Dr. Sanjeev Tuteja, M.B.B.S; D.A; F.MAS.A

Consultant Anesthesiologist

MGS Hospital, Panjabi Bagh, New Delhi

Abstract:

Laparoscopy results in multiple post-operative benefits including fewer traumas, less pain, less pulmonary dysfunction quicker recovery and shorter hospital stay. These advantages are regularly emphasized and explained. With increasing success of laparoscopy, it is now proposed for many surgical procedures. Intra operative cardio respiratory changes occur during pneumoperitoneum PaCO₂ increases due to CO₂ absorption form peritoneal cavity [6].in addition theses procedures are associated with potential life threatening complications that are not usually encountered with traditional open approach [7]. An understanding of the patho-physiologic consequence of increased intra-abdominal pressure is important for anesthesiologist who must prevent or when prevention is not possible adequately respond to these changes. Evaluate and prepare the patient preoperative in the light of these disturbances. Therefore pathophysiologic changes and complication of laparoscopy are first reviewed in compromised patients, cardio respiratory disturbance aggravate this increase in PaCO_2. Hemodynamic changes are accentuated in high risk cardiac patient. Improved knowledge of hemodynamic changes in healthy patient allows successful anesthetic management of cardiac patient. This paper is to find out all the safety considerations during anesthesia in laparoscopy.

Keywords:

Pneumoperitoneum, patient positioning, CO2 Insufflation  , patient monitoring, Anesthesia Technique in laparoscopic surgeries, Complications of laparoscopy, Post operative care in laparoscopic surgery.

Introduction:

Patients comfort is a great consideration in the 21^st century. A major expansion in equivalent technology advancement in instrument development affords a better choice of mode of surgery. Nowadays, more involved surgical procedures are being performed through laparoscopy. It is imperative that we obtain a clear understanding as well as its potential problems, physiological changes, and safety consideration that may occur during laparoscopy.

Pneumoperitoneum, patient position and CO2 absorption required for laparoscopy induce patho physiologic changes that complicate anesthetic management. The duration of some operative laparoscopies, the risk of unsuspected visceral injury, difficulty in evaluating the amount of blood loss, extra peritoneal gas insufflations and venous embolism are other factors that make anesthesia for laparoscopy a potentially high-risk procedure.

With the development of laparoscopy for gastrointestinal surgery, we now must care for older patients who are more likely to have known or undiagnosed disease. The postoperative period is considered (nausea, pain). Patient with cardiac disease and COPD should not be considered as good candidates for laparoscopic anesthesia in inexperienced hands.

Three major factors that uniquely alter physiology during laparoscopy.

1. Pneumoperitoneum
2. Positioning
3. Carbon dioxide.

Although physiologic are well tolerated by most healthy patients they could have adverse consequences in patient with limited cardiopulmonary reserve [6, 7].

Pneumoperitoneum

Increases Risk of regurgitation and pulmonary aspiration

Respiratory and ventilatory changes.

Increase in intra-abdominal pressure causes upward displacement of the Diaphragms ms resulting in reduction of the lung compliance, FRC, Increase airway resistance, Ventilation perfusion mismatch with hypercarbia and hypoxemia [6].

Hemodynamic changes :

Elevated intra-abdominal pressure causes the decrease in venous return and increases the systemic vascular resistance and decreases the myocardial performance leading to decrease in cardiac output [6]. Increase in systemic vascular resistance may increase myocardial oxygen demand. But cardiac output dose not appear to decrease significantly when intra-abdominal pressure is <12 mm Hg [10]. minimizing the IAP should decrease the risk of potentially significant  physiologic changes[12].numerous regional circulatory changes also occurs during laparoscopy including increased cerebral blood flow, and increase ICP, decrease hepatic blood flow, bowel blood flow , renal blood flow and urine output, decrease femoral blood flow which may increase the risk of DVT[6].

