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Jean L.

Joris

68

Anesthesia for
Laparoscopic Surgery

Key Points
1. CO2 pneumoperitoneum results in ventilatory and
respiratory changes. Pneumoperitoneum decreases
thoracopulmonary compliance. PaCO2 increases (15% to
25%) due to CO2 absorption from the peritoneal cavity.
Capnography reliably reflects this increase, which
plateaus after 20 to 30 minutes.

6. Similar pathophysiologic changes occur during


pregnancy and in children. Laparoscopy can be safely
managed in pregnant women before the 23rd week of
pregnancy provided that hypercarbia is prevented. The
open laparoscopy approach should be considered to
avoid damaging the uterus.

2. In compromised patients, cardiorespiratory disturbances


aggravate the increase in PaCO2 and enlarge the gradient
between PaCO2 and PETCO2.

7. Gasless laparoscopy may be helpful to reduce


pathophysiologic changes induced by CO2
pneumoperitoneum but unfortunately increases
technical difficulty.

3. Any increase in PETCO2 larger than 25% or occurring later


than 30 minutes after the beginning of peritoneal CO2
insufflation should suggest CO2 subcutaneous
emphysema, the most frequent respiratory complication
during laparoscopy.
4. Peritoneal insufflation induces alterations of
hemodynamics, characterized by decreases of cardiac
output, elevations of arterial pressure, and increases of
systemic and pulmonary vascular resistances.
Hemodynamic changes are accentuated in high-risk
cardiac patients.
5. The pathophysiologic hemodynamic changes can be
attenuated or prevented by optimizing preload before
pneumoperitoneum and by vasodilating agents, 2adrenergic receptors agonists, high doses of opioids,
and -blocking agents.

Surgical procedures have been improved to reduce trauma to the


patient, morbidity, mortality, and hospital stay, with consequent
reductions in health care costs. The provision of better equipment
and facilities, along with increased knowledge and understanding
of anatomy and pathology, has allowed the development of endoscopy for diagnostic and operative procedures. Starting in the early
1970s, various pathologic gynecologic conditions were diagnosed
and treated using laparoscopy. This endoscopic approach was
extended to cholecystectomy in the late 1980s. Since the introduction of the first laparoscopic cholecystectomy procedures,1
laparoscopy has expanded impressively both in scope and volume.
It quickly became apparent that laparoscopy results in multiple

8. Laparoscopy results in multiple postoperative benefits,


allowing for quicker recovery and shorter hospital stay.
These advantages explain the increasing success of
laparoscopy, which is proposed for many surgical
procedures.
9. Although no anesthetic technique has proved to be
clinically superior to any other, general anesthesia with
controlled ventilation seems to be the safest technique
for operative laparoscopy.
10. Improved knowledge of the intraoperative repercussions
of laparoscopy permits safe management of patients
with more and more severe cardiorespiratory disease,
who may subsequently benefit from the multiple
postoperative advantages offered by this technique.

benefits compared with open procedures2,3 and was characterized


by better maintenance of homeostasis. Overenthusiasm ensued,
which explains the eort to use the laparoscopic approach for
gastrointestinal (e.g., colonic, gastric, splenic, hepatic surgery),
gynecologic (e.g., hysterectomy), urologic (e.g., nephrectomy,
prostatectomy), and vascular (e.g., aortic) procedures.
The pneumoperitoneum and the patient positions required
for laparoscopy induce pathophysiologic changes that complicate
anesthetic management. An understanding of the pathophysiologic consequences of increased intra-abdominal pressure (IAP)
is important for the anesthesiologist who must ideally prevent
or, when prevention is not possible, adequately respond to these
2185

Adult Subspecialty Management

changes and who must evaluate and prepare the patient preoperatively in light of these disturbances. The pathophysiologic changes
and the complications of laparoscopy are reviewed first. The postoperative period is considered next, with examination of the benefits of laparoscopy and certain specific postoperative problems
(e.g., pain, nausea). Practical consequences for the anesthetic
management of laparoscopy are presented. Many animal and
human studies of the consequences of laparoscopy have been
published since the early 1970s. Because much higher IAPs
(>20 mm Hg) were previously used and because of potential
species dierences, we have focused on the human literature
published after 1990 using low IAP (<15 mm Hg) and modern
anesthesia techniques.

Ventilatory and Respiratory


Changes During Laparoscopy
Intraperitoneal insuation of carbon dioxide (CO2), the currently routine technique to create pneumoperitoneum for laparoscopy, results in ventilatory and respiratory changes and can cause
four principal respiratory complications: CO2 subcutaneous
emphysema, pneumothorax, endobronchial intubation, and gas
embolism.4

Ventilatory Changes

)(mm Hg)

Pneumoperitoneum decreases thoracopulmonary compliance


by 30% to 50% in healthy5-7 and obese patients.8,9 Reduction
in functional residual capacity10 and development of atelectasis
due to elevation of the diaphragm11 and changes in the distribution of pulmonary ventilation and perfusion from increased
airway pressure can be expected.11 However, increasing IAP to
14 mm Hg with the patient in a 10- to 20-degree head-up or
head-down position does not significantly modify either physiologic dead space or shunt in patients without cardiovascular
problems.12,13

50

During uneventful CO2 pneumoperitoneum, the partial pressure


of arterial carbon dioxide (PaCO2) progressively increases to reach
a plateau 15 to 30 minutes after the beginning of CO2 insuation
in patients under controlled mechanical ventilation during gynecologic laparoscopy in the Trendelenburg position14 or during
laparoscopic cholecystectomy in the head-up position (Fig.
68-1).15,16 Any significant increase in PaCO2 after this period
requires a search for a cause independent of or related to CO2
insuation, such as CO2 subcutaneous emphysema. The increase
in PaCO2 depends on the IAP.17 During laparoscopy with local
anesthesia, PaCO2 remains unchanged but minute ventilation significantly increases.18
Capnography and pulse oximetry provide reliable monitoring of PaCO2 and arterial oxygen saturation in healthy patients and
in the absence of acute intraoperative disturbances (see Figure
68-1).15,16 Although mean gradients (a-ETCO2) between PaCO2
and the end-tidal carbon dioxide tension (PETCO2) do not change
significantly during peritoneal insuation of CO2, individual
patient data regularly show variations of this dierence during
pneumoperitoneum.19,20 PaCO2 and a-ETCO2 increase more in
ASA class II and III patients than in ASA class I patients (Fig. 682).21,22 These findings have been documented in patients with
chronic obstructive pulmonary disease (COPD)23 and in children
with cyanotic congenital heart disease.24 These data therefore
highlight the lack of correlation between PaCO2 and PETCO2 in sick
patients, particularly those with impaired CO2 excretion capacity,
and in otherwise healthy patients with acute cardiopulmonary
disturbances. Consequently, hypercapnia can develop, even in the
absence of abnormal PETCO2. Postoperative intra-abdominal CO2
retention results in increased respiratory rate and PETCO2 of
patients breathing spontaneously after laparoscopic cholecystectomy as compared with open cholecystectomy.25
During CO2 pneumoperitoneum, the increase of PaCO2
may be multifactorial: absorption of CO2 from the peritoneal
cavity, impairment of pulmonary ventilation and perfusion by
mechanical factors such as abdominal distention, patient posi-

