ahaPro

Department of Anesthesiology, A

Received 7 June 2004; accepted 27

1. Introduction

pain while reducing hospital stay and postoperative pain.

medical cost, less intraoperative bleeding, less postoperative

In recent years, advanced laparoscopic surgery has

performed on an outpatient basis hence demanding extreme

caution regarding the anesthetic technique. Furthermore, the

Keywords:Laparoscopy;

Patophysiological

changes;

Anesthesia;

General;

Regional;

Recovery;

Complications

Journal of Clinical Anesthesia (2006) 18, 6778* Corresponding author. Tel.: +961 1 350 000x6380; fax: +961 1 744

464.Thereafter, laparoscopy for general surgery followed and

proved to be advantageous in reduction of postoperative pain,

better cosmetic results, quicker return to normal activities,

reduction in hospital stay resulting in overall reduction in

targeted older and sicker patients, rendering anesthesia during

laparoscopy more technically demanding. On one hand,

laparoscopy can compromise the cardiovascular and respira-

tory function of the patients, whereas on the other, it was

introduced as a safe and simple procedure that may beLaparoscopy started in the mid 1950s when gynecologists

declared this technique as a safe way to diagnose pelvic

pulmonary complications, less postoperative wound infec-

tion, reduced metabolic derangement, and better postopera-

tive respiratory function [1].discusses recovery and postoperative complications after laparoscopic abdominal surgery.

D 2006 Elsevier Inc. All rights reserved.0952-8180/$ see front matter D 2006

doi:10.1016/j.jclinane.2005.01.013

E-mail address: sj00@aub.edu.lb (Smerican University of Beirut-Medical Center, Beirut 1107-2020, Lebanon

January 2005

Abstract Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbondioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several

pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient

positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal

anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most

common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia

for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be

tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several

intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and

cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe

alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory

depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for

limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This

article considers the pathophysiological changes during laparoscopy using carbon dioxide for intra-

abdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, andReview article

Anesthesia for laparoscopy:

Frederic J. Gerges MD (Chief Resident), GSamar I. Jabbour-khoury MD (AssociateElsevier Inc. All rights reserved.

.I. Jabbour-khoury).review

ssan E. Kanazi MD (Associate Professor),fessor)*application of laparoscopy has expanded and is currently

used safely and effectively in children [2], in vascular cases

intra-abdominal pressure (IAP), hypercapnia, and carbon

dioxide embolization. Furthermore, it provides a better

limited cardiac, pulmonary, or renal function, abdominal wall

However, the critical determinants of cardiovascular func-

tion during laparoscopy are the IAP and patient position.

F.J. Gerges et al.68cardiovascular condition with a resultant higher heart

performance and lower preload and afterload, as compared

with carbon dioxide laparoscopy [11]. Alijani et al [12] have

demonstrated that the abdominal wall lift approach avoids fall

in cardiac output associated with carbon dioxide pneumo-

peritoneum and is associated with a more rapid recovery of

postoperative cognitive function. Hence, abdominal wall-

lifting approach in laparoscopic cholecystectomy is a method

worthy of consideration for elderly patients or those with

cardiopulmonary problems [13]. However, in patients withsuch as total laparoscopic aortomesenteric bypass [3], in

complicated urology cases such as laparoscopic nephrectomy

for large renal arteriovenous malformation [4], for radical

prostatectomy, in hand assisted laparoscopic radical cystec-

tomy [5], in advanced general surgery for distal pancreatec-

tomy [6], and in hepatic resection [7,8]. Consequently,

laparoscopic surgery presents several new challenges for

the anesthesiologist where an appraisal of the potential

problems is essential for optimal anesthetic care, allowing

early detection and reduction of complications.

2. The choice of insufflated gas

The ideal gas for insufflation would have the following

properties: minimal peritoneal absorption, minimal physio-

logical effects, rapid excretion of any absorbed gas, inability

to support combustion, minimal effects from intravascular

embolization, and high blood solubility [9].

Air and oxygen cannot be used for insufflations during

laparoscopy because they support combustion whenever

bipolar diathermy or lasers are used. Helium and nitrogen are

relatively insoluble, as compared with carbon dioxide, and

can result in more serious cardiovascular sequelae whenever

an intravascular gas embolization occurs. Furthermore,

concerns about helium cost effectiveness in laparoscopy

have been raised. Argon may have unwanted hemodynamic

effects, especially on hepatic blood flow. Although nitrous

oxide is advantageous for procedures requiring local/

regional anesthesia and, in some cases, of depressed

pulmonary function, it does not suppress combustion [9].

Carbon dioxide approaches the ideal insufflating gas and

maintains its role as the primary insufflation gas in

laparoscopy. Residual carbon dioxide pneumoperitoneum

is cleared more rapidly than that created with other gases,

minimizing the duration of postoperative discomfort [9].

However, the chief drawback of carbon dioxide is its

significant vascular absorption across the peritoneum,

leading to hypercapnia and intravascular embolization [10].

The gasless laparoscopic technique avoids using any gas

for insufflation, relying instead on an abdominal wall lift to

create an intra-abdominal space at atmospheric pressure,

consequently eliminating the problems attributed to increasedAt IAP levels below 15 mm Hg, venous return is aug-

mented as blood is bsqueezedQ out of the splanchnic venousbed, producing an increase in cardiac output. Further increase

in cardiac output at lower IAP may result from increasedlifting have no clinically relevant advantages compared with

low-pressure (5-7 mm Hg) pneumoperitoneum; furthermore,

abdominal wall lifting combined with low-pressure pneumo-

peritoneum might be a good alternative [14].

3. Pathophysiological changes duringlaparoscopy

Laparoscopy induces particular pathophysiological

changes in response to pneumoperitoneum. Knowledge of

the pathophysiology of a carbon dioxide pneumoperitoneum

can help minimize complications and render laparoscopic

surgery a safer technique.

