lap anesthesia
TRANSCRIPT
Anesthesia for Laparoscopic surgeries
DR CHANDRA SEKHAR BEHERAPG FINAL YEAR ANAESTHESIOLOGY
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DEPT OF ANAESTHESIOLOGY M.K.C.G
MEDICAL COLLEGE 1
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DEPT OF ANAESTHESIOLOGY M.K.C.G
MEDICAL COLLEGE 2
Objectives
To understand the principles of anaesthesia for
laparoscopic surgery
To increase awareness of the risks of CO2
Peritonium
Benefits of laparoscopic surgery from patient’s
point of view
Special considerations in geriatrics, COPD,
heart disease, pregnancy, paediatrics and
obese patients
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MEDICAL COLLEGE 3
History
ALBUKASSAM 1st used reflected light for visualisation of cervix
In 1901 KILLINK has inspected viscera of dog by insufflation of abdomen with air
In 1910 JACOBIN applied this tecnique to human and named the procedure LAPAROSCOPY
In 1968 SEEM developed CO2 pneumosufflation
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DEPT OF ANAESTHESIOLOGY M.K.C.G
MEDICAL COLLEGE 4
Laparoscopic Procedures
General Surgery:
○ Cholecystectomy
○ Appendicectomy
○ Varicocoelectomy
○ Hernioplasty
○ Diagnostic laparoscopy
○ Hiatus hernia repair
○ Adhesiolysis
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MEDICAL COLLEGE 5
Laparoscopic Procedures
OBG:
○ Diagnostic tool for infertility
○ Ectopic pregnancy
○ Myomectomy
○ Endometriosis
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Advantages of Laparoscopy
Shorter hospital stay
Less post-op ileus
Faster recovery
Rapid return to normal activities
Minimal pain
Small scar
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Contraindications for
Laparoscopy
Increased ICP
V – P shunt
Hypovolemia
CCF
Valvular heart diseases
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MEDICAL COLLEGE 8
Laparoscopy – Anesthetic
issues
CO2 pneumo peritoneum
Due to patient positioning
Cardiovascular effects
Respiratory effects
Gastro intestinal effects
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR
Pneumo Peritonium…
Insufflator Gas used
N2O /CO2 /Argon /He/ Air
Preferred gas : CO2
Working pressure : 12 to 14 mm Hg
Slow inflation of 1 liter / minute
(Air is insoluble in blood –risk of embolism
high. N2O risk of thermal injury. He & Argon
not available here)
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DEPT OF ANAESTHESIOLOGY M.K.C.G
MEDICAL COLLEGE 9
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MEDICAL COLLEGE 10
Pneumo Peritonium
CO2 as Insufflator Gas
○ More soluble in blood than air
○ Carriage is high due to bicarbonate buffering
and combination with Hb
○ Rapidly eliminated by lungs
○ Inert & not irritant to tissues
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Physiological effects
Cardiovascular effects depends on
○ Patient’s preexisting cardiopulmonary status
○ The anesthetic technique
○ Intra-abdominal pressure (IAP)
○ Carbon dioxide (CO2) absorption
○ patient position
○ Duration of the surgical procedure
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Physiological effects
Cardiovascular
- There is biphasic response on CO
- If IAP <10mmHg, milking effect on veins CO
- If IAP >15mmHg, 10%-30% reduction in CO
Increase in systemic vascular resistance, meanarterial pressure, and cardiac filling pressures
More severe in patients with preexisting cardiacdisease
Significant changes occur at pressures greater than12 - 15 mmHg
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Physiological Effects
1. Increased noradrenalin levels leads to increased SVR
2. increased plasma renin activity (PRA) due to
increased intra-abdominal pressure (IAP) and the
local compression of renal vessels
3. Hypertension, tachycardia leading to increased
myocardial oxygen demand
4. Hypercarbia and acidosis
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Cardiac Arrhythmias during
Laparoscopy
common during insufflation and during desufflation
Volatile anaesthetic agents
Hypercarbia, hypoxia and gas embolism ppt
tachyarrythmias
Sudden stretching of peritoneum causes vagal
stimulation
Electro coagulation of fallopian tubes
Light planes of anaesthesia
Cardiovascular
Management :
Adequate preload will improve cardiac
output
Intermittent SPC to legs will improve
venous return
Use of alpha 2 agonist such as clonidine or
dexmedetomidine & or beta blocker reduces
haemodynamic changes
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MEDICAL COLLEGE 16
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Physiological effects
Pulmonary changes:
Exaggerated in obese patients, ASA classII and III patients & in those with respiratory dysfunction
Intra-abdominal distension leads to a decrease in pulmonary dynamic compliance
1. increased IAP displaces the diaphragm upward
2. Functional residual capacity and total lung compliance decreases
3. Early closure of smaller airways, basal atelectasis
4. Increased peak airway pressures
5. Increase in minute ventilation required to maintain normocarbia
6. Increase in intra pulmonary shunting
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Gastro intestinal system
Risk factor for Regurgitation
Increased intra-abdominal pressure
Decreased lower esophageal sphincter tone
(if barrier pressure is increased>30cm of H2O)
Head down position
NG tube mandatory
Gastro intestinal system..