7.50

48

7.48

46
44

7.46
7.44

42

) and PETCO2 (

Increase in the Partial Pressure of


Arterial Carbon Dioxide

40

38

7.42

*
*

36
34

7.40
7.38

32

7.36
7.34
7.32

30
28
0

10

20
15
25 30
Min after insufflation

35

40

45

7.30

pH (

2186

PaCO2 (

Figure 68-1 Ventilatory changes (pH, PaCO2, and PETCO2) during


CO2 pneumoperitoneum for laparoscopic cholecystectomy. For
13 American Society of Anesthesiologists (ASA) class I and II
patients, minute ventilation was kept constant at 100 mL/kg/min
with a respiratory rate of 12 breaths/min during the study. Intraabdominal pressure was 14 mm Hg. Data are given as the mean
SEM.*, P < .05 compared with time 0.

Anesthesia for Laparoscopic Surgery 2187

PETCO2(mm Hg)

37
35
ASA IIIII

33

During

31
ASA I

29
27
25

Before
25

30

35

40

45

50

PaCO2 (mm Hg)


Figure 68-2 Ventilatory changes as a function of patient physical status. The
PaCO2 and PETCO2 were measured before and during CO2 insufflation. Patients
were grouped according to ASA classification: group 1 (green circles), ASA I
(n = 20); group 2 (blue circles), ASA II-III (n = 10). (Data from Wittgen CM,
Andrus CH, Fitzgerald SD, et al: Analysis of the hemodynamic and ventilatory
effects of laparoscopic cholecystectomy. Arch Surg 126:997, 1991.)

tion, and volume-controlled mechanical ventilation. The observation of an increase in PaCO2 when CO2, but not nitrous oxide
(N2O) or helium, was used as the insuating gas suggests that the
main mechanism of the increased PaCO2 during CO2 pneumoperitoneum is absorption of CO2 rather than the mechanical ventilatory repercussions of increased IAP.26,27 Accordingly, direct
! CO2 ) using a metabolic
measurement of CO2 elimination ( V
monitor combined with investigation of gas exchange showed a
! CO2 without significant changes in phy20% to 30% increase of V
siologic dead space in healthy patients undergoing pelvic laparoscopy (IAP of 12 to 14 mm Hg) in the head-down position14,28
or laparoscopic cholecystectomy in the head-up position.14,29 The
! CO2 and PaCO2 are similar. The
time courses of the increase in V
absorption of a gas from the peritoneal cavity depends on its diffusibility, the absorption area, and the perfusion of the walls of
that cavity. Because CO2 diusibility is high, absorption of large
quantities of CO2 into the blood and the subsequent marked
increases in PaCO2 would be expected to occur. The limited rise
of PaCO2 actually observed can be explained by the capacity of
the body to store CO230 and by impaired local perfusion due to
increased IAP.17 During deflation, CO2 that accumulated in collapsed peritoneal capillary vessels reaches the systemic circula! CO2 .31
tion, leading to transient increases in PaCO2 and V
Respiratory changes during the laparoscopic procedure
may contribute to increasing CO2 tension. Mismatched ventilation and pulmonary perfusion can result from the position of the
patient and from the increased airway pressures associated with
abdominal distention.18,32 Lister and colleagues17 investigated the
! CO2 and intraperitoneal CO2 insuation
relationship between V
! CO2
pressure in pigs. For an IAP up to 10 mm Hg, increased V
accounts for the increased PaCO2. At higher IAPs, the continued
! CO2 results
rise of PaCO2 without a corresponding increase in V
from an increase in respiratory dead space, as reflected by a widening of the a-ETCO2 gradient.17 If controlled ventilation is not

Respiratory Complications
CO2 Subcutaneous Emphysema
CO2 subcutaneous emphysema can develop as a complication of
accidental extraperitoneal insuation33 but can also be considered as an unavoidable side eect of certain laparoscopic surgical
procedures that require intentional extraperitoneal insuation,
such as inguinal hernia repair, renal surgery, and pelvic lymphadenectomy (Fig. 68-3).14,34,35 During laparoscopic fundoplication for hiatal hernia repair, the opening of the peritoneum
overlying the diaphragmatic hiatus allows passage of CO2 under
pressure through the mediastinum to the cervicocephalic region.
! CO2 , PaCO2, and PETCO2 increase.14 Any
In these circumstances, V
increase in PETCO2 occurring after PETCO2 has plateaued should
! CO2 may be such that
suggest this complication. The increase in V
prevention of hypercapnia by adjustment of ventilation becomes
almost impossible. In this case, laparoscopy must be temporarily
interrupted to allow CO2 elimination and can be resumed after
correction of hypercapnia using a lower insuation pressure.
Indeed, CO2 pressure determines the extent of the emphysema
and the magnitude of CO2 absorption. CO2 subcutaneous emphysema readily resolves once insuation has ceased. CO2 subcutaneous emphysema, even cervical, does not counterindicate
tracheal extubation at the end of surgery.36 We recommend
keeping the patient mechanically ventilated until hypercapnia is
corrected, particularly in COPD patients, to avoid an excessive
increase in the work of breathing.
Pneumothorax, Pneumomediastinum,
Pneumopericardium
Movement of gas during the creation of a pneumoperitoneum
can produce pneumomediastinum,37 unilateral and bilateral
pneumothoraces,38 and pneumopericardium.39 Embryonic remnants constitute potential channels of communication between
the peritoneal cavity and the pleural and pericardial sacs, which
can open when intraperitoneal pressure increases. Defects in the
diaphragm or weak points in the aortic and esophageal hiatus
may allow gas passage into the thorax. Pneumothoraces may also
develop secondary to pleural tears during laparoscopic surgical
procedures at the level of the gastroesophageal junction (e.g.,
fundoplication for hiatal hernia). Although opening of peritoneopleural ducts is associated with mainly right-sided pneumothoraces (in the same way that ascites or peritoneal dialysis may
be associated with right-sided pleural eusions40), the pneumothorax associated with fundoplication is more frequently in the
left side of the chest.