3.1. Effects of carbon dioxide absorption

Carbon dioxide diffuses to the body more during

extraperitoneal than intraperitoneal insufflation, and its

diffusion is not influenced by the duration of intraperitoneal

insufflation [15]. Furthermore, extraperitoneal carbon diox-

ide insufflation leads to higher Paco2 (tension of carbon

dioxide in arterial blood) values in the postoperative period

[16]. Intraperitoneally, carbon dioxide was shown to be

affected by raising the intraperitoneal pressure above the

venous vessels pressure, which prevents carbon dioxide

resorption leading to hypercapnia. Hypercapnia by itself

increases minute ventilation by as much as 60% to normalize

the end-tidal carbon dioxide (etco2) and activates the

sympathetic nervous system leading to an increase in blood

pressure, heart rate, myocardial contractility, and arrhyth-

mias. It also sensitizes the myocardium to catecholamines,

particularly when volatile anesthetic agents are used [10].

3.2. Creation of the pneumoperitoneum

The creation of a pneumoperitoneum is ideally done with

2.5 to 5.0 L of insufflated carbon dioxide to permit adequate

visualization and manipulation of the abdominal viscera.

The pneumoperitoneum necessarily raises IAP, which

can have significant cardiovascular, respiratory, and neuro-

logic effects.

3.2.1. Cardiovascular effectsMajor hemodynamic changes include alterations in

arterial blood pressure (ie, hypotension and hypertension),

arrhythmias, and cardiac arrest. The extent of the cardiovas-

cular changes associated with creation of pneumoperitoneum

will depend on the IAP attained, volume of carbon dioxide

absorbed, patients intravascular volume, ventilatory tech-

nique, surgical conditions, and anesthetic agents used.

cardiac filling pressures due partly to mechanical factors and parts of the lung, which results in ventilation-perfusion (V/Q)

Anesthesia for laparoscopy 69partly to sympathetically mediated peripheral vasoconstric-

tion along with the effects of hypercapnia on cardiac efferent

sympathetic activity, which can increase systemic vascular

resistance and reduce cardiac index. At IAP levels greater

than 15 mm Hg, venous return decreases as the inferior vena

cava is compressed along with the surrounding collateral

vessels leading to decreased cardiac output and hypotension

[17]. Recent studies recommend a moderate to low IAP (b12mmHg) as it limits the alteration in splanchnic perfusion, and

consecutive organ dysfunctions will be minimal, transient,

and will not influence the outcome [10]. Zuckerman and

Heneghan [18] demonstrated that these changes are short

lived and lose their statistical significance at 10 minutes from

the time a patient undergoes pneumoperitoneum.

Bradyarrhythmias, including significant bradycardia,

atrioventricular dissociation, nodal rhythm, and asystole

have been reported. These are attributed to vagal stimulation

caused by insertion of the Veress needle or the trocar,

pneumoperitoneum-induced peritoneal stretch, stimulation

of the fallopian tube during bipolar electrocauterization, or

carbon dioxide embolization [19]. Tachyarrhythmias can

occur because of increased concentrations of carbon dioxide

and catecholamines. Paroxysmal tachycardia and hyperten-

sion, followed by ventricular fibrillation, have been reported

during laparoscopic adrenalectomy [20]. The induction of

pneumoperitoneum with the patient in the horizontal

position rather than in head-up or head-down position can

decrease the severity of these hemodynamic changes.

Patients with normal cardiovascular function are able to

well tolerate these variations in preload and afterload. Those

with cardiovascular disease, anemia, or hypovolemia require

meticulous attention to volume loading, positioning, and

insufflation pressures. However, many cases of cardiovas-

cular collapse during laparoscopy occurs in healthy patients,

because of, namely, vasovagal reflex response to peritoneal

stimulation from trocars or insufflation, myocardial sensiti-

zation by halothane, reduced venous return secondary to

reverse Trendelenburg position, inferior vena cava compres-

sion, high insufflation pressures, hypovolemia, hypercapnia

particularly in longer procedures, and venous gas embolism.

3.2.2. Respiratory effectsChanges in pulmonary function during laparoscopy

include reduction in lung volumes, increase in peak airway

pressures, and decrease in pulmonary compliance secondary

to increased IAP and patient positioning [21].

Creation of pneumoperitoneum at an IAP of 15 mm Hg

reduces respiratory system and compliance and increases

peak inspiratory and mean airway pressures, which quickly

return to normal values after deflation. Elevated IAP reduces

diaphragmatic excursion and shifts the diaphragm cephalad,

resulting in early closure of smaller airways leading to

intraoperative atelectasis with a decrease in functional

residual capacity. On one hand, upward displacement of the

diaphragm leads to preferential ventilation of nondependentmismatch with a higher degree of intrapulmonary shunting,

whereas on the other, it leads to endobronchial intubation.

These pulmonary pathophysiological changes lead to hyper-

capnia and hypoxemia in case of noneffective ventilation

leading to pulmonary vasoconstriction [10]. Higher IAP

reduces more the thoracic compliance and can cause

pneumothorax and pneumomediastinum owing to the in-

crease in alveolar pressures, particularly in patients with

extensive pulmonary disease undergoing laparoscopic upper

abdominal surgeries [21].

In patients with significant pulmonary dysfunction, pre-

operative pulmonary function testing including arterial blood

gas analysis should be performed, and intraoperative radial

artery cannula should be placed. If refractory hypoxemia,

hypercapnia, or high airway pressures occur during the lapa-

roscopy, the pneumoperitoneum should be released followed

by slow reinsufflation using lower IAPs. If complications

recur, conversion to an open procedure is a must [21].

3.2.3. Neurologic effectsIncreased intracranial pressure (ICP) along with a

decrease in cerebral perfusion pressure is encountered

whenever hypercapnia, increased systemic vascular resis-

tance, head-down positioning, and elevated IAP are present.

Because of this phenomenon, it is inadvisable to perform

laparoscopic surgery on patients with reduced intracranial

compliance unless absolutely necessary [22].

3.3. Patient positioning

Adverse patient positions can further compromise

cardiac and respiratory function, can increase the risk of

regurgitation, and can result in nerve injuries. These

complications were relatively rare when laparoscopy was

mainly confined to brief gynecologic procedures in healthy

patients but become more likely with longer and more

complex surgery performed in older and sicker patients.