Mesentric circulation:
1. Reduced bowel circulation resulting in
decreased gastric intra mucosal pH
2. Due to IAP, collapse of capillaries and small
veins,
3. Reverse Trendelenburg position,
4. Release of vasopressin
all lead to decreased mesenteric circulation
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Gastro intestinal system...
Porto Hepatic circulation:
Rise in IAP result in decreased total
hepatic blood flow due to splanchnic
compression
Hormonal release (catecholamine,
Vasopressin & Angiotensin lead on to
overall reduction in splanchnic blood
flow except for Adrenal glands
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Renal function
Increased IAP
Decreased RBF
Increased sympathetic activity
Elevated plasma Renin activity
Fall in filtration pressure
Fall in urine output
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Central Nervous System
Increased IAP Increased lumbar spinal
pressure Decreased drainage from
lumbar plexus Increased ICP
Hypercapnia, high systemic vascular
resistance and head low position combine
to elevate intracranial pressure.
The induction of pneumoperitoneum itself
increases middle cerebral artery blood flow
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Coagulation System
Increased IAP may lead to increased
venous stasis
Causing deep vein thrombosis
especially in prolonged surgery
Deep vein thrombosis prophylaxis
should be done in such patients.
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Temperature Variation
Continuous flow of dry gases into peritoneal cavity under pressure can lead to fall in body temperature.
(sudden expansion of gas produces hypothermia due to Joule Thompson effect)
0.30 C fall in core temperature/50 Lit flow of CO2
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Neuro humoral response
Activation of Hypo thalamo pituitary
Adreno cortical Axis
Rise in ACTH, Cortisol and Glucogon
Altered glucose metabolism
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MEDICAL COLLEGE 25
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Problems related to patient’s
positioning
Head Down tilt - for pelvic and sub meso-colic
surgery
HeadUp tilt - for supra mesocolic surgery
Lithotomy position - for gynecological
procedures
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Position – Respiratory Effects
Head-down position
○ Endo-bronchial intubation
○ Promotes atelectasis
○ Decreases FRC
○ Decreases TLC
○ Decreases pulmonary compliance
Head-Up position: favorable for respiration
Position- Cardio-Vascular Effects
Head up tilt----- Blood pooling
Venous stasis
Thrombo-embolism
↓ venous return
↓cardiac output
→ ↓ Blood Pressure
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MEDICAL COLLEGE 28
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Position- Cardio-Vascular
Effects
Head down Position:
○ Increases CVP
○ Increases cardiac output
○ Increases cerebral circulation
Increased ICP
Increased intra-ocular pressure
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Positions : Nerve Injury
Hyper extension of arm --- brachial plexus injury
Lithotomy position --- common peroneal injury
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Complications of lap surgeries
Due to trochar injury
Positioning and
compression effect
CVS and RS complications
Thermal injuries
Gas embolism
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Complications of gas insufflation
Subcutaneous emphysema ○ occur if the tip of the Veress needle does not penetrate the
peritoneal cavity prior to insufflation of gas.