Section V Adult Subspecialty Management

adjusted in response to the increased dead space, alveolar ventilation will decrease and PaCO2 will rise. In healthy patients, absorption of CO2 from the abdominal cavity represents the main (or
the only) mechanism responsible for increased PaCO2,13 but in
patients with cardiorespiratory problems, ventilatory changes
also significantly contribute to increasing PaCO2.21 PaO2 values
and intrapulmonary shunt do not significantly change during
laparoscopy.12,13
It is wise to maintain PaCO2 within a physiologic range by
adjusting the mechanical ventilation. Except in special circumstances, such as when CO2 subcutaneous emphysema occurs (see
later), correction of increased PaCO2 can be easily achieved by a
10% to 25% increase in alveolar ventilation.

39

68

2188

Adult Subspecialty Management


Capnography

Pulse oximetry

Airway pressure
Clinicial examination
a) Reduced air entry
b) Hyperresonance
c) Swelling and
crepitus
Presumptive
diagnosis

Increased PETCO2

Decreased PETCO2

No

Yes

Yes

Desaturation

No change

Desaturation

Desaturation

Desaturation

Increased Paw

Increased Paw

No change

Yes
Yes
Possibly

Yes
Yes
Possibly

Murmur
Hypotension
ECG changes

Pneumothorax

Massive CO2
embolism

Increased Paw No change

Yes
No
No

No
No
Yes

Endobronchial Subcutaneous Capnothorax


intubation
emphysema

Yes

Yes

Figure 68-3 Diagnosis of respiratory complications during laparoscopy. ECG, electrocardiographic; Paw, airway pressure; PETCO2, end-tidal carbon dioxide
tension. (Data from Wahba RW, Tessler MJ, Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 43:77,
1996.)

These complications are potentially serious and may lead


to respiratory and hemodynamic disturbances. Capnothorax
(CO2 causing a pneumothorax) reduces thoracopulmonary
! CO2 , PaCO2, and
compliance and increases airway pressures. V
41
PETCO2 also increase. In eect, the absorption surface of CO2
is increased and the absorption from the pleural cavity is
greater than from the peritoneal cavity. When a pneumothorax
occurs secondary to alveolar rupture, the PETCO2 decreases
because of decreased cardiac output. Hemodynamic changes and
oxygen desaturation should suggest the presence of a tension
pneumothorax. The laparoscopist may observe abnormal motion
of one hemidiaphragm when a tension pneumothorax has
occurred. It should be noted that cervical and upper thoracic
subcutaneous emphysema can develop without the presence of a
pneumothorax.
When a pneumothorax is caused by highly diusible gas
such as N2O or CO2 without associated pulmonary trauma, spontaneous resolution of the pneumothorax occurs within 30 to 60
minutes without thoracocentesis.42 When capnothorax develops
during laparoscopy, treatment with positive end-expiratory pressure (PEEP) is an alternative to chest tube placement.41 In contrast, if the pneumothorax is secondary to rupture of preexisting
bullae, PEEP must not be applied and thoracocentesis is
mandatory.
Endobronchial Intubation
Cephalad displacement of the diaphragm during pneumoperitoneum results in cephalad movement of the carina in children43
and adults,44 potentially leading to an endobronchial intubation.
Cases of endobronchial intubation associated with laparoscopy
are reported during procedures in the head-down position45 and
in the head-up position.44,46 This complication results in a decrease
in the oxygen saturation as measured by pulse oximetry (SpO2)
associated with an increase in plateau airway pressure (see Fig.
68-3).

Gas Embolism
Although rare, gas embolism is the most feared and dangerous
complication of laparoscopy. Intravascular injection of gas may
follow direct needle or trocar placement into a vessel, or it may
occur as a consequence of gas insuation into an abdominal
organ. This complication develops principally during the induction of pneumoperitoneum,47,48 particularly in patients with previous abdominal surgery.49 Gas embolism may also occur later
during surgery.50,51 CO2 is used most frequently for laparoscopy
because it is more soluble in blood than either air, oxygen, or
N2O.30 Rapid elimination also increases the margin of safety in
case of intravenous injection of CO2. All these characteristics
explain the rapid reversal of the clinical signs of CO2 embolism
with treatment. Consequently, the lethal dose of embolized CO2
is approximately five times greater than that of air.
The pathophysiology of gas embolism is also determined
by the size of the bubbles and the rate of intravenous entry of the
gas.52,53 During laparoscopy, the rapid insuation of gas under
high pressure probably causes a gas lock in the vena cava and
right atrium; obstruction to venous return with a fall in cardiac
output or even circulatory collapse can result. Acute right ventricular hypertension may open the foramen ovale, allowing paradoxical gas embolization.50,54 Paradoxical embolism, however,
may occur without patent foramen ovale.55 Volume preload
diminishes the risk of gas embolism56 and of paradoxical embo! mismatching develops with
! Q)
lism.57 Ventilation-perfusion ( V
increases in physiologic dead space and hypoxemia.
The diagnosis of gas embolism depends on the detection
of gas emboli in the right side of the heart or on recognition of
the physiologic changes from embolization. Early events, occurring with 0.5 mL/kg of air or less, include changes in Doppler
sounds and increased mean pulmonary artery pressure. The low
incidence of gas embolism during laparoscopy precludes the
routine use of invasive or expensive monitors to detect embolization of small quantities of gas. When the size of the embolus

Anesthesia for Laparoscopic Surgery 2189

Risk of Aspiration of Gastric Contents


Patients undergoing laparoscopy might be considered to be at
risk for acid aspiration syndrome (see also Chapter 50). However,
the increased IAP results in changes of the lower esophageal
sphincter that allow maintenance of the pressure gradient across
the gastroesophageal junction and that may therefore reduce the
risk of regurgitation.59,60 Furthermore, the head-down position
should help to prevent any regurgitated fluid from entering the
airway.

Hemodynamic Problems
During Laparoscopy
Hemodynamic changes observed during laparoscopy result from
the combined eects of pneumoperitoneum, patient position,
anesthesia, and hypercapnia from the absorbed CO2. In addition
to these pathophysiologic changes, reflex increases of vagal tone
and arrhythmias can also develop.