3.3.1. Cardiovascular changes and patient positioningCardiovascular changes are complicated by the patients

position during laparoscopic surgery. The head-up position

reduces venous return and cardiac output, with a decrease in

mean arterial pressure and cardiac index, as well as an

increase in peripheral and pulmonary vascular resistance

[10,17,23]. These effects may be mistaken as the side effects

of anesthetic agents. Furthermore, a study done by Cunning-

ham et al [24] using transesophageal echocardiography has

showed an increase in left ventricular end-systolic wall

stress, along with a decrease in left ventricular end-diastolic

area, with left ventricular ejection fraction being the same.

Conversely, head-down position increases venous return

and normalizes blood pressure [17].

3.3.2. Respiratory changes and patient positioningBlood gas changes and respiratory mechanics are

affected by the duration of pneumoperitoneum and patient

positioning. The deterioration in respiratory function is

reduced when the patient is in the reverse Trendelenburg

4. Patient monitoring

5. Anesthetic techniques

successfully and safely used with great emphasis on short

F.J. Gerges et al.70Because more laparoscopic procedures are done on an

outpatient basis, general and regional anesthesia have beenAppropriate anesthetic techniques with proper monitor-

ing to detect and reduce complications must be used to

ensure optimal anesthesia care during laparoscopy. Hence,

electrocardiogram, noninvasive arterial pressure monitor,

airway pressure monitor, pulse oximeter, etco2 concentra-

tion monitor, peripheral nerve stimulation and body

temperature probe are routinely used. For hemodynamically

unstable patients or those with compromised cardiopulmo-

nary function, careful monitoring of cardiovascular and

blood gases by an arterial cannulation is indicated along

with urine output measurement. These measures also apply

for obese patients [14].

End-tidal carbon dioxide is most commonly used as a

noninvasive substitute for Paco2 in evaluating the adequacy

of ventilation during laparoscopic surgery. However, a careful

consideration should be taken for the gradient between Paco2and PEco2 (tension of carbon dioxide in expired air) because

the etco2 may differ considerably from Paco2 because of

V/Q mismatching. In patients with compromised cardiopul-

monary function, the gradient between Paco2 and PEco2increases to become unpredictable so that direct estimation of

Paco2 by arterial blood gas analysis may be necessary to

detect hypercarbia. Therefore, a radial artery cannulation for

continuous blood pressure recording and frequent arterial

blood gas analysis should be considered in patients with

preoperative cardiopulmonary disease and in situations

where intraoperative hypoxemia, high airway pressures, or

elevated etco2 are encountered [14].

An airway pressure monitor is routinely used during inter-

mittent positive pressure ventilation. A high airway pressure

alarm can aid detection of excessive elevation in IAP [14].

Nerve stimulation ensures adequate muscle paralysis,

which reduces the IAP necessary for abdominal distension

and prevents sudden patient movement that can lead to

accidental injuries of intra-abdominal structures by laparo-

scopic instruments [14].

Inadequate anesthesia may occur in the presence of

neuromuscular block, resulting in awareness. The use of a

Bispectral Index, a possible monitor of depth of hypnosis,

can help to reduce the occurrence of awareness. Some

anesthesiologists have used this monitor to titrate intrave-

nous and inhaled anesthetic drugs to fasten emergence and

improve recovery [26-28].position and worse when the patient is in the Trendelenburg

position [25].duration drugs, cardiovascular stability, rapid recovery and

fast-tracking, mobility, and freedom from postoperative

nausea and vomiting and pain.

5.1. General anesthesia for laparoscopy

General anesthesia using balanced anesthesia technique

including inhalational agents such as nitrous oxide, sevo-

flurane, isoflurane, and desflurane; intravenous induction

agents such as thiopentone, propofol, and etomidate; and a

variety of muscle relaxants including succinylcholine, miva-

curium, atracurium, and vecuronium have been reported.

Shorter-acting drugs such as sevoflurane, desflurane, and con-

tinuous infusions of propofol represent the maintenance

agents of choice. In fact, comparative studies have demon-

strated an early recovery, which is similar with any of these

drugs. Propofol, however, does have the advantage of produc-

ing less postoperative nausea and vomiting (PONV) [29,30].

The use of more rapid and shorter-acting volatile

anesthetics such as desflurane and sevoflurane and

bultrashort-actingQ opioid analgesics such as remifentanilhas allowed anesthesiologist to more consistently achieve a

recovery profile that facilitates fast tracking after the

administration of general anesthesia. Fast tracking in the

ambulatory setting implies taking a patient from the

operating room directly to the less extensively monitored

phase II step-down unit bypassing the postanesthesia care

unit. It is applied in multiple laparoscopic procedures

including cholecystectomy, gastric fundoplication, splenec-

tomy, adrenalectomy, and donor nephrectomy [31]. Nowa-

days, fast-track anesthesia is gaining more and more practice

in laparoscopic surgery to include the pediatric age group

where laparoscopic appendectomy is demonstrated to be

safely performed as fast-track or same-day surgery with a

postoperative stay of 24 hours or less [32]. Furthermore,

endoscopic thoracic sympathectomy is currently performed

safely on an outpatient basis [33].

Compared with standard monitoring practices, the use of

an auditory evoked potential or Bispectral Index monitor to

titrate the volatile anesthetic leads to a significant reduction

in the anesthetic requirement, resulting in a shorter

postanesthesia care unit stay and an improved quality of

recovery from the patients perspective [34]. Song et al [35]

demonstrated that the electroencephalographic Bispectral

Index values at the end of anesthesia is useful in predicting

fast-track eligibility after laparoscopic tubal ligation with

either a desflurane or propofol-based anesthetic technique.

Total intravenous anesthesia using the following agents:

propofol, midazolam and ketamine, and alfentanil and

vecuronium have been reported for outpatient laparoscopy.

Propofol-based anesthesia provided inferior perioperative

conditions comparedwith isoflurane caused bymore frequent

movement in spontaneously breathing patients. Furthermore,

sevoflurane and desflurane were still superior to propofol,

even when PONV was considered, and resulted in a higher

percentage of patients being judged fast-track eligible [36].

