3.

Laparoscopic techniques have rapidly increased in popularity because of the multiple

benefits associated with much smaller incisions than traditional open techniques. These
benefits include decreased postoperative pain, less postoperative pulmonary impairment,
a reduction in postoperative ileus, shorter hospital stays, earlier abulation and smaller
surgical scars. Thus, laparoscopic surgery can provide substantial medical and economic
advantages.
4.The hallmark of laparoscopy is the creation of penumoperitoneum with pressurized
!"
#.$s general,The resulting increase in intra%abdominal pressure displaces the diaphragm
cephalad, causing a decrease in lung compliance and an increase in peak inspiratory
pressure. The high solubility of !" increases systemic absorption by the vasculature of
the peritoneum. This, combined with smaller tidal volumes because of poor lung
compliance leads to increased arterial !" levels and decrease p&.
'.$ head down position (trendelenburg position) is commonly requested during insertion
of the *eress needle and cannula. This position causes a cephalad shift in abdominal
viscera and the diaphragm. +unctional ,esidual capacity, total lung volume, and
pulmonary compliance will be decreased. $lthough these changes are usually well
tolerated by healthy patients, -atient with obese and pree.isting lung disease increase the
likelihood for hypo.emia.
(click)
$ head%down position also tends to shift the trachea upward, so that an endotracheal tube
anchored at the mouth may migrate into the right main%stem bronchus. This
tracheobronchial shift may be e.acerbated during insufflation of the abdomen.
/.0oderate insufflation pressures usually leave heart rate, central venous pressure, and
cardiac output unchaged or slightly elevated. This appears to result from increased
effective cardiac filling because blood tends to be forced out of the abdomen and into the
chest.
lick
&igher insufflation pressures however, tend to collapse the ma1or abdominal veins
(particularly the inferior vena cava),which decreases venous return and leads to a drop in
preload and cardiac output in some patients.
lick.
2e.ter et al using transesophageal 2oppler found that cardiac output was depressed to a
ma.imum of "34 at an insufflation pressure of 5#mm&g but was maintained at an
insufflation pressure of /mm&g. 67 an animal model, 6shizaki et al report the threshold
6ntra abdominal pressure that had minimal effects on hemodynamic function was 8 9
5"mmhg and recommend this pressure limit to avoid cardiovascular compromise during
!" insufflation.
3.&ypercarbia, if allowed to develop, will stimulate the sympathetic nervous system and
thus increase blood pressure, heart rate, and the risk of dysrhythmias. $ttempting to
compensate by increasing the tidal volume or respiratory rate will increase the mean
intrathoracic pressure, further hindering venous return and increasing mean pulmonary
artery pressures. These effects can prove especially challenging in patients with
restrictive lung disease, impaired cardiac function, or intravascular volume depletion.
:.$nesthetic approaches to laparoscopic surgery include infiltration of local anesthetic
with an intravenous sedative, epidural or spinal anesthesia or general anesthesia.
;.perience with local anesthesia has been largely limited to brief gynecologic procedures
(laparoscopic tubal sterilization, intrafallopian transfers in young healthy and motivated
patients. $lthough postoperative recovery is rapid, patient discomfort and suboptimal
visualization of intra abdominal organs precludes the use of this local anesthesia
technique for laparoscopic cholecystectomy.
lick
;pidural or spinal anesthesia represent another alternative for laparoscopic suergery. $
high level is required for complete muscle rela.ation $72 T! -,;*;7T
26$-&,$<0$T6 6,,6T$T6!7 $=>;2 ?@ <$> 67>=++L$T6!7 $72
>=,<6$ 0$76-=L$T6!7>. 2isadvantage of this type of anesthesia is the need to
give a high spinal anesthesia and the occasional occurrence of referred shoulder pain
from diaphragmatic irritation.
5A. ;ndotracheal intubation is usually favored for many reasonsB the risk of regurgitation
from increased intra%abdominal pressure during insufflation, the necessity for controlled
ventilation to prevent hypercapnia, the need for muscle paralysis during surgery to allow
lower insufflation pressures.
lick
Therefore general anesthesia would be the preferred technique for laparoscopic patient.
55. 0onitoring end tidal !" normally provides an adequate guide for determining the
minute ventilation required to maintain normocarbia. This assumes a constant gradient
between arterial !" and end tidal !" which is generally valid in healthy patients
undergoing laparoscopy.
lick
+or e.ample, any significant reduction in lung perfusion increases alveolar dead space,
dilutes e.pired co" and therby lessens end tidal co" measurements. This may occur
during laparoscopy if cardiac output drops because of high inflation pressures, the reverse
trendelenburg position of gas embolism.
5".The gradient between ;T!" and -a !" (normally "%#mmhg) reflects alveolar dead
space (alveoli that are ventilated but not perfused). $ny significant reduction in lung
perfusion (e. air embolism, upright positions, decreased output or decreased blood
pressure) increases alveolar dead space, dilutes e.pired co" and lessens ;T!".
$. $ normal capnograph demonstrating the three phases of e.pirationB
-hase 5 dead space
-hase " mi.ture of dead space and alveolar gas
-hase 3 alveolar gas plateau.
?. apnograph of a patient with severe chronic obstructivbe pulmonary disease. 7o
plateau is reached before the ne.t inspiration. The gradient between end tidal co" and
arterial co" is increased.
. 2epression during phase 3 indicates spontaneous respiratory effort.
2. +ailure of the inspired co" to return to zero may represent an incompetent e.piratory
valve or e.hausted co" absrobent
;. the persistence of e.haled gas during part of the inspiratory cycle signals the presence
of an incompetent inspiratory valve.
53. >urgical complications include hemorrhage if a ma1or abdominal vessel is lacerated
or peritonitis if a viscus is perforated during trocar introduction.
5#. $rrhythmias during laparoscopic procedures may be multifocal and include
hypercapnia as a result of intraperitoneal co" insufflation and increased vagal tone
following peritoneal stretching, especially associated with light levels of anesthesia.
?radycardia, cardiac arrhytmias and asystole have all been reported.
5'. 6ncrease 6$- during penumoperitoneum has been reported to cause venous stasis that
can increase the potential for deep vein thrombosis and pulmonary embolism. The
incidence of fatal pulmonary embolism following laparoscopic cholecystectomy is lower
than after open surgery. 0easure to reduce venous stasis such as graduated elastic
compression stockings are indicated in the perioperative period.
lick
-ostoperatvie nausea aned vomiting is common and requires appropriate prhophyla.is
and treatment.