Hemodynamic Repercussions of
Pneumoperitoneum in Healthy Patients
Peritoneal insuation to IAPs higher than 10 mm Hg induces
significant alterations of hemodynamics.61,62 These disturbances
are characterized by decreases in cardiac output, increased arterial pressures, and elevation of systemic and pulmonary vascular
resistances. Heart rates remain unchanged or increased only
slightly. The decrease in cardiac output is proportional to the
increase in IAP.63 Cardiac output has also been reported to be
increased64 or unchanged during pneumoperitoneum.65,66 These
discrepancies might be caused by dierences in rates of CO2
insuation, IAP,67 steepness of patient tilt, time intervals between
insuation and collection of data, techniques used to assess
hemodynamics, and anesthetic techniques. However, most studies
have shown a fall of cardiac output (10% to 30%) during peritoneal insuation whether the patient was placed in the headdown68,69 or head-up position.70,71 These adverse hemodynamic
eects of pneumoperitoneum have been confirmed by studies
using pulmonary artery catheterization,69,71 thoracic electrical
bioimpedance,68,70 esophageal echo-Doppler,72 and transesophageal echocardiography.73-75 Normal intraoperative values of
venous oxygen saturation (SvO2 ) and lactate concentrations
suggest that changes in cardiac output occurring during pneumoperitoneum are well tolerated by healthy patients.71,76 Cardiac
outputs, which decrease shortly after the beginning of the peritoneal insuation, subsequently increase, probably as a result of
surgical stress.70,71 Hemodynamic perturbations occur mainly at
the beginning of peritoneal insuation.
The mechanism of the decrease of cardiac output is multifactorial (Fig. 68-4). A decrease in venous return is observed after
a transient increase in venous return at low IAPs (<10 mm Hg).77,78
Increased IAP results in caval compression,79 pooling of blood in
the legs,80 and an increase in venous resistance.77,78 The decline in
venous return, which parallels the decrease in cardiac output,63 is
confirmed by a reduction in left ventricular end-diastolic volume
measured using transesophageal echocardiography.74 Cardiac
filling pressures, however, rise during peritoneal insuation.69,71
The paradoxical increase of these pressures can be explained by
the increased intrathoracic pressure associated with pneumoperitoneum.70,81,82 Right atrial pressure and pulmonary artery occlusion pressure can no longer be considered reliable indices of
cardiac filling pressures during pneumoperitoneum. The fact
that atrial natriuretic peptide concentrations remain low despite
increased pulmonary capillary occlusion pressure during pneumoperitoneum further suggests that abdominal insuation
interferes with venous return.83 The reduction in venous return
and cardiac output can be attenuated by increasing circulating
volume before the pneumoperitoneum is produced (Fig.
68-5).77,84 Increased filling pressures can be achieved by fluid
loading or tilting the patient to a slight head-down position before
peritoneal insuation, by preventing the pooling of blood with
intermittent sequential pneumatic compression device,85 or by
wrapping the legs with elastic bandages.86
The ejection fraction of the left ventricle, assessed by
echocardiography, does not appear to decrease significantly when
IAP increases to 15 mm Hg.73,74 However, all studies describe an
increase in systemic vascular resistance during the existence of
the pneumoperitoneum. This increase in afterload is not a reflex
sympathetic response to the decreased cardiac output.73,82

Section V Adult Subspecialty Management

increases (2 mL/kg of air), tachycardia, cardiac arrhythmias,


hypotension, increased central venous pressure, alteration in
heart tones (i.e., millwheel murmur), cyanosis, and electrocardiographic changes of right-sided heart strain can develop; all these
changes are rarely consistently positive.58 Pulmonary edema can
also be an early sign of gas embolism.54 Although pulse oximetry
is helpful in recognizing hypoxemia, capnometry and capnography are more valuable in providing early diagnosis of gas embolism and determining the extent of the embolism. PETCO2
decreases in the case of embolism owing to the fall in cardiac
output and the enlargement of the physiologic dead space. Consequently, a-ETCO2 increases. The decrease in PETCO2 may be
preceded by an initial increase secondary to pulmonary excretion
of the CO2, which has been absorbed into the blood.53 Aspiration
of gas or foamy blood from a central venous line establishes the
diagnosis. Routine preoperative insertion of a central venous line,
however, does not appear justified for these procedures.
Treatment of CO2 embolism consists of immediate cessation of insuation and release of the pneumoperitoneum. The
patient is placed in steep head-down and left lateral decubitus
(Durant) position. The amount of gas that advances through the
right side of the heart to the pulmonary circulation is less if the
patient is in this position because the buoyant foam is displaced
laterally and caudally away from the right ventricular outflow
tract. Discontinuing N2O will allow ventilation with 100% O2 to
correct hypoxemia and reduce the size of the gas embolus and its
consequences.53 Hyperventilation increases CO2 excretion and is
made necessary by the increase in the physiologic dead space. If
these simple measures are not eective, a central venous or pulmonary artery catheter may be introduced for aspiration of the
gas. Cardiopulmonary resuscitation must be initiated if necessary.
External cardiac massage may be helpful in fragmenting CO2
emboli into small bubbles. The high solubility of CO2 in blood,
resulting in rapid absorption from the bloodstream, accounts for
the rapid reversal of the clinical signs of CO2 embolism with
treatment.48 CO2 embolism, however, may be fatal. Cardiopulmonary bypass has been used successfully to treat massive CO2
embolism.50 Hyperbaric oxygen treatment should be strongly
considered if cerebral gas embolism is suspected.54

68

2190

Adult Subspecialty Management

Intra-abdominal pressure

Caval
compression

Pooling of blood
in the legs

Venous
resistance

Intrathoracic
pressure

Stimulation of
peritoneal receptor?

Vasc. resistance
of intraabd. organs

Release of neurohumoral
factor(s) (vasopressin,
catechol )

Venous return

Systemic vascular
resistance

Inotropism??

Cardiac output

Arterial pressure

Figure 68-4 Schematic representation of the different mechanisms leading to decreased cardiac output during pneumoperitoneum for laparoscopy.