Patients are more liable to develop perioperative aware- their use more frequent, although none of them are quite as

Anesthesia for laparoscopy 71ness and PONV whenever opioid-based techniques are used

for laparoscopy. Therefore, opioid supplementation of

intravenous or inhalation-based anesthesia is more appro-

priate. The ultrashort-acting opioid remifentanil, which is

rapidly hydrolyzed by circulating and tissue nonspecific

esterases, has been shown to provide better control of

perioperative hemodynamic responses, compared with

alfentanil [37]. A major advantage of remifentanil is that

doses sufficient to attenuate cardiovascular responses can be

used without the risk of postoperative respiratory depression

and delayed recovery. However, postoperative analgesia

should be considered. Song and White [38] demonstrated

that the adjunctive use of a remifentanil infusion during

desfluranenitrous oxide anesthesia facilitates early recov-

ery without increasing PONV, pain, or the need for rescue

medication after laparoscopic surgery. Yang et al [39] did

not find any difference in PONV, pain, or anesthetic/

recovery times or costs between sevoflurane-remifentanil

induction and propofol-fentanyl-rocuronium induction in

the first 24 hours after laparoscopic surgery.

Preemptive analgesic techniques using nonopioids such

as acetaminophen, non steroidal anti-inflammatory drugs,

a2-agonists, and N-methyl D-aspartate antagonists proved tobe of benefit in multimodal analgesia and ambulatory

surgery where rapid recovery is the aim. Non-opioids are

increasingly used during laparoscopy to decrease opioid

requirements and avoid delayed recovery [40].

Nitrous oxide is commonly used to provide perioperative

analgesia and to reduce the requirements for inhaled or

intravenous anesthetics. The contribution of nitrous oxide to

nausea and vomiting is still controversial. There is

apparently no clinical advantage to omitting nitrous oxide,

and any benefit from its elimination must be balanced

against a greater risk of awareness [41]. Earlier anesthetic

techniques described for laparoscopic cholecystectomy

avoided nitrous oxide. Further studies have confirmed

similar surgical conditions and view regardless of whether

nitrous oxide was used, questioning its contraindication

during laparoscopic cholecystectomy. However, omission of

nitrous oxide improves surgical conditions for intestinal and

colonic surgery by avoiding the possible nitrous oxide

diffusion into the bowel lumen. Diemunsch et al [42] have

demonstrated that nitrous oxide diffuses into a carbon

dioxide pneumoperitoneum up to a level that can support

combustion in a 2-hour interval. Whether nitrous oxide

diffusion represents a real clinical risk of fire and explosion

during prolonged laparoscopy remains unclear, however. In

practice, some gas usually leaks from the abdomen and is

replaced by fresh carbon dioxide, which would somewhat

compensate for the ingress of nitrous oxide.

Succinylcholine was once commonly used as the muscle

relaxant of choice for short laparoscopic procedures, but it

was associated with a high incidence of postoperative

muscle pains. Currently, there is a considerable choice in

nondepolarizing neuromuscular blocking drugs renderingshort acting as succinylcholine. When they are used in place

of succinylcholine, the amount of muscle pain especially in

the neck is reduced [43,44]. Shoulder pain is still common,

however, being largely a consequence of the pneumo-

peritoneum. The lack of a very-brief-duration nondepolariz-

ing neuromuscular blocking drug is no longer a significant

problem because laparoscopic surgery has become more

complex and takes more time. However, it is desirable to use

repeated doses of short-acting agents rather than occasional

doses of longer-acting drugs. Using short-acting drugs

makes it feasible to reverse residual neuromuscular block

even if the last increment of a short-duration drug were

given within the previous 5 to 10 minutes. Some anesthesi-

ologists avoid the use of reversal drugs because it has been

suggested that they increase the incidence of PONV [43].

However, others have not found an increase in PONV

associated with the use of neostigmine and glycopyrrolate to

reverse residual neuromuscular block [45]. More impor-

tantly, even minor degrees of residual neuromuscular block

can produce distressing symptoms, such as visual distur-

bances, facial and generalized weakness, and the inability to

sit without assistance [46]. These symptoms can be present

despite signs of clinical recovery from neuromuscular block

and can prolong the recovery process. These findings should

present an incentive to minimize the use of neuromuscular

blocking drugs in ambulatory anesthesia. When they are

used, however, reversal drugs should be administered in

appropriate doses without hesitation.

General anesthesia without intubation can be performed

safely and effectively with a ProSeal laryngeal mask airway

(LMA) in nonobese patients [47]. Moreover, a correctly

placed classic LMA or a ProSeal (ProSeal LMA, San Diego,

CA, USA) LMA is as effective as an endotracheal tube for

positive pressure ventilation without clinically important gas-

tric distension in nonobese and obese patients [48]. However,

it should be restricted to short procedures performed using

low IAP and small degrees of tilt. It results in less sore throat

and might be proposed as a safe alternative to endotracheal

intubation [49]. Furthermore, it allows controlled ventilation

and accurate monitoring of etco2. However, decreased thor-

acopulmonary compliance during pneumoperitoneum fre-

quently results in airway pressures exceeding 20 cm H2O.

Because the LMA cannot guarantee an airway seal above this

pressure, its use for controlled ventilation should be limited to

healthy, thin patients. If tracheal intubation is still required, it

can be performed under deep intravenous [50] or inhalation

anesthesia [51], eliminating the potential problem of exces-

sively prolonged paralysis. Lu et al compared the ProSeal

LMAwith the classic LMA for positive pressure ventilation

during laparoscopic cholecystectomy and found the ProSeal

LMA to be amore effective ventilatory device than the classic

LMA. Hence, he did not recommend the use of classic LMA

for laparoscopic cholecystectomy [52].

Because general anesthesia with endotracheal intubation

and controlled ventilation is certainly the safest technique, it

is recommended for inpatients and for long laparoscopic within the rectus sheath, provides anesthesia of the anterior

F.J. Gerges et al.72procedures. During pneumoperitoneum, controlled ventila-

tion must be adjusted to maintain etco2 at approximately

35 mm Hg, requiring no more than a 15% to 25% increase in

minute ventilation.

