Post on 16-Feb-2017
Anesthesia For Laparoscopic Surgeries
ANESTHESIA FOR LAparoscopic
surgeryPRESENTER- DR SHABBIR
Todays SeminarHistoryWhat is laparoscopy and its applicationsAdv. and disadv.ContraindicationsPhysiological changes Choice of anaesthesiaAnaesthetic management for laparoscopyComplications Laparoscopy for special groups (children, preg, cardiac ds)
HISTORYGeorge Kelling used cystoscope to observe abd organs of dogs CYSTOSCOPYLaparoscopy introduced in 20 th Century 1975 : first laparoscopic salpingectomy 1970 -- 80 : used for gyne procedures1981: Semm, from Germany,1st lap appendectomy 1989: laparoscopic cholecystectomy
HISTORY1980: Patrick Steptoe (UK): started laparoscopic procedures.
1983: Semm (German gynecologist): performed the first laporoscopic appendectomy.
1985: Erich Muhe (Germany): 1st reported lapaorscopic cholecystectomy.
1987: Ger: lap repair of inguinal hernia.
HISTORY1987: Phillipe Mouret (France): 1st Laparoscopic Cholecystectomy using video technique
1988: Harry Reich: laparoscopic lymphadenectomy for t/t of ovarian cancer.
1989: Harry Reich: first laparoscopic hysterectomy using bipolar dissection.
1990: Bailey and Zucker (USA): laparoscopic anterior highly selective vagotomy with posterior truncal vagotomy.
DEFINATIONIt is a minimally access procedure allowing endoscopic access to peritoneal cavity after insufflation of gas to create space between the anterior abd. Wall & viscera for safe manipulation of instruments & organs.TYPESIntraperitonealExtraperitonealAbd wall retraction (gasless laproscopy)Hand assisted (Hassans tech.)
ADVANTAGES
1 Minimal pain & illeus2 Improved cosmesis3 Shorter hospital stay , faster recovery & rapid return to work4 Non muscle splinting incision & less blood loss5 Post op respiratory muscle function returns to normal more quickly6. Wound complications i.e. infection & dehiscence are less7 Lap surgery can be done as day care surgery
DISADVANTAGES
More expensiveMore operating timeDifficult in complicated casesPotential for major complications in inexperienced hand
LAPROSCOPIC PROCEDURESCholecystectomyVagotomyAppendectomyColectomyInguinal hernia repairAdrenalectomyNephrectomyProstatectomyPancreatectomyBariatric surgeryNissen fundoplicationPara-esophageal hernia repairSplenectomyLiver resectionCystectomy with ileal conduit
LAPAROSCOPIC SURGERY [GYNAC]Ectopic pregnancyOvarian cystectomyReversal of ovarian torsionSalpingo-oophorectomyHysterectomyMyomectomySacrocolpopexyLymphadenectomyLymphadenectomy, stagingAblation of endometriosis
LAPROSCOPY EQUIPMENTSCameraLight SourceInsufflatorTV MonitorTelescopesLight Guide Cable Apart from the insufflator the system will work better if all the components are from the same company as one piece talks to another
SURGICAL REQUIRMENTS
Pneumo-peritoneum created by gas insufflation in peritoneal cavity separate abd. wall from viscera
Surgical site accessed by trocars & cannulae inserted through puncture wound in ant. abdominal wall , An endovideo camera attached to primary cannula to displays surgical site
Gas insufflator-can deliver gas at flow rate of4-6l/min. Insufflation pressure and IAP is electronically controlled
IAP of around 15mm of hg is adequate for most proced.