Systemic vascular resistance was reported to be increased in


studies where no decrease in cardiac output was found.73,76
Although the normal heart tolerates increases in afterload under
physiologic conditions, the increases in afterload produced by the
presence of a pneumoperitoneum can be deleterious to patients
with cardiac disease.87
The increase in systemic vascular resistance is aected
by patient position. The Trendelenburg position attenuates
this increase; the head-up position aggravates it.65,69,76,83 The
increase in systemic vascular resistance can be corrected by the
administration of vasodilating anesthetic agents, such as isoflurane,82 or direct vasodilating drugs, such as nitroglycerin88 or
nicardipine.89
Cardiac index

The increase in systemic vascular resistance is thought to


be mediated by mechanical and neurohumoral factors.90 The
return of hemodynamic parameters to baseline values is gradual,
taking several minutes, suggesting the involvement of neurohumoral factor(s).68,82,87 Catecholamines, the renin-angiotensin
system, and especially vasopressin are all released during the presence of the pneumoperitoneum and may contribute to increasing
the afterload.70,71,81,83,91,92 However, only the time course of vasopressin release parallels that of the increase in systemic vascular
resistance.70,71,92 Increases in plasma vasopressin concentrations
correlate with changes in intrathoracic pressure and transmural
right atrial pressure.81 Mechanical stimulation of peritoneal receptors also results in increased vasopressin release,93 systemic vas-

Control
Volume loaded

!""-5)

(L/min/m2)

3000

Systemic vascular resistance

2500
2000
1500
1000

500
Post
induct

5 min

15 min

Pneumoperitoneum

30 min

Post
induct

15 min
5 min
30 min
Pneumoperitoneum

Figure 68-5 Changes in the cardiac index and systemic vascular resistance during laparoscopy in two groups of patients. For group 1 (controls, n = 10, yellow
bars), pneumoperitoneum was induced with patients in a 10-degree head-up position. Group 2 (volume loaded, n = 10, blue bars) patients received 500 mL of
lactated Ringers solution before anesthesia induction and were insufflated in the supine position. Data are presented as the mean SEM.

Anesthesia for Laparoscopic Surgery 2191

Effect of Pneumoperitoneum on
Regional Hemodynamics
Increased IAP and the head-up position result in lower limb
venous stasis.80,85,99 Femoral vein blood flow decreases progressively with increasing IAP, and no adaptation to the reduced
femoral venous outflow occurs, even during prolonged procedures.100 These changes may predispose to the development of
thromboembolic complications. Although cases of thromboembolism have been reported in the literature, their actual incidence
does not seem to be increased by laparoscopy.101-103
The eect of CO2 pneumoperitoneum on renal function
has also been investigated.104-106 Urine output, renal plasma flow,
and glomerular filtration rate decrease to less than 50% of baseline values during laparoscopic cholecystectomy and are significantly lower than those during open cholecystectomy.104 Urine
output significantly increases after deflation.
Controversy exists regarding the eect of the CO2 pneumoperitoneum on splanchnic and hepatic blood flow. A significant reduction was reported in animals107 and humans.108-110
However, others have not observed any significant changes.111-114
Blobner and coworkers,112 comparing CO2 pneumoperitoneum
and air pneumoperitoneum in pigs, observed a reduction in
splanchnic blood flow during air pneumoperitoneum but not
during CO2 pneumoperitoneum. They suggest that the direct
splanchnic vasodilating eect of CO2 may counteract the mechanical eect of increased IAP.
Cerebral blood flow velocity increases during CO2 pneumoperitoneum in response to the increased PaCO2.115,116 When
normocarbia is maintained, pneumoperitoneum combined with
the head-down position does not induce harmful changes in
intracranial dynamics.117 Intracranial pressure nevertheless rises
during CO2 pneumoperitoneum, independently of changes in
PaCO2, in pigs with preoperative induced intracranial hypertension or normal intracranial pressure118,119 and in children with
ventriculoperitoneal shunts.120 Intraocular pressure is not aected
by pneumoperitoneum in women with no preexisting eye
disease.121 In an animal model of glaucoma, pneumoperitoneum
only slightly increases intraocular pressure.122

Hemodynamic Repercussions of
Pneumoperitoneum in High-Risk
Cardiac Patients
The demonstration of significant hemodynamic changes during
pneumoperitoneum raises the question of tolerance of these
changes in cardiac patients (see Chapters 35 and 60). In patients

with mild to severe cardiac disease, the pattern of change in mean


arterial pressure, cardiac output, and systemic vascular resistance
is qualitatively similar to that in healthy patients.87,88,123-126 Quantitatively, these changes appear to be more marked. In a initial
study including ASA class III or IV patients, SvO2 decreased in
50% of patients despite preoperative hemodynamic optimization
using a pulmonary artery catheter.124 Patients who experienced
the most severe hemodynamic changes with inadequate oxygen
delivery were patients with low preoperative cardiac outputs and
central venous pressures and high mean arterial pressures and
systemic vascular resistancesa profile suggesting depleted intravascular volume. The investigators suggest preoperative preload
augmentation to oset the hemodynamic eect of pneumoperitoneum. Intravenous nitroglycerin, nicardipine, or dobutamine
has been used to manage the hemodynamic changes induced by
increased IAP in selected patients with heart disease.88,126 Nitroglycerin was chosen to correct the reduction in cardiac output
associated with increased pulmonary capillary occlusion pressures and systemic vascular resistance. The administration of
nicardipine may be more appropriate than that of nitroglycerin.
Right atrial and pulmonary capillary occlusion pressures are not
reliable indices of cardiac filling pressure during pneumoperitoneum. Increased afterload is a major contributor to the altered
hemodynamics seen during pneumoperitoneum in cardiac
patients. Nicardipine acts selectively on arterial resistance vessels
and does not compromise venous return.127 This drug is beneficial
in case of congestive heart failure.128 Because normalization of
hemodynamic variables does not occur for at least 1 hour postoperatively in certain patients,87,125 congestive heart failure can
develop in the early postoperative period. Dhoste and associates129 did not observe impaired hemodynamics in elderly ASA
class III patients, but they used low IAP (10 mm Hg) and slow
insuation rates (1 L/min). The hemodynamic consequences of
pneumoperitoneum are minor in heart transplant recipients who
have good ventricular function.130,131 Laparoscopic adrenalectomy
in patients with pheochromocytoma can be successfully managed
using a continuous infusion of nicardipine.89,132 Several studies
suggest that hemodynamic changes during pneumoperitoneum
are well tolerated by morbidly obese patients.8,133,134

Cardiac Arrhythmias During Laparoscopy


Arrhythmias during laparoscopy have several causes. The
increased PaCO2 may not be the cause of the arrhythmias occurring during laparoscopy. Arrhythmias do not correlate with the
level of the PaCO2 and may develop early during insuation,
when high PaCO2 is not present.
Reflex increases of vagal tone may result from sudden
stretching of the peritoneum and during electrocoagulation of the
fallopian tubes.135 Bradycardia, cardiac arrhythmias, and asystole
can develop. Vagal stimulation is accentuated if the level of
anesthesia is too superficial or if the patient is taking -blocking
drugs. These events are easily and quickly reversible. Treatment
consists of interruption of insuation, atropine administration,
and deepening of anesthesia after recovery of the heart rate.
Cardiac irregularities occur most often early, during insufflation, when pathophysiologic hemodynamic changes are the
most intense. For this reason, arrhythmias may also reflect intolerance of these hemodynamic disturbances in patients with

Section V Adult Subspecialty Management

cular resistance, and arterial pressure.94 However, whether


increasing IAP to 14 mm Hg is sucient to stimulate these receptors is unknown. The increase in systemic vascular resistance also
explains why the arterial pressure increases but the cardiac output
falls.62,90 Use of 2-adrenergic agonists such as clonidine71,95 or
dexmedetomidine96,97 and of -blocking agents98 significantly
reduces hemodynamic changes and anesthetic requirements.
Use of high doses of remifentanil almost completely prevents the
hemodynamic changes.66

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known or latent cardiac disease. Gas embolism can also result in


cardiac arrhythmias.