In patients with chronic obstructive pulmonary disease

(COPD) and in patients with a history of spontaneous

pneumothorax or bullous emphysema, an increase in

respiratory rate rather than tidal volume is preferable to

avoid increased alveolar inflation and reduce the risk of

pneumothorax [53,54].

Anesthetic agents that directly depress the heart should be

avoided in patients with compromised cardiac function in

favor of anesthetics with vasodilating properties such as iso-

flurane. Infusion of vasodilating agents, such as nicardipine,

reduces the hemodynamic repercussions of pneumoperito-

neum and might facilitate management of cardiac patients.

Because of the potential for reflex increases of vagal tone

during laparoscopy, atropine should be administered before

the induction of anesthesia or should be available for

injection if necessary.

5.2. Regional anesthesia for laparoscopy

Regional anesthesia offers several advantages: quicker

recovery, decreased PONV, less postoperative pain, shorter

postoperative stay, cost effectiveness, improved patient

satisfaction, and overall safety, early diagnosis of complica-

tions, and fewer hemodynamic changes [55,56]. Sequelae of

general anesthesia such as sore throat, muscle pain, and

airway trauma can be avoided. However, this anesthetic

approach requires a relaxed and cooperative patient, low IAP

to reduce pain and ventilatory disturbances, reduced tilt, a

precise and gentle surgical technique, and a supportive

operating room staff. Any compromise may result in

increased patient anxiety, pain, and discomfort, necessitating

supplementation with intravenous sedation. The combined

effect of pneumoperitoneum and sedation can lead to

hypoventilation and arterial oxygen desaturation [57].

Laparoscopic tubal ligation might be a good indication for

regional anesthesia. However, any other laparoscopic proce-

dure that requires multiple puncture sites, considerable organ

manipulation, steep tilt, and voluminous pneumoperitoneum

makes spontaneous breathing difficult for the patient and,

consequently, must not be managed with regional anesthesia.

Regional anesthetic techniques are subdivided into 3

main categories: peripheral nerve blocks, neuraxial blocks,

and local anesthetic infiltration.

5.2.1. Peripheral nerve blocksFive techniques have been described for laparoscopy:

rectus sheath block, rectus sheath block combined with

mesoplanix block, inguinal block, pouch of Douglas block,

and paravertebral block. They represent either the principal

method of anesthesia or an adjunct to general anesthesia.

5.2.1.1. Rectus sheath block. The rectus sheath block,with successful blockade of the relevant intercostal nervesabdominal wall. When administered in conjunction with

general anesthesia, rectus sheath block resulted in improved

postoperative analgesia and a faster discharge [56].

5.2.1.2. Rectus sheath block and mesosalpinx block.When administered with general anesthesia, rectus sheath

and mesosalpinx blocks resulted in less postoperative pain

and analgesic requirement and earlier hospital discharge, as

compared with general anesthesia with rectus sheath block

alone [58].

5.2.1.3. Inguinal block. Inguinal block is a useful adjunctto general anesthesia for laparoscopic hernia repair [56].

5.2.1.4. Pouch of Douglas block. A catheter can be placedin the pouch of Douglas under direct vision using an epidural

needle inserted through the abdominal wall. Local anesthetic

placed into the pouch of Douglas provides effective pain

relief after tubal ligation, whereas the use of a catheter tech-

nique permits repetition of the dose to prolong analgesia [59].

5.2.1.5. Paravertebral block. Bilateral paravertebral block-ade at T5-6 level combined with general anesthesia for

patients undergoing laparoscopic cholecystectomy im-

proved postoperative pain relief and resulted in less PONV,

as compared with general anesthesia alone [60].

5.2.2. Neuraxial blocksRegional anesthesia, including epidural and spinal

techniques, combined with the head-down position, can be

used for gynecologic laparoscopy without major impairment

of ventilation. In fact, the respiratory changes are less

evident when laparoscopy is performed in awake patients

under regional anesthesia, and arterial blood gases are

maintained within normal limits [61]. Globally, epidural and

local anesthesia share the same benefits and disadvantages;

however, neuraxial anesthesia alone has the advantages of

reducing the need for sedatives and narcotics, produces

better muscle relaxation, and can be proposed for laparo-

scopic procedures other than sterilization.

5.2.2.1. Epidural anesthesia. Epidural anesthesia wasconsidered as a safe alternative to general anesthesia for

outpatient laparoscopy without associated respiratory de-

pression because the respiratory control mechanism remains

intact, allowing the patients to adjust their minute ventila-

tion and, therefore, maintaining an unchanged etco2 [61].

Moreover, despite the increase in respiratory work and V/Q

mismatch, alveolar ventilation was not compromised even

in the Trendelenburg position, and the time to discharge was

significantly reduced using epidural compared with general

anesthesia. Shoulder pain, which is secondary to diaphrag-

matic irritation that results from abdominal distension, is

incompletely alleviated using epidural anesthesia alone.

Extensive sensory block (T4 through L5) is necessary for

surgical laparoscopy and may also lead to discomfort. The

epidural administration of opiates and/or clonidine might

help to provide adequate analgesia [56].

In case of gasless laparoscopy for gynecologic surgery,

epidural anesthesia can provide comfort and more adequate

pain relief while avoiding most of the side effects of carbon In a prospective randomized study, Hirschberg et al [74]

Anesthesia for laparoscopy 73dioxide pneumoperitoneum. Furthermore, no significant

difference in cardiorespiratory function is present in gasless

gynecologic laparoscopy whenever general or epidural

anesthesia is performed [62].

In patients with COPD, epidural anesthesia could be

safely and effectively used for laparoscopic cholecystecto-

my, therefore avoiding general anesthesia in patients with

chronic respiratory disease [63,64].

Laparoscopic extraperitoneal herniorrhaphy can be per-

formed effectively under epidural anesthesia, obviating the

need for general anesthesia [65].