○ Occur in inguinal hernia repair, renal surgery
○ During fundoplication for hiatus hernia repair
Extraperitoneal insufflation, which is associated with higher levels of CO2 absorption than intraperitoneal insufflation, is reflected by a sudden rise in the EtCO2, excessive changes in airway pressure
and respiratory acidosis
CO2 subcutaneous emphysema readily resolves after insufflation has ceased
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Complications of gas
insufflation
Pneumothorax, Pneumomediastinum and
Pneumopericardium
Patent pleuro-peritoneal channels
Pleural injuries
Ruptured emphysematous bullae
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Complications of gas
insufflation
Pneumothorax, Pneumomediastinum and Pneumopericardium
Sudden hypoxia, rise in peak airway pressure, hypercarbia, haemodynamic alterations
abnormal movement of the hemidiaphragm on laparoscopic view should raise a suspicion of pneumothorax
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Management of
Pneumothorax
Recommended Guidelines ◦ Stop N2O ◦ Adjust ventilator settings to correct hypoxemia ◦ If due to pleuro peritoneal channel route Apply
PEEP ◦ Reduce intra-abdominal pressure ◦ Communicate with surgeon ◦ Avoid thoracocentesis unless necessary◦ Avoid PEEP if there is rupture of
emphysematous bulla and thoracocentesis is mandatory
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Gas Embolism
Most feared & fatal complication Seen frequently when laparoscopy is associated with
hysteroscopy
Intra vascular injection of gas following direct trocar placement into vessel
Gas insufflation into abdominal organ
Suspicion of Gas Embolism Blood on aspiration from Vere’s needle
Pulsation of flow meter pressure gauge
Disappearance of abdominal distention despite sufficient volume of gas
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Effects of Massive Air Embolism
Depends on volume of air and rate of iv entry
Rapid insufflation of gas into blood (2ml/kg)
-> larger bubbles -Gas lock in RA & venacava
-> Fall in cardiac output
->High pressure in RA
-> Open foramen ovale
->Embolus in cerebral & coronary beds
-> Paradoxical embolism
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Diagnosis of Gas-embolism
Detection of gas in right side of Heart –foamy blood aspirated in the central venous catheter
Recognition of physiological changes secondary to emboli: ○ Tachycardia
○ Cardiac arrhythmia
○ Hypotension
○ CVP rise
○ Mill-wheel murmur
○ Cyanosis
○ Right heart strain pattern in ECG
○ Pulmonary edema
Doppler & TEE ---- very sensitive (0.5ml/kg)
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Treatment of Gas Embolism
Immediate cessation of insufflation
Release of pneumo-peritoneum
Patient in head down and left lateral decubitus(Durant’s) position
Cessation of N2O
Give 100% oxygen
CVP insertion and aspiration of gas
CPR help to fragment CO2 emboli into small bubbles
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Postoperative morbidity
Postoperative Pain
Abdominal and shoulder tip pain after laparoscopic
surgery
Complete removal of the insufflating gas is essential
Infiltration of the portal sites with a local anaesthetic
reduces pain
Right-sided subdiaphragmatic instillation with a local
anaesthetic reduces shoulder tip pain
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Postoperative morbidity
Post Operative Nausea & Vomiting (PONV)
Peritoneal insufflation, bowel manipulation and
pelvic surgery are some of the causative factors
A meticulous anaesthetic technique along with
antiemetics is helpful in reducing the incidence
of PONV
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Gasless laparoscopy
Peritoneal cavity is expanded using
abdominal wall lifter.
This avoids haemodynamic & respiratory
repercussions of increased IAP
It increases technical difficulty
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Anaesthesia for lap surgeries
Anaesthetic Goals
Accommodate surgical requirements and allow for
physiological changes during surgery.
Monitoring devices available for the early detection
of complications.
Recovery from anaesthesia should be rapid with
minimal residual effects.
The possibility of the procedures being converted to
open laparotomy to be considered
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Anaesthetic Plan
Pre-operative assessment
The cardiac and pulmonary status of all patients should be carefully assessed
Pre-medication ○ Anxiolytics
○ Antiemetic
○ H2 receptor blockers
○ Gastro-kinetic drugs
○ Preemptive analgesia with NSAIDs
○ Atropine to prevent vagally mediated bradyarrhythmias
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Monitoring
1.Routine Patient Monitoring Include Continuous ECG Intermittent NIBP Pulse oximetry (SpO2) Capnography (EtCO2) Temperature Intraabdominal pressure
2. Optional Monitoring Include Pulmonary airway pressure Oesophageal stethoscope Precordial doppler Transoesophageal echocardiography
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Anaesthetic techniques
General anaesthesia
◦ Preloading with crystalloid solution is recommended
◦ Preoxygenation
◦ During induction of Anaesthesia, avoid stomach
inflation
◦ Tracheal Intubation – mandatory
◦ PLMA should only be used by experienced LMA
users
◦ NG tube placement for Stomach decompression
◦ Catheterisation to empty the urinary bladder
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G.A : Anaesthetic Management
…
Maintenance of Anaesthesia
Intermittent positive pressure ventilation (IPPV) .
Normocarbia (34-38mmHg) to be maintained by adjusting the
minute volume
The use of nitrous oxide during laparoscopic surgery is
controversial (bowel distension during surgery and the increase in
postoperative nausea) .
Halothane increases the incidence of arrhythmia
Isoflurane / sevoflurane comparatively better
Reversal of NM blockade
General anaesthesia
Recovery room -Post-op Period
1.Continue monitoring
2.Post-op pain relief
3.Post-op shivering
4.O2 thru’ Mask
5.Measures to Prevent pulmonary
atelectasis
6.DVT prophylaxis
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Regional anaesthesia
○ Epidural anaesthesia for outpatient gynaecological
laparoscopic procedures to reduce complications and
shorten recovery time after anaesthesia .