Problems Related to
Patient Position
Patient positioning (see Chapter 36) depends on the site of
surgery; whereas head-down tilt is used for pelvic and lower
abdominal surgery, the head-up position is preferred for upper
abdominal surgery. The patient is often placed in the lithotomy
position. These positions may be responsible for, or contribute to,
the development of pathophysiologic changes or injury during
laparoscopy. The steepness of the tilt also aects the magnitude
of these changes.

Cardiovascular Effects
In normotensive subjects, the head-down position results in an
increase in central venous pressure and cardiac output. The
baroreceptor reflex response to increased hydrostatic pressure
consists of systemic vasodilation and bradycardia. Although these
dierent reflexes may be impaired during general anesthesia, the
hemodynamic changes induced by this position during laparoscopy remain insignificant.69,76 However, central blood volume and
pressure changes are greater in patients with coronary artery
disease, particularly with poor ventricular function, leading to
potentially deleterious increased myocardial oxygen demand.32
The Trendelenburg position may also aect the cerebral circulation, particularly in case of low intracranial compliance,136 and
result in elevation of the intraocular venous pressure (which can
worsen acute glaucoma).121 Although the intravascular pressure
increases in the upper torso, the head-down position decreases
transmural pressures in the pelvic viscera, reducing blood loss but
increasing the risk of gas embolism.32,56
With the head-up position, a decrease in cardiac output
and mean arterial pressure results from the reduction in venous
return.69,76,82 This decrease in cardiac output compounds the
hemodynamic changes induced by pneumoperitoneum. The
steeper the tilt, the greater the fall in cardiac output.
Venous stasis in the legs occurs during the head-up position and may be aggravated by the lithotomy position with knees
flexed.32 Because pneumoperitoneum further increases blood
pooling in the legs,80,99 any additional factor contributing to circulatory dysfunction should be avoided. The legs must be freely
supported and not tightly strapped, and pressure on the popliteal
space must be prevented.

Respiratory Changes
The head-down position facilitates the development of atelectasis.
Steep head-down tilt results in decreases in the functional residual capacity, the total lung volume, and the pulmonary compliance. These changes are more marked in obese, elderly, and
debilitated patients. In healthy patients no major changes are
seen.32 The head-up position is usually considered to be more
favorable to respiration.30,32

Nerve Injury
Nerve compression is a potential complication during the headdown position. Overextension of the arm must be avoided. Shoulder braces should be used with great caution and must not
impinge on the brachial plexus. Lower extremity neuropathies
(e.g., peroneal neuropathy, meralgia paresthetica, femoral neuropathy) have been reported after laparoscopy.137,138 The common
peroneal nerve is particularly vulnerable and must be protected
when the patient is placed in the lithotomy position. Prolonged
lithotomy position, such as required for some operative laparoscopies, can result in lower extremity compartment syndrome.

Postoperative Benefits and


Consequences of Laparoscopy
Implicit in the decision to use the laparoscopic approach is the
assumption that the intraoperative consequences of pneumoperitoneum described in the previous sections are counterbalanced
by multiple postoperative benefits. In contrast to laparotomy,
improved and more rapid recovery, reduced postoperative
fatigue,139,140 and a heightened feeling of well-being are commonly
reported and reflect better maintenance of homeostasis.3,139

Stress Response
In patients undergoing cholecystectomy, the laparoscopic
approach allows for a reduction of the acute phase reaction seen
after open cholecystectomy. Plasma concentrations of C-reactive
protein and interleukin-6, which reflect the extent of tissue
damage, are significantly lower after laparoscopy as compared
with laparotomy.3,139,141-143 The metabolic response (e.g., hyperglycemia, leukocytosis) is also reduced after laparoscopy. As a consequence, nitrogen balance and immune function might be better
preserved.144-147 Laparoscopy avoids prolonged exposure and
manipulation of the intestines and decreases the need for peritoneal incision and trauma. Consequently, postoperative ileus and
fasting, duration of intravenous infusion, and hospital stay are
significantly reduced after laparoscopy.2,3,141,147-149 The duration of
postoperative ileus is less shortened when compared with laparotomy than previously reported.150 The economic implications of
these factors are self-evident and beneficial.151-153
Surprisingly, whereas laparoscopy allows for a reduction of
surgical trauma, the endocrine response to laparoscopic and open
cholecystectomy does not dier significantly; plasma concentrations of cortisol and catecholamines,3,139,154,155 urinary concentrations of cortisol and catecholamine metabolites,141 and anesthetic
requirements3 are similar after both procedures. Combined general
and epidural anesthesia for laparoscopic cholecystectomy does
not result in a decreased stress response compared with general
anesthesia alone.154 Several hypotheses can be invoked to explain
these observations. Pain and discomfort from peritoneal stretching, hemodynamic disturbances, and ventilatory changes induced
by pneumoperitoneum may contribute to the stress response of
laparoscopy. Although parietal aerence, which is markedly
reduced by laparoscopy, appears to be an important stimulus for
postoperative hyperglycemia, visceral nociception, which is less

Anesthesia for Laparoscopic Surgery 2193

aected by laparoscopy, may contribute more to adrenocortical


stimulation.139 The intraoperative stress response, however, can be
reduced by preoperative administration of 2-agonists.71,96,97

Surgical trauma contributes to pain and pulmonary dysfunction.


