Propofol (bolus- .4mg/kg & infusion .1- 1.5
mg/kg/hr) or I V ketamine (bolus- .1mg/kg & infusion .3- 1.0 mg/kg/hr or
Ketofol (Their combination)
Ali Y, El masry MN et al: The feasibility of Spinal anesthesia with sedation for laparoscopic general abdominal proceduresin moderate risk
patients: MEJ Anaes 19 (5)
Yi JW, Choi SE: Laparoscopic cholecystectomy performed under regional anesthesia in a pt undergone pneumonectomy: Korean J.
Anesthesiol 56 (3) 330-33.

42. CONCLUSION
 Laparoscopy has come in as a boon
 Conventional/ Open methods definitely have
higher morbidity and mortality
 Should not be taken lightly
 Deep circumspection of patho physiologic
changes involved, complications that can
happen and how to prevent them and
overcome them.

43. CONCLUSION
A problem oriented team approach
 Interdisciplinary respect
 total peri-operative management
 dispel myths / auras
 very precise, clear cut and evidence
based guidelines