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Anesthesia for Laparoscopic Interventions

Anesthesia for Laparoscopic Interventions. Peter Biro Department of Anesthesiology University Hospital Zurich peter.biro@usz.ch. The „Good“. Advantages. Better cosmetic results Less pain, less analgesics required Shorter in-hospital stay Less complications (outcome?)

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Anesthesia for Laparoscopic Interventions

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  1. Anesthesia for Laparoscopic Interventions Peter Biro Department of Anesthesiology University Hospital Zurich peter.biro@usz.ch

  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. 240 210 180 150 120 90 60 30 0 1990 1991 1992 1993 1994 1995 1996 1997 2001 2002 Open Laparoscopic Cholecystectomies in my Hospital

  5. 240 Open portion 50% 210 180 150 120 90 60 30 0 1990 1991 1992 1993 1994 1995 1996 1997 2001 2002 Open Laparoscopic Cholecystectomies in my Hospital

  6. 240 Open portion 33% 210 180 150 120 90 60 30 0 1990 1991 1992 1993 1994 1995 1996 1997 2001 2002 Open Laparoscopic Cholecystectomies in my Hospital

  7. 240 Open portion 13% 210 180 150 120 90 60 30 0 1990 1991 1992 1993 1994 1995 1996 1997 2001 2002 Open Laparoscopic Cholecystectomies in my Hospital

  8. Gynecologist Surgeon Urologist 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 maintenanceof 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 FEV1 (post- vs. preoperative) ―55% ―30% • Duration till return to baseline FEV1 9.5 days 5 days • FRC on 1st postoperative day ―20% ―34% • PEF25-75% on 2nd postoperative day ―50% ―25% • Confirmed post operative atelectasis (X-ray) ―90% ―40% Open vs. Laparoscopic Cholecystectomy

  13. Other Effects of Pneumoperitoneum • Resorption of CO2 (hypercarbia, acidosis) • Increase of PCO2 (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. Baseline Pneumoperitoneum Example for Overlaping Effects mmHg Beats/min Dyne/s/cm-5/20 120 120 120 100 100 100 80 80 80 60 60 60 40 40 40 MAP HR SVR

  17. CO2 Homeostasis and Pneumoperitoneum • CO2 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 CO2 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 CO2 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. CO2 Homeostasis and Pneumoperitoneum • Amount of CO2 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 CO2 insuflation ►check for airway obstruction • Vascular injury and bleeding • may occurr during insertion of scope ►avoidance by muscular relaxation

  29. Complications • Pneumothorax • ► stop CO2 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 (CO2) embolism • Etiology • intravasal gas insufflation (CO2 voulme 5x larger than for air) • Symptoms • fast decrease of PetCO2 • decrease of oxygen saturation (SpO2) without change of airway pressure • Hypotension • Cardiac arrhytmia • Precordial „mill wheel sound“ • ► Measures • stop CO2 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 CO2 uptake • Therapy • corticoids, 5-HT3 antagonists, dehydrobenzperidol Schulte Steinberg H., Euchner Wamser I., Zalunardo M.P. Anästhesie für laparoskopische Eingriffe. Anaesthesist 1999, 48: 755-768

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