Laparoscopy allows a significant reduction in postoperative pain
and analgesic consumption (see Chapter 87).3,141,154,156-160 Nevertheless, pain intensity may be significant.161-163 The nature of pain
varies depending on the surgical technique; after laparotomy,
patients complain more of parietal pain (e.g., abdominal wall),
whereas after laparoscopic cholecystectomy, patients report also
visceral pain (e.g., biliary colic [cholecystectomy], pelvic spasm
[tubal ligation]), and shoulder-tip pain resulting from diaphragmatic irritation.162,163 Pain after laparoscopy is multifactorial, and
dierent treatments have been proposed to provide pain relief.164,165
Local anesthetic infiltration (e.g., intraperitoneal, port-site infiltration) for postoperative pain relief after laparoscopic cholecystectomy produces contradictory results.166-170 Benefits of
intraperitoneal local anesthetic are greater after gynecologic
laparoscopy.166,171 Mesosalpinx block decreases postoperative pain
and analgesic consumption after laparoscopic sterilization.166
Residual CO2 pneumoperitoneum contributes to postoperative
pain. Careful evacuation of residual CO2 after desuation
was shown to be eective.164,172,173 Preoperative administration
of nonsteroidal anti-inflammatory drugs (NSAIDs) and of
cyclooxygenase-2 inhibitors decreases pain, as does opiate consumption after gynecologic laparoscopy174-177 and laparoscopic
cholecystectomy.178-182 However, others have failed to demonstrate
any significant eect of preoperative NSAID on pain after laparoscopic sterilization more severe than after diagnostic gynecologic
laparoscopy.183-186 Dexamethasone is also eective in reducing
postoperative pain.187 Multimodal analgesia is now recommended
to prevent and treat post-laparoscopy pain.188-190

Pulmonary Dysfunction
Upper abdominal surgery results in postoperative changes in
pulmonary function (see also Chapter 93). Respiratory dysfunction is less severe and recovery is quicker after laparoscopy.3,90,141,154,156,157,191-193 Nevertheless, diaphragmatic function
remains significantly impaired after laparoscopy.194-196 Thoracic
epidural analgesia does not improve lung function after laparoscopic cholecystectomy.154 Greater reductions in expiratory
volumes and slower recovery of pulmonary function after laparoscopy are reported in older patients,197 obese patients,159,198
smokers, and patients with COPD198 than in healthy patients.
Postoperative pulmonary function of these patients, however, is
improved after laparoscopy as compared with laparotomy.159,160,198
Postoperative pulmonary function is less impaired after gynecologic laparoscopy than after upper abdominal laparoscopic
surgery.199

Postoperative Nausea and Vomiting


Laparoscopy is frequently associated with minor postoperative
sequelae that can persist more than 48 hours and that can signifi-

Alternatives to CO2
Pneumoperitoneum
New approaches have been investigated to reduce pathophysiologic consequences of CO2 pneumoperitoneum.

Inert Gases
Insuation of inert gas (e.g., helium, argon) instead of CO2 avoids
the increase in PaCO2 from absorption.219,220 Consequently, hyperventilation is not required.27,221-223 Also, the ventilatory consequences of the increased IAP persist. The hemodynamic changes
produced by pneumoperitoneum using inert gas are similar to
those observed with CO2. However, the use of these gases accentuates the decrease in cardiac output, whereas the increase in
arterial pressure is attenuated.27,90,223,224 Unfortunately, the low
blood solubility of the inert gases raises the issue of safety in the
event of gas embolism.225,226

Gasless Laparoscopy
Another alternative is gasless laparoscopy. The peritoneal cavity
is expanded using abdominal wall lift obtained with a fan retractor. This technique avoids the hemodynamic and respiratory
repercussions of increased IAP and the consequences of the use
of CO2.227-231 Renal and splanchnic perfusion is not altered.108,232
Port-site metastases after laparoscopic surgery for cancer are
reduced after gasless laparoscopy.233,234 This technique, therefore,
is appealing for patients with severe cardiac or pulmonary disease.
However, gasless laparoscopy compromises surgical exposure and
increases technical diculty.229,233,234 Combining abdominal wall
lifting with low pressure CO2 pneumoperitoneum (5 mm Hg)
may improve surgical conditions.

Laparoscopy During Pregnancy


and in Children
The most common nonobstetric surgical procedures during pregnancy are adnexal surgery, appendectomy, and cholecystectomy,

Section V Adult Subspecialty Management

Postoperative Pain

cantly delay discharge of outpatients.200 In addition to postoperative pain of various types, one of the main complaints is
postoperative nausea and vomiting (PONV) (40% to 75% of
patients).201-203 Whereas perioperative opioids increase the incidence of PONV,204-206 propofol anesthesia can markedly reduce the
high incidence of these side eects.206,207 The eect of N2O on the
incidence of nausea is still controversial.206,208,209 Intraoperative
drainage of gastric contents also reduces PONV.210 Intraoperative
administration of droperidol and a 5-hydroxytryptamine type 3
antagonist appears to be helpful in the prevention and treatment
of these side eects.206,211-215 Transdermal scopolamine reduces
nausea and vomiting after outpatient laparoscopy.201 Perioperative
liberal intravenous fluid therapy can contribute to decreasing
these symptoms and to improve postoperative recovery.216-218

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and they are amenable to laparoscopic surgery (see Chapter 69).235


Laparoscopy during pregnancy raises several concerns. Abdominal surgery increases the risk of miscarriage or premature labor.
However, all the reports in the literature of laparoscopy carried
out between 4 and 32 weeks of estimated gestational age have
resulted in uncomplicated pregnancies.236-240 Another concern is
the risk of damaging the gravid uterus. This can be avoided by
alternative entry sites for the Veress needle and trocars. CO2
pneumoperitoneum induces significant fetal acidosis. Fetal heart
rate and arterial pressure increase, but these changes are
minimal.241 Provided maternal PaCO2 is maintained at normal
levels, fetal placental perfusion pressure and blood flow, pH, and
blood gas tensions are unaected by insuation or desuation.242
Capnography is adequate to guide ventilation during laparoscopy
in pregnant patients.243 Hemodynamic changes induced by pneumoperitoneum are similar in pregnant and nonpregnant women.244
The following recommendations are for safe laparoscopy in pregnant patients236:
1. The operation should occur during the second trimester,
ideally before the 23rd week of pregnancy, to minimize the
risk of preterm labor and to maintain adequate intraabdominal working room.
2. Tocolytics are beneficial to arrest preterm labor, but their
prophylactic use is debatable.
3. Open laparoscopy should be used for abdominal access to
avoid damaging the uterus.
4. Fetal monitoring may be performed using transvaginal
ultrasonography.
5. Mechanical ventilation must be adjusted to maintain a
physiologic maternal alkalosis.
Gasless laparoscopy is an alternative to avoid the potential
side eects of CO2 pneumoperitoneum and can sometimes be
managed using epidural anesthesia.245,246
Laparoscopy is frequently performed in infants and children (see Chapter 82). Knowledge of the pathophysiologic
changes induced by laparoscopy in children is necessary to adapt
their monitoring and anesthetic technique.247 CO2 pneumoperitoneum induces the same changes in respiratory mechanics to
those reported in adults.248-250 PaCO2 and PETCO2 increase during
pneumoperitoneum, but PETCO2 may sometimes overestimate
PaCO2.251 The profile of CO2 absorption and the magnitude of CO2
! CO2 are similar in infants
absorption compared with metabolic V
and children to those recorded in adults.252 The hemodynamic
changes observed in children are similar to those reported in
adults.253-257 Pneumoperitoneum results in oliguria or anuria in
children, reversible after desuation.258 Controversy concerning
the benefits (improved analgesia and postoperative recovery) of
laparoscopy for appendectomy, the most frequent indication for
laparoscopy in children, persists.259-261

Complications of Laparoscopy
With the development of more sophisticated endoscopic operations, it is important to consider the risks and benefits of laparoscopy. Although the benefits of the laparoscopic approach are
well documented, knowledge of the incidence of complications is
more imprecise and is frequently based on retrospective studies.