Patient is positioned to produce gravitational displacement of abd viscera away from surgical site
PNEUMOPERITONEUM
Created by insufflations of gas in peritoneal cavity to provide sufficient space to ensure adequate visualization and manipulation
Ideal gas for pneumo-peritoneumLimited systemic absorptionLimited systemic effects if absorbedRapid excretionHigh solubility in bloodShould not support combustionColourless, inert, non-explosiveReadily available, non explosive, nontoxic
Helium Insoluble, gas embolismArgon
N2O: Supports combustion, diffuses into the bowel, PONV
N2
Air
CO2:Safe during electrocauteryCan be easily eliminated through the lungsRapidly absorbed into the bloodstream
CARBON DIOXIDE-Advantagesdoes not support combustionHigh solubility, eliminated by lungslow risk of gas embolism, readily available ,less expensive
-DisadvantagesHypercarbia and acidosisSympathetic stimulation
OTHER GASESNITROUS OXIDEAdvantage-biologically inert,highly soluble,insignificant change in acid base balance,less post operative painDisadvantages-supports combustion,hazardous for operative teamHELIUM-Advantages neither combustible nor support,decreased cardiopulmonary changes,minimal effect on acid base balance.Disadvantages-risk of gas embolism(less soluble),more diffusible, post op emphysema takes days to get absorbedARGON Advantage-non combustible,chemically inert,stable AB balance.Disadvantage-cardiac depressant
CONTRAINDICATIONS
Diaphragmatic herniaAcute or recent MISevere obstructive lung diseaseIncreased ICP Hypovolemia CCF Severe Valvular heart diseases
POSITIONINGLap cholecystectomy rTn & TnUrology Tn,supine & lateral OBG DorsolithotomyUpper GIT & biliary Head upThoracoscopy lateral decubitus Nephrectomy Adrenalectomy
Laparoscopy Anesthetic issues CO2 pneumo peritoneum Due to patient positioningCardiovascular effects Respiratory effects Gastro intestinal effects Unsuspected visceral injuries Difficulty in estimating blood loss Darkness in the OR
Respiratory & Ventilatory ChangesIncreased Intra-abdominal pressure
Upward displacement of diaphragm/Impaired diaphragmatic excursion
Reduced lung compliance, FRCIncreased airway pressure & barotraumaV/Q mismatch with hypoxemia & hypercarbiaCompression of basilar lung segments & atelectasis
CAUSES OF PaCO 2
PHYSIOLOGICAL EFFECTSCardiovascular effects depends on Patients preexisting cardiopulmonary status the anesthetic technique intra-abdominal pressure (IAP) carbon dioxide (CO2) absorption patient position duration of the surgical procedure
HEMODYNAMIC CHANGES IAP
Venous return & SVR
Cardiac Output & Cardiac Index
- There is biphasic response on CO - If IAP 15mmHg, 10%-30% reduction in CO increase in systemic vascular resistance, mean arterial pressure, and cardiac filling pressures more severe in patients with preexisting cardiac disease significant changes occur at pressures greater than 12 - 15 mmHg
RENALDecrease in renal blood flow when IAP >15 mmHgDecrease in GFRDecrease in urine outputDecrease in creatinine clearanceDecrease in sodium excretionPotential for volume overload in the face of excessive fluid administration.
LOWER LIMB
Femoral venous blood flow
Pooling of blood (Reverse Trendelenberg position)
DVT
Effect of Pneumoperitoneum On Pharmacokinetics
Prolonged T1/2 of drugs eliminated by liver (reduction of hepatic perfusion)
Reduced Clearance of drugs eliminated through kidneys (reduced creatinine clearance and urine flow)
Neurohumoral Responses
RAA system activation ( renin, angiotensin, and aldosterone)
Sympathetic system activation ( catecholamines)
1. CO2 s/c emphysemaCause a) accidental extraperit insufflation (malpositioned verris needle) b) deliberate extraperit insufflations- retroperit surg, TEPP, . fundoplication, pelvic lymphadenectomy Diagnosis ETCO2 -cannot be corrected by adjusting ventilation - even after plateau reached ABG, Palpation