○ Not Been Reported For laparoscopic cholecystectomy or
other upper abdominal surgical procedures except in patients
with cystic fibrosis .
○ The high block produces myocardial depression and
reduction in venous return, aggravating the haemodynamic
effects of tension pneumoperitoneum
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Local Anesthesia
Local Anesthesia With IV Sedation
Quick Recovery
Less PONV
Less Haemodynamic Changes
Early Diagnosis Of Complications
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Nerve blocks for lap surgery
Peripheral nerve blocks
Rectus sheath block
Inguinal block
Para vertebral block
Pouch of Douglas block
Pre requisites:
relaxed cooperative patient
low IAP
reduced tilt
precise gentle surgical technique
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COPD and LAP surgery
Risk for post operative pulmonary complications can be minimised by meticulous pre op.preparation.
Procedure time should be minimized to less than 2hrs
PFT,CXR,ABG, SpO2 in addition to history and physical examination
Cessation of smoking, adequate bronchodilators, steroids and chest physiotherapy with incentive spirometry help to reduce post op pul c/o
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COPD and LAP surgery
Standard monitoring
IAP less than 12mmHg
GA with controlled ventilation
Helium for pneumo peritonium
Monitor peak airway pressure to avoid barotraumas
Minimal tilt
Multimodal approach for P.O.analgesia to avoid respiratory depression
Laparoscopic surgery in obese
patients
Obesity is defined as a body mass index (BMI) >30kg/m2.
Obesity is associated with Diabetes Mellitus, hypertension and hypercholesterolemia, angina and sudden death.
Laparoscopy is not contraindicated in healthy obese patients who experience reduced pain, faster recovery and fewer postoperative problems compared to laparotomy
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Laparoscopic surgery in obese
patients Detrimental effect in respiratory
mechanics is due to supine position and increased weight
Carbon dioxide production and oxygen consumption are increased.
Reduced chest wall compliance & decreased lung compliance.
Functional residual capacity (FRC) will be reduced 25 per cent in the supine position, with a further reduction of 20 per cent with Anaesthesia.
Airway closure and hypoxemia, Increase in intrapulmonary shunting. Alterations to gastric function and drug
distribution.
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Laparoscopic surgery in obese
patients
Potential airway and intubation problems
Difficulties may be encountered during intravenous access, positioning, pneumoperitoneum induction, trocar access
In obese patients, the umbilicus is located 3-6cm caudal to the aortic bifurcation, making trocarplacement more difficult.
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Laparoscopic surgery in obese
patients Two tables may be necessary. Mechanical
lifting devices, with extra padding should be available.
Monitoring equipment such as a large blood pressure cuff, compression lower extremity stockings and pneumatic boots should be available.
Intravenous access may need to be central rather than peripheral in some cases.
Positioning should include padded stirrups with extra padding, compression devices
Towels behind shoulder blades to elevate the head, facilitating intubation and airway access .
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Laparoscopic surgery in obese
patients
complications may be reduced by filling the peritoneal cavity with carbon dioxide (CO2) to a predetermined pressure level rather than to a preset volume
Tilt Test:Placing the patient in steep Trendelenburg for two to five minutes following intubation and positioning, observing the patient’s cardiac and respiratory indices. Patients who remain Normotensive and maintain peak airway pressures at < 30-40mmHg during the Tilt Test before and after insufflation , the surgery is relatively straightforward, producing excellent results.
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Laparoscopic surgery in obese
patients
Postoperative Care: Early mobilisation and avoidance of the
supine position will facilitate early recovery. oxygen therapy Aggressive pulmonary care and
positioning. Abdominal pain may restrict ventilation and
ambulation. analgesia is paramount. Obese patients must have sequential
compression devices on their lower extremities
Prophylactic anticoagulation to prevent pulmonary emboli (five to 12 per cent obese patients)7.
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Laparoscopy in the Elderly
Age related physiological and pathological
changes and age related concomitant
diseases
Narrow margin of safety
decrease in organ reserve
Lead to high incidence of Peri operative
complications
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Laparoscopy in the Elderly
Positioning the patient:
1.Fragile osteoporotic & spondylytic
changes in vertebrae
2.Protect from nerve injury
3.Prevention of venous stasis
4.Careful tilting (increment of 5° )
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Anaesthesia For Laparoscopy In
The Elderly
During intra-op period:
- to maintain EtCO2 – 35mm.Hg.