5.2.2.2. Spinal anesthesia. Spinal anesthesia is thesimplest and most reliable of the regional anesthesia

techniques. It has become more common in ambulatory

practice with the introduction of fine-gauge pencil-point

needles. Spinal anesthesia, as the primary technique for

laparoscopy, offers many benefits over general anesthesia;

however, conventional dose hyperbaric spinal anesthesia

might not be ideal for laparoscopy. In fact, the Trendelen-

burg position predisposes to cephalad spread of the spinal

block, a greater sympathetic block, bradycardia, and

hypotension [66]. Administration of reduced doses of the

local anesthetics or hypobaric solutions minimizes side

effects such as hypotension, bladder distension, and

prolonged sensory and motor block traditionally associated

with conventional doses [67]. For short-duration laparosco-

py, a spinal hypobaric solution of 10 mg lidocaine with

10 lg of sufentanil provides adequate analgesia [68].In ambulatory gynecologic laparoscopy, small-dose

spinal anesthesia is an effective alternative to a desflurane

general anesthetic. It results in less postoperative pain, cost,

and faster recovery [69]. As compared with propofol-based

anesthesia, small-dose selective spinal anesthesia has

significantly shorter recovery period [70].

Laparoscopic extraperitoneal inguinal hernia repair under

spinal anesthesia and extraperitoneal nitrous oxide insuffla-

tion has been performed safely and effectively [71].

Laparoscopic cholecystectomy under spinal anesthesia

with nitrous oxide pneumoperitoneum has been performed

successfully [72].

In patients with severe COPD undergoing laparoscopic

intraperitoneal inguinal hernia repair, spinal anesthesia

using hyperbaric bupivacaine is an effective alternative to

general anesthesia [73].

With the advent of gasless laparoscopy and micro-

laparoscopy, the role of spinal anesthesia will probably

increase in the future.

5.2.2.3. Combined spinal-epidural anesthesia. Onedisadvantage of epidural anesthesia is the relatively slow

onset of anesthesia. Recently, there has been increasing

interest in combining spinal and epidural anesthesia.

Potential advantages of combined spinal-epidural (CSE)

anesthesia include rapid onset of anesthesia and the

ability to administer minimally effective doses of intrathecal

agents initially.studied the clinical impact of CSE anesthesia in patients

undergoing total extraperitoneal laparoscopic hernia repair

vs balanced general anesthesia with controlled ventilation.

The respiratory compensation of extraperitoneal gas insuf-

flation was not decreased by CSE anesthesia; however, most

of the patients with CSE anesthesia showed severe agitation

often accompanied by chest pain. Hence, the author did not

recommend this technique.

5.2.2.4. Caudal epidural block. Caudal epidural blocks arean effective modality for providing postoperative analgesia

after laparoscopic hernia surgery in children. Children

receiving caudal anesthesia as an adjunct to general

anesthesia have lower pain scores and do not require

supplemental analgesia in the postoperative period [75].

When combined with general anesthesia, caudal epidural

block is more effective than ilioinguinal/iliohypogastric

block in controlling pain after laparoscopic herniorrhaphy in

children, thereby resulting in earlier hospital discharge [76].

5.2.3. Local anesthetic infiltrationThe advances in optical fiber technology have now

produced laparoscopes with external diameters of as little

as 1.2 to 2.2 mm. These instruments allow micro-

laparoscopyQ to be performed with local anesthesia alone orsupplemented by sedation. Therefore, local anesthesia could

be used as a reliable and affordable alternative to general

anesthesia. It is safe, effective, and less costly and has been

primarily used for patients with infertility, chronic pelvic

pain, and tubal ligation [77,78].

Office microlaparoscopy for female sterilization under

local anesthesia is cost-effective and safe [79], with less post-

operative analgesic requirement as compared with conven-

tional laparoscopic sterilization [80]. In the therapy for

polycystic ovarian syndrome, ovarian drilling in minilaparo-

scopy under local anesthesia has similar therapeutic results to

those achieved by traditional laparoscopy. It offers a less-

invasive technique with an early hospital discharge that can be

carried out in an outpatient service without the need for

general anesthesia and postoperative additional analgesia [81].

Obese patients are unsuitable for microlaparoscopy; the

short instrument is likely to end up in the extraperitoneal

space, and the low insufflation pressures can be insuffi-

cient to lift the weight of the abdomen and provide a good

view. Patients with multiple adhesions from previous

surgery are also less suitable. Further developments in

optics and small instruments could increase the indications

for microlaparoscopy.

In laparoscopic cholecystectomy under general anesthe-

sia, preinsertion of local anesthesia at the trocar site

significantly reduces postoperative pain and decreases

medication usage costs [82]. Moreover, intraperitoneal spray

of local anesthetic significantly decreases postoperative pain

[83]. The extraperitoneal laparoscopic repair of inguinal

hernia is feasible under local anesthesia alone. This

technique adds a new treatment option in the management

of bilateral inguinal hernias, particularly in the population

of side effects, but most patients tolerate short-term admin-

6.1.3. Opioids

F.J. Gerges et al.74istration of NSAIDs remarkably well [88].where general anesthesia is contraindicated [84].

6. Recovery after laparoscopy

During the early postoperative period, respiratory rate

and etco2 of patients breathing spontaneously are higher

after laparoscopy as compared with open surgery. The

additional carbon dioxide load can lead to hypercapnia even

in the postoperative period. This causes an increased

ventilatory requirement, when the ability to increase

ventilation is impaired by residual anesthetic drugs and

diaphragmatic dysfunction. Patients with respiratory disease

can have problems excreting excessive carbon dioxide load,

which results in more hypercapnia and eventually respira-

tory failure. Patients with cardiac disease are more prone to

hemodynamic changes and instability caused by the hyper-

dynamic state developing after laparoscopy.

As compared with other outpatient procedures, laparo-

scopic surgery still produces substantial morbidity. Tele-

phone follow-up revealed incisional pain in about 50% of

laparoscopic patients, double the overall incidence of pain in

outpatients. Drowsiness (36%) and dizziness (24%) were also

more common after laparoscopic surgery than after any other

ambulatory procedure [85]. A high incidence of minor morbi-

dities is noticed: abdominal pain (71%), shoulder pain (45%),

sore throat (26%), headache (12%), and nausea (3%), and

only 8%of the patientswould have preferred anovernight stay

[86]. Although morbidity is considerable, most symptoms re-

solve within a week [87]. The anesthesiologist must deal with

these postoperative problems and address them adequately.