Positioning

• Cardiovascular Effect

1. Trendelenburg position (Head down Position) during lower abdominal surgery.
2. Increases venous return (CVP/PCWP) Cardiac output, systemic vascular resistance
3. This causes deleterious effect in patient with CHF, terminal valvular dysfunction and with poor ventricular function. [3]
4. Head up position: Decrease venous return and cardiac output compound the effect of pneumoperitoneum.

• Respiratory effects:

1. Head down Position: cephaloid displacement of mediastinum causes endobronchial intubation. It decreases FRC, total lung volume facilitate atelectasis, increases risk of embolism [3].
2. Head up Position: It is favorable for respiration.

• CO2 insufflations:

1. CO2 is not an inert gas. It causes direct peritoneal irritation and pain by forming carbonic acid. Post operatively it remains intraperitoneal and causes referred shoulder pain
2. It causes hypercarbia and respiratory acidosis
3. It causes sympathetic stimulation which leads to tachycardia, hypertension, and arrhythmias.

Anesthesia for laparoscopy:

Preoperative Evaluation

Pneumoperitoneum is undesirable in patient with:

• Increased intracranial pressure (tumor Hydrocephalus, head trauma)
• Hypovolumia.
• Ventriculoperitoneal and peritoniojuglar shunt
• Glaucoma.
• Heart disease patient with sever congestive heart failure and terminal valvular lesion.
• Renal failure
• Respiratory disease: COPD, Emphysema, Bulle.
• DVT.
• Coagulopathy, diaphragmatic hernia, morbid obesity, sickle cell disease (because sickle cell disease may be precipitated by acidosis)[1]

Patient positioning and monitoring

• Patient must be positioned with great care to prevent:
  1. Nerve injury: padding and shoulder braces to protect from nerve compression.
  2. Tilt should not exceed 15deg to 20deg: to avoid sudden respiratory and hemodynamic changes.
  3. Check for endobronchial intubation.
  4. Gastric deflation by Nasogastric tube should be done before trocar placement to prevent gastric perforation.
  5. Bladder should be emptied before pelvic laparoscopy or prolong procedure.

Monitoring

1. Arterial Blood Pressure
2. ECG
3. Pulse Ozymetery
4. Heart Rate
5. Capnometry
6. Minute Ventilation and Peak Airway Pressure Monitoring
7. Temperature Monitoring
8. Neuromuscular Monitroing
9. Esophagial and Precordial stethoscope

For cardiac patients more invasive hemodynamic monitoring is required like

• CVP
• Pulmonary Artery Pressure
• Trans Escophagel Echocardiography
• Radial Artery Cannulation

Anesthesia technique

General Anesthesia

1. General anesthesia with endobronchial intubation and controlled ventilation certainly the safest technique because of the following reasons:
2. Procedure may be long
3. Patient may be anxious
4. Trendelenburg position may cause respiratory compromise and dysnea in the aware or in the spontaneously breathing patient with abdominal contents under pressure. The obese patient may be especially uncomfortable in this position.
5. A nasogastric tube, difficult to insert in conscious patient to minimize the risk of aspiration and perforation by trocar.
6. Muscle relaxation: most important reason, muscle relaxation and paralysis are necessary because the increase in intra-abdominal pressure and splinting of diaphragm make spontaneous breathing difficult. It provides quicker surgical fields and exposure. Bucking and coughing increase the negative pressure in chest, increasing risk of pnumothorax or gas dissection. It also increase intra-abdominal pressure and hence chance of perforation   by intra-abdominal instruments. Moreover muscle relaxation is necessary to control and augment ventilation to compensate for hypercarbia and respiratory acidosis that result from absorption of CO2.[5,8,11]