Treatment 1. stop CO2 insufflation, interrupt lap temporarily 2. CMV continued till hypercapnia resolves 3. resume lap at low insufflation P thereafter
Pneumothorax / pneumomediastinumCause 1. pleuroperitoneal communications (R>L) 2. Diaph defects( aortic, esophageal, GE jn surg) 3. Rupture of preexisting bullae 4. Perf falciform ligamentDiagnosis airway P, sudden Sp O2 , sudden / ETco2, Abnormal motion of hemidiaph by laparoscopist
CO2 embolism (rare but potentially fatal)Risk factors - hysteroscopies, previous abd surg, needle/Trocar in vslConsequences- GAS LOCK in vena cava ,RA VR collapse - Ac RV HTN opens foramen ovale paradoxical gas embolismDiagnosis HR, BP, CVP, hypoxia, cyanosis,ET CO2 biphasic change, a ETco2 ECG- Rt heart strain, TEE, pulm art. aspiration of gas/ foamy bld from CVP line
Treatment1. Release source (stop co2 + release pneumoperit)2. position steep head low + durant position 3. stop N2O + 100%O24. Hyperventilation5. CVP/PA catheter to aspirate CO26. Cardiac massage may break embolus- rapid absorption7. Hyperbaric o2 - cerebral embolism
Endobronchial intubationDue to cephalad movement of diaph with head down tilt and IAP
Diagnosis - Sp O2 airway P
Treatment Repositioning of ETT
AspirationMendelson syndromeAt IAP>20 mmHg
Changes in LES due to IAP that maintain transsphincteric Pgradient + head down position protect against entry of gastriccontent in airways
Nerve injuriesPrevented byavoid overextension of armspadding at P points
ARRHYTHMIAS IN LAPAROSCOPIC SURGERYHypercapnia is the major causehypoxia , hemodynamic changesVagal reflexes [ stretching of peritoneum and fallopian tube clamping ]Depth of anesthesia HalothaneArrythmia may be first sign of gas embolism
LAPROSCOPY IN CHILDRENPhysiological changes = adultsPaco2 ETco2 increase but ETco2 overestimates Paco2Co2 abs more rapid and intense due to larger peritoneal SA / body wt.More chances of trauma to liver during trocar insertionMore chances of bradycardia , maintain IAP to as low as possible
LAPROSCOPY IN PREGNANCYIndications- appendicectomy cholecystectomyRisk preterm labour, miscarriage, fetal acidosisTiming II trimester (< 23 wk)Lap technique HASSANS techSpecial considerations 1.prophylactic- antithrombolytic measures + tocolytics2.operating time to be minimised3.IAP as low as possible4.Continous fetal monitoring (TVS)5.Lead shield to protect foetus if intraop cholangiography needed
Trendelenberg
Rev Trendelenberg15-20 head down VR,CBV,CO,MAPVC,FRC,Compliance Paw (atelectasis)Endobronchial intubation
20-30 head up VR,CBV,CO,MAPImproves diaph function
Predisposition to DVT
ANESTHESIA IN LAPPAEDone in usual manner with special attention tocardiac & pulmonary systemInvestigations Complete hemogramRBSNa, KBUN, CreatinineCoagulation profileCXR, ECGBG, CMSpecial investigations 1. ECHO2. PFT
PREMEDICATION1. NPO 2. Complete bowel preparation3. Antibiotics as per surgical team4. Awareness about post op shoulder tip pain5. Written informed consent for laparotomy6. Anxiolytics/antiemetics/H2 receptor antagonist/analgesic7. Antisialagogue (glyco-P) and vagolytic may be administered at induction of anaes.8. DVT prophylaxis (rTn, pelvic Sx, long duration, malignancy, obesity)9. clonidine/ dexmetetomidine to decrease stress response
MONITORINGHRNIBPContinous ECGPulse oximetryCapnographyTemperatureAirway pressureIAPIf required, ABG, precordial doppler,TEE may be instituted.
ANESTHESIA FOR LAP GAPreloading- 5-10 ml/kg to prevent hemodynamic changes during pneumoperitoneumInduction- propofol, thiopentone Na, TIVA (propofol+fentanyl)3. Msl relaxation Scoline (RSI) for antireflux surg. NDMR4. Maintainence O2 +? N2O + sevo/iso
4. Folleys catheter and NG tube insertion to avoid bladder/bowel injury (PONV, improve surgical view)Ventilatory settings- To maintain normocarbia (ETco2 34-38 mm Hg)- RR rather than TV as the lung compliance is low.6. Positioning gradually, tilt < 15-20, check ETT position, padding at pressure points.7. Gas insufflation slow (1-1.5 1-2.5 L/min) IAP