- Isoflurane less arrhythmogenic
- IAP maintained below 15mm.Hg
- Atropine to counteract ref.vagal tone
- Monitor urine out put & Electrolytes
- Careful titration of all anaesthetic agents-
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Anaesthesia For Laparoscopy In
The Elderly
-During recovery—
-Exaggerated hypotension on
correcting lithotomy
- Expected delay in recovery
Inc.sensitivity to drugs.
Imp.metabolism
Delayed excretion
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Lap during pregnancy
Indications:
Appendicectomy
Cholecystectomy
Ovarian cystecomy
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Lap during pregnancy
Increased risk of acid aspiration
Increased risk of abortion/ miscarriage / premature
labor
Greater distribution volume due to increase in
blood volume
More prone to hypoxemia due to decrease in FRC
and increase in O2 consumption
Lap during pregnancy
Difficult airway due to wt. gain, soft tissue in the neck, breast enlargement, and laryngeal edema
Relatively safe in 8-24 wks of pregnancy.
Chances for damage to gravid uterus by Verees needle
Fetal acidosis common
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SAGES recommendations for safe
lap in pregnancy
Operation in 2nd trimester before 24 wks Tocolytics therapy if risk of preterm labor Open laparoscopy for abdominal access
(HASSON’S) to avoid damage to gravid uterus IAP less than 12mmHg Continuous Fetal heart monitoring with trans
vaginal USG PaCO2 to be maintained at normal levels with the
help of EtCO2 monitor/ABG Mechanical ventilation to maintain physiologic
maternal alkalosis (pH7.44) Pneumatic compression devices to calf muscles to
prevent DVT
Lap surgery in children
Small abdominal surface and organs demand small telescopes for laparoscopy.
The abdominal surface / cavity ratio in infants and children is less than that of adults.
The abdominal wall in children is pliable and attention is needed while placing the cannulas and trocars to prevent intraabdominal injuries.
The trans umbilical open laparoscopic technique for insufflation under direct vision is recommended to prevent complications with veress-needle
Gasless laparoscopic surgery can now be performed in these children and smaller infants .
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Lap surgery in children
In neonates, the foramen ovale or the ductus arteriosus is potentially patent and may reopen during the procedure.
The pulmonary arterial resistance is relatively high, predisposing to reverse flow through a patent ductus arteriosus or foramen ovale.
There is a risk of reopening of right-to-left shunts, cardiac insufficiency and gas embolism into the systemic circulation which may result in cardiac ischemia and neurological damage.
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Lap surgery in children
In infants less than 5 kg weight, periumbilical area should not be used for port access because of risk of puncture of umbilical vessels.
Cold, non-humidified CO2 directly in to the abdominal cavity also contributes to a major risk of hypothermia
A fluid bolus of 20 ml.kg-1 can be used to offset hemodynamic effects
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Lap surgery in children
CO2 absorption is more intense and faster in infants
Volume of gas for creation of pneumo peritoneumis less
IAP should be limited to 5 – 10 mm Hg in neonates and infants and 10 – 12 mm Hg in older children.
Risk of injuries to vitals is higher, so care is must.
Prone for hypothermia & PONV
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Key points
CO2 peritoneum results in ventilatory /respiratory changes
PaCO2 rise will aggravate cardio respiratory disturbances
Increase in EtCO2 >25% later than 30mts after beginning, suspect CO2
sub.cut.emphysema
Haemodynamic changes decrease CO and this is more in haemo
dynamically compromised patients
Preload augmentation, use of vaso dilators, clonidine and
Dexmedetomedine, high dose opioids, & beta blockers – will attenuate
pathophysiologic hemodynamic changes
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Key points
In pregnancy, lap surgery can be safely performed before23 wks (avoid hypercarbia) & open laparoscopic approach to avoid injury to gravid uterus.
Gasless laparoscopy may be helpful but technical difficulty is more
Laparoscopy has proven benefits allowing quick recovery, shorter hospital stay, less p.o.pain
General anesthesia with controlled ventilation has proved to be clinically superior anesthetic technique
Improved knowledge of pathophysiology and good perimoperative monitoring permit safe management in patient with severe cardio respiratory disease
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Conclusion
Laparoscopy surgery presents new
challenges to the anaesthesiologist.
A thorough knowledge of the patho
physiological changes during laparoscopy
along with vigilant monitoring is the backbone
for an uneventful and complete success.
References
Miller anaesthesia
Anaesthesia by Wiley
Anesthesia for laparoscopic surgery
review article by Jayasree Sood &V.P
Kumar
RACE-2009
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