Ventilation must be adjusted to maintain PETCO2 at appropriately 35 mm Hg. Increase of respiration rate rather than increase in tidal volume is preferable in patient with COPD or with history of spontaneous   pnumothorax or bullas emphysema to avoid increase alveolar inflation and reduce the risk of pnumothorax. Anesthetic agent that directly depresses the heart should be avoided in patient with compromised cardiac function in favor of anesthetic with vasodilating property such as isoflurane [2, 5]. Halothane increases the risk of arrhythmia in presence of hypercarbia. Infusion of vasodilating agent such as nicardipine reduces hemodynamic repercussion of pneumoperitoneum and might facilitate management of cardiac patient. Omission of nitrous oxide improves surgical condition in intestinal and colonic surgery. IAP should not exceed 15mmhg. Increase in IAP can be avoided by ensuring deep plane of anesthesia. Reflex increase in vagal tone can be controlled by atropine if necessary. LMA should be limited in healthy and thin patient. Decreased thoracopulmonary compliance during pneumoperitoneum frequently results in airway pressure exceeding 20cmh2o as it cannot guarantee an airway seal above this pressure.  

Local Anesthesia:

Manipulation of pelvic and abdominal organs causes pain, anxiety and discomfort. For this reason local anesthesia is supplemented with IV sedation. Continued effect of pneumoperitoneum and sedation can lead to hyperventilation. Success of LA requires relaxed and cooperative patient and skilled surgeon. CO2 causes pain intra peritoneal and in shoulder. It is for this reason N2O, which is non irritating to the peritoneum has been used as the insufflating gas for laparoscopy under local anesthesia. However rapid peritoneal distension causes nausea, which may be worsened without a naso-gastric tube. Also the possibility although remote of having to open the abdomen speaks against local anesthesia.

Regional Anesthesia:

Can be used for laparoscopy however it too has serous drawbacks. It requires high level of sensory block, possibly causing dyspnea in trendelenberg   position. Naso gastric tube may not be tolerated. Hyperventilation in response to hypercarbia, high level of sensory block and sedation causes too much movement in surgical field creating difficulty for surgeon and increase risk of visceral injury by instrument.

COMPLICATIONS:

Early detection and treatment of complications associated with laparoscopic surgery improves patient care and safety [7]

1. Injuries from Instruments: Improper placement of veress needle or trocar can cause abdominal wall bleeding, blood vessel or visceral puncture, subcutaneous emphysema; peritonitis wound infections, hernia at trocar site and hemorrhage. Thermal injury can occur from cautery or laser use. Staple and clips can cause nerve entrapment.
2. Complications of Pneumoperitoneum: Bowel ischemia ,omental and bowel irritation, gastric regurgitation, excessive compression of venacava, decreases venous return, venous stasis in legs, hypotension, increase intrathorasic pressure, mediastinal and subcutaneous emphysema, pnuemothorax ,barotraumas, CO2 gas embolism ,atelactasis, nausea, vomiting, brady arrhythmia, shoulder pain from retained CO2.

Gas embolism: insufflations of large amount of CO2 directly in to the blood vessels can occur after blind veress needle insertion especially at high pressure so initial rate of flow should be <1L/min.

Embolism can be diagnosed by:

• Mill wheal murmur (alteration in heart tone) by esophageal of precordial stethoscope.
• Aspiration of frothy blood by CVP.
• Hypercarbia, Hypoxemia, hypotension, Cynosis, cardiac arrest can also occur [22].
• The most sensitive means to detect gas embolism are precordial stethoscope and transesophagial Doppler and transesophagial echocardiography [21]

Treatment :

• Nitrous Oxide should be discontinued and fiO2 should be increase to 1.
• Identify and occlude the air entrainment site. insufflation should be stopped
• Increase the rate and volume and controlled ventilation with PEEP. It decreases air entrainment. Place the it in left lateral deceits and head down position.
• Aspiration of air through CVP line[23,30]

Puemothorax :  it occurs when insufflated CO2 tracking in to the thorax  through a tear in the visceral peritoneum, breach of partial plural during dissection or congenital defect in diaphragm[36]. It can be diagnosed by sudden decrease in pulmonary compliance, an increase in airway pressure, increase in petCO2 , unchanged or decrease in BP, abnormal motion of the involved side of diaphragm, absence of breath sound on effected side[32].