6.1. Postoperative pain

Although laparoscopic surgery results in substantially

less severe and prolonged discomfort compared with the

corresponding open procedure, postoperative pain still can

be considerable. Prevention and treatment of pain relies on

local anesthesia, nonsteroidal anti-inflammatory drugs, and

opioid analgesics, often used in combination.

6.1.1. Local anesthesiaAll the regional anesthesia techniques previously de-

scribed reduce postoperative pain and delay the requirement

for rescue analgesics.

6.1.2. Nonsteroidal anti-inflammatory drugsBecause nonsteroidal anti-inflammatory drugs (NSAIDs)

have analgesic properties comparable with opioid com-

pounds without opioid-related side effects, these drugs are

often administered as adjuvant during and after surgery.

There is no significant difference between the various

NSAIDs in their efficacy, provided that an adequate dose is

used and sufficient time is allowed for the onset of effect.

There could beminor differences between drugs in the patternOpioid analgesics are obviously effective in treating pain

after laparoscopic procedures; however, these drugs are

associated with numerous side effects, including nausea,

respiratory depression, and sedation, which are especially

undesirable in outpatients.

6.1.4. Multimodal analgesia techniquesThe most effective pain relief can be obtained by

combining opioids, local anesthetics, and NSAIDs into

balanced analgesia. This approach at least allows the opioid

dose to be reduced by the use of other modalities, thereby

limiting side effects, reducing postoperative pain and

analgesic requirements, and facilitating an earlier return to

normal activities [89,90].

6.1.5. Other analgesic techniquesAvariety of other therapeutic modalities have been used to

try to reduce pain after laparoscopy, including anticholinergic

drugs, tramadol, acetaminophen, and dexmedetomidine.

6.1.5.1. Anticholinergic drugs. Anticholinergic smoothmuscle relaxants have been used to treat pain induced by

spasm in the smooth muscle of the fallopian tube after

laparoscopic sterilization. Glycopyrrolate reduced patient

pain scores on patients awakening and reduced require-

ments for morphine [91], but buscopan failed to achieve the

same results [92].

6.1.5.2. Tramadol. Tramadol is a weak opioid that also hasanalgesic effects through inhibition of neurotransmitter

uptake. It is effective in reducing pain scores and opioid

analgesic requirements [93].

6.1.5.3. Acetaminophen. Combinations of acetamino-phen with either dextropropoxyphene or codeine are as

effective as tramadol administration in treating postopera-

tive pain [94].

6.1.5.4. aaaaaa2 Agonist. Dexmedetomidine has sedative,hypnotic, and analgesic properties. It diminishes the need

for other anesthetics and sympathicolytics, and it reduces

catecholamine release. Furthermore, it lowers the need both

for other sedatives and for analgesic morphine, although

spontaneous breathing is not affected [95].

6.2. Postoperative nausea and vomiting

Postoperative nausea and vomiting is extremely common

after laparoscopic surgery and can delay discharge after

outpatient surgery. Some aspects of the anesthetic technique

as well as the use of antiemetic medications could decrease

the incidence of PONV.

6.2.1. Anesthetic techniqueBecause propofol has the lowest incidence of PONV,

maintenance of anesthesia for laparoscopic surgery with

propofol results in a lower incidence of PONV, compared

with inhalation anesthetics [29,30]. Nitrous oxide is known to

increase the incidence of PONV; however, its omission failed

to reduce the occurrence of PONV after laparoscopies [41].

Because opioids are a potent cause of PONV, the concomitant

use of NSAIDs and opioids helps to better control postop-

5-HT3 antagonists, are effective as well [100,101].

laparoscopic procedures. Special care must be taken in

Direct intravascular gas insufflation, a tear in an abdom-

Anesthesia for laparoscopy 75patients with increased ICP resulting from brain tumors,

hydrocephalus, or head trauma. Patients having ventricular

peritoneal shunt must have the shunt clamped before

peritoneal insufflation.

8. Complications of laparoscopy

The incidence of complications associated with laparo-

scopic procedures varies significantly, depending on the

type of procedure and the training and experience of the

surgeon. The anesthesiologist has to be aware and deal with

these potential problems to avoid any undesirable outcome.

8.1. Inadvertent extraperitoneal insufflation

Misplacement of the Veress needle can lead to intravas-

cular, subcutaneous tissue, preperitoneal space, viscus,

omentum, mesentery, or retroperitoneum insufflation of

carbon dioxide.Dexamethasone reduced PONV in the first 24 hours after

laparoscopic sterilization and reduced the requirement for

rescue antiemetics with no adverse effects noted from this

single dose of steroid [102].

7. Contraindications for laparoscopy

Laparoscopy brings the highest benefits to the highest

risk group of patients notably in intensive care unit patients,

patients with cardiac and/or respiratory compromise, renal

failure, obese, children, and the elderly. However, extreme

care to anesthetic management and surgical performance

must be considered. Absolute contraindications for lapa-

roscopy include shock, markedly increased ICP, severe

myopia and/or retinal detachment, inadequate surgical

equipments, and inadequate monitoring devices. Relative

contraindications include bullous emphysema, history of

spontaneous pneumothorax, pregnancy, life-threatening

emergencies, prolonged laparoscopy more than 6 hours

associated with acidosis and hypothermia, and newerative pain, while decreasing opioid-related side effects. The

routine use of neostigmine to reverse residual neuromuscular

block has been reported to increase the incidence of PONV

compared with spontaneous recovery from mivacurium [43];

however, others have failed to confirm an adverse effect of

neostigmine in a similar study [96].