Treatment of pnumothorax: deflation of abdomen and supportive treatment. Stop n2o and give 100% o2. Give PEEP and increase minute ventilation to re inflate lung [31].

Systemic Effects of CO2 Absorption: Hypercarbia, acidosis, increases sympatho adrenal stimulation, hypertension, hypercarbia, increases ICP, sickle cell crises, arrhythmias form hypercarbia, hypoxemia in presence of catecholamine and halothane.

Trendelenburg position: In lower abdominal surgeries and in gynecological surgeries Discussed already [33]

Hypothermia: It is important to take aggressive approach in maintaining patient's temperature including humidification of anesthetic gases, infusion of heated IV fluids, prewarming of irrigant fluid, and forced air warming to improve post operative outcome.

Late complication: Bowel obstruction form injury, cautery burn, intestine or omental herniation, adhesion, DVT, nerve injury due to improper adding, bowel

Post operative care:

PONV: it is the most important in causing an over night admission after ambulatory surgery [15] Increase incidence of nausea and vomiting after laparoscopy due to rapid peritoneal distension. Propofol anesthesia can markedly reduce the nausea and vomiting [27]. recent data suggest that combination of antiemitics administrated prophylactic ally are more effective than either antiemitic administrated alone, particularly in high risk patients [6]. A multimodal approach to prevention of PONV includes use of combinations of droperidol 0.625-1mg, 5ht3 antagonists ( ondensterone 4mg or dolasterone 12.5-5mg), and dexamethasone 4-8mg, as well as aggressive hydration, use of minimal dose of opiods, and aggressive pain control [6].

Pain management :

Although laparoscopy is less intense as compare to open surgery, pain after laparoscopic surgery may be quite severe, particularly in early post operative period [28]. The visceral pain is more after laparoscopic procedures as compared with parietal pain after open surgery. Shoulder pain secondary to diaphragmatic irritation is a frequent occurrence after laparoscopy and can persist for as long as four days. There is a strong correlation between severity of shoulder pain and residual sub diaphragmatic gas [6, 28]. Therefore every attempt should be made to remove as much CO2 as possible at the end of procedure the severity of post operative pain has also been associated with duration of surgery. Stretching of the intra abdominal cavity from higher insufflations pressure significantly increases the severity of pain. Multimodal analgesia techniques (i.e. combination of opioids, NSAIDs and local anesthetics) provide more effective pain relief with fewer side effects and early recovery. Infiltration of laparoscopy portals with local anesthetic provides excellent analgesia. Intra peritoneal instillation of 20ml of 0.25% bupivecaine. Preoperative administration of NSAIDs and IV ketorlac intra operatively decreases pain and opioids consumption after laparoscopic surgery

Patient should be transferred in semi recumbent position .Hemodynamic monitoring should be continued in post anesthesia care unit .Indeed hemodynamic changes induced by pneumoperitoneum and more particularly the increased systemic vascular resistance outlasts the release of pneumoperitoneum. Hyper dynamic state developing after laparoscopy could lead to a precarious hemodynamic situation in patient with cardiac disease.

Despite the reduction in post operative pulmonary dysfunction PO2 still decreases after laparoscopic cholecystectomy. Although laparoscopy tends to be considered minor surgical procedure O2 should by administered post operatively even to the healthy patient.

During early post operative period, respiratory rate and PETCO2 of patients breathing spontaneously are higher after laparoscopy as compared with open surgery. Depending on surgery carried out there may be some interference in bowel function leading to abdominal distension and colicky discomfort. Tramadol it effective of these type of pain.

Nursing management include O2 therapy, early mobilization, pain management, incentive spirometery and chest physiotherapy. On morning of second post operative day patient should be pain free and should start soft diet.

Conclusion:

Knowledge of patho-physiological changes, adequate monitoring and good planning in patient with cardio respiratory disease makes anesthesia for laparoscopy safe who may subsequently benefit from multiple post operative advantage offered by this approach.

General anesthesia with controlled ventilation seems to be the safest technique for operative laparoscopy.

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