6.2.2. Antiemetic medicationsAlthough ondansetron (an antagonist of the 5-HT3

receptor), is as effective as older antiemetics such as droper-

idol [97] or cyclizine [98], it avoids most of their adverse

effects. Ondansetron given at the end of surgery results in a

significantly greater antiemetic effect, compared with

preinduction dosing [99]. Dolasetron and granisetron, otherinal wall or peritoneum vessel, can lead to gas embolism. It is

a rare but potentially lethal complication of laparoscopic

surgery where profound hypotension, cyanosis, dysrhyth-

mias, and asystole may occur after intravascular embolization

of carbon dioxide. Initially, there is a sudden increase in

etco2 concentration, which then can decrease owing to

cardiovascular collapse and reduction of pulmonary blood

flow. A mill-wheel murmur can be auscultated. By using a

precordial Doppler probe or transesophageal echocardiogra-

phy, embolized carbon dioxide is detected earlier and

confirmed. Rapid absorption of the carbon dioxide embolus

facilitates dissolution of the resulting intracardiac or intra-

vascular foam and leads to rapid reversal of hemodynamic

impairment whenever the volume of carbon dioxide embolus

is low [10]. If gas embolism is suspected, carbon dioxide

insufflation should be discontinued and the abdomen

deflated. The patient should be turned to the left lateral

decubitus with a head-down position to allow the gas to rise

into the apex of the right ventricle and prevent entry into the

pulmonary artery. Hyperventilation with 100% O2 for rapid

carbon dioxide elimination, central venous catheter place-

ment for aspiration of gas, and aggressive cardiopulmonary

resuscitation should be done [103].

Pulmonary air embolism after inadvertent vascular

puncture by an air-cooled laser has been reported during

laparoscopic cholecystectomy. Because carbon dioxide is

more soluble in blood than air or nitrous oxide, a greater

volume of carbon dioxide embolism can be tolerated when

compared with air or nitrous oxide embolism [103].

Subcutaneous insufflation of carbon dioxide leads to

subcutaneous emphysema. It is identified by the development

of crepitus over the abdominal and chest wall, associated with

an increase in airway pressures and etco2 concentrations,

leading to significant hypercapnia and respiratory acidosis. In

most cases, no specific intervention is necessary, and the

subcutaneous emphysema resolves soon after the abdomen is

deflated and nitrous oxide is discontinued to avoid expansion

of carbon dioxidefilled space [103,104].

8.2. Pneumothorax

Pneumothorax can occur with the gas traversing into

the thorax either through a tear in the visceral peritoneum,

breach of the parietal pleura during dissection around

the esophagus, a congenital defect in the diaphragm

(patent pleuroperitoneal canal), and spontaneous rupture of

preexisting emphysematous bulla. Subcutaneous emphyse-

ma in the neck and face can result in gas tracking to the

thorax and mediastinum, thereby resulting in pneumothorax

or pneumomediastinum. Pneumothorax can be asymptom-

atic or can increase peak airway pressures, decrease

oxygen saturation and, in severe cases, can lead to

significant hypotension and cardiac arrest. The treatment

is according to the severity of cardiopulmonary compromise

from conservative treatment with close observation to chest

tube placement [103].

Accidental insertion of the Veress needle or trocar into

F.J. Gerges et al.76major vessels such as the aorta, common iliac vessels,

inferior vena cava, or cystic or hepatic artery can lead to

serious and even fatal complications requiring conversion to

laparotomy for control of bleed. Other minor vascular

injuries involve the abdominal wall vessels and can be

managed during laparoscopy [103].

8.5. Gastrointestinal injuries

Gastrointestinal injuries frequently involve the small

intestine, colon, duodenum, and stomach. Lacerations of

the liver, spleen, and colonic mesentery also have been

reported. Gastric decompression before placement of the

Veress needle should minimize stomach injuries. In patients

undergoing laparoscopic Nissen fundoplication, the anesthe-

siologist should carefully insert the esophageal bougies to

avoid esophageal or gastric perforation especially in patients

with Barretts esophagus, ulcers, or strictures [103].

8.6. Urinary tract injuries

Although injuries to the bladder and ureters are rare,

decompression of the bladder by placement of a urinary

catheter before laparoscopy is advisable [103].

9. Summary

Laparoscopy is most commonly performed with the

patient under general anesthesia. For prolonged and upper

abdominal procedures, this remains the only realistic option

at present, but regional techniques involving peripheral and

neuraxial blocks and local anesthetic infiltrations could be

used with precautions for pelvic laparoscopy. Rectus sheath,

mesosalpinx, inguinal, pouch of Douglas, paravertebral and

caudal blocks are useful adjuncts to general anesthesia

and facilitate postoperative analgesia. Other techniques

such as spinal and epidural anesthesia and combination

of the two are suitable as a sole anesthetic technique for

pelvic laparoscopy.8.3. Pneumomediastinum and pneumopericardium

Extension of subcutaneous emphysema from the cervical

region into thorax and mediastinum can lead to pneumo-

mediastinum. Although, pneumopericardium can occur

when the carbon dioxide is forced through the inferior vena

cava into the mediastinum and pericardium or when carbon

dioxide tracks through the defect in the membranous portion

of the diaphragm, which can have embryonic communica-

tion between the pericardial and peritoneal cavities. The

management of pneumomediastinum and pneumopericar-

dium depends on the severity of associated cardiopulmonary

dysfunction. Release of the pneumoperitoneum is adequate

in many patients [103].

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Anesthesia for laparoscopy: a reviewIntroductionThe choice of insufflated gasPathophysiological changes during laparoscopyEffects of carbon dioxide absorptionCreation of the pneumoperitoneumCardiovascular effectsRespiratory effectsNeurologic effects

Patient positioningCardiovascular changes and patient positioningRespiratory changes and patient positioning

Patient monitoringAnesthetic techniquesGeneral anesthesia for laparoscopyRegional anesthesia for laparoscopyPeripheral nerve blocksRectus sheath blockRectus sheath block and mesosalpinx blockInguinal blockPouch of Douglas blockParavertebral block

Neuraxial blocksEpidural anesthesiaSpinal anesthesiaCombined spinal-epidural anesthesiaCaudal epidural block

Local anesthetic infiltration

Recovery after laparoscopyPostoperative painLocal anesthesiaNonsteroidal anti-inflammatory drugsOpioidsMultimodal analgesia techniquesOther analgesic techniquesAnticholinergic drugsTramadolAcetaminophenalpha2 Agonist

Postoperative nausea and vomitingAnesthetic techniqueAntiemetic medications

Contraindications for laparoscopyComplications of laparoscopyInadvertent extraperitoneal insufflationPneumothoraxPneumomediastinum and pneumopericardiumVascular injuriesGastrointestinal injuriesUrinary tract injuries

SummaryReferences