The experience of gynecologic laparoscopists extends over


a relatively long time and, as a result, large surveys are available.262,263 Mortality rates have varied from 1 per 10,000 to 1 per
100,000 cases. The number of serious complications requiring
laparotomy was 2 to 10 per 1000 cases. Intestinal injuries
accounted for 30% to 50% of these and remained undiagnosed
during laparoscopy in one half of the cases. Vascular complications also accounted for 30% to 50%. Burns were responsible for
15% to 20% of the reported complications. Although the death
rate decreased, the complication rate was slightly higher in the
most recent surveys, probably because of the increased complexity of the laparoscopies performed over the past few years.
Large surveys of complications after laparoscopic cholecystectomy are available.152,264-268 The overall mortality rate is 0.1 to
1 per 1000 cases.268 Conversion to laparotomy was necessary in
approximately 1% of patients. Bowel perforation occurred in
about 2 per 1000 cases, common bile duct injury in 2 to 6 per
1000 cases, and significant hemorrhage in 2 to 9 per 1000 cases.
Laparoscopic cholecystectomy was accompanied by a greater
frequency of minor operative complications, whereas open
cholecystectomy had a more frequent rate of minor general complications. A learning curve was demonstrated for laparoscopic
cholecystectomy; experience was associated with decreased operative times and rates of minor or moderate complications.
Some of these complications might be prevented by open
laparoscopy.269
Although large vessel injury (e.g., aorta, inferior vena
cava, iliac vessels) caused emergency situations, retroperitoneal
hematoma can develop insidiously and result in significant blood
loss without major intraperitoneal eusion, leading to delayed
diagnosis. During gynecologic laparoscopy, complications occur
more frequently during the creation of pneumoperitoneum and
the introduction of trocars, whereas during gastrointestinal
surgery they are more closely related to the surgical procedure
itself.152,270,271 Injuries provoked by the Veress needle are usually
less severe than those by trocars and may even remain undiagnosed. Unrecognized gastrointestinal tract injury and subhepatic
abscess formation can lead to potentially lethal septic complications.272 The rate of postoperative infections (e.g., surgical site,
respiratory) seems to be significantly lower after laparoscopy than
after laparotomy.273 Although all these events are surgery related,
the anesthesiologist must be aware of the complications and
timing of their occurrence. He or she must be ready to respond
promptly and adequately to these mishaps and to help the surgeon
diagnose a complication.

Anesthesia for Laparoscopy


Preoperative Evaluation of the Patient
and Premedication
Without regard to surgical contraindications, absolute contraindications to laparoscopy and pneumoperitoneum are rare, and
some still require characterization (see Chapter 34). Pneumoperitoneum is undesirable in patients with increased intracranial
pressure (e.g., tumor, hydrocephalus, head trauma) and hypovolemia. Laparoscopy can be performed safely in patients with ventricular peritoneal shunt and peritoneojugular shunt that are

Anesthesia for Laparoscopic Surgery 2195

Table 68-1 Management of Patients with Cardiac Disease for Laparoscopy


Preoperative Evaluation: Echocardiography
If left ventricular ejection fraction < 30%:
Intraoperative monitoring
Intra-arterial line
Pulmonary artery catheter?
Transesophageal echocardiography
Continuous ST-segment analysis?
Gasless laparoscopy?
Laparotomy?
Intraoperative Management
Slow insufflation
Low intra-abdominal pressure
Hemodynamic optimization before pneumoperitoneum (preload
augmentation)
Patient tilt after insufflation
Anesthesia: remifentanil, vasodilating anesthetic and drugs (nicardipine,
nitroglycerin), cardiotonic agents
Experienced surgeon
Postoperative Care
Slow recovery from anesthesia (benefit of clonidine)

the intraoperative stress response and improve hemodynamic


stability.71,95-97

Patient Positioning and Monitoring


Patients must be positioned (see Chapter 36) with great care to
prevent nerve injuries; padding should protect from nerve compression, and shoulder braces, if needed, should be placed overlying the coracoid process. Patient tilt should be reduced as much
as possible and should not exceed 15 to 20 degrees. Tilting must
be slow and progressive to avoid sudden hemodynamic and respiratory changes. The position of the endotracheal tube must
be checked after any change in patient position. Induction and
release of the pneumoperitoneum must be smooth and progressive. Mask ventilation before intubation can inflate the stomach
with gas, which must be aspirated before trocar placement to
avoid gastric perforation, particularly for supramesocolic laparoscopy. The bladder should be emptied before pelvic laparoscopy or
prolonged procedures.
During laparoscopy, arterial blood pressure, heart rate,
electrocardiography, capnometry, and pulse oximetry must be
continuously monitored. Although this level of monitoring is
valuable for detection of cardiac arrhythmias, gas embolism, CO2
subcutaneous emphysema, and pneumothorax, it provides only
indirect evidence of the hemodynamic changes induced by
the pneumoperitoneum. Although more invasive hemodynamic
monitoring may be necessary in patients with cardiac diseases,
increased intrathoracic pressure complicates the interpretation of
measured central venous and pulmonary artery pressures. Transesophageal echocardiography may be more helpful in patients
with severe cardiac disease (see Table 68-1). PETCO2 and SpO2
reliably reflect PaCO2 and arterial oxygen saturation (SaO2).
However, the a-ETCO2 may vary from patient to patient and
during the course of laparoscopy in the same patient. PETCO2
must be monitored carefully to avoid hypercapnia and to detect
gas embolism. Because a-ETCO2 may increase more in patients
with cardiac and pulmonary diseases, cannulation of a radial
artery may be helpful to allow direct measurement of PaCO2 from
an arterial blood sample.

Anesthetic Techniques
General, local, and regional anesthesia have all been used successfully and safely for laparoscopy.
General Anesthesia
General anesthesia with endotracheal intubation and controlled
ventilation is certainly the safest and most commonly used
technique and therefore is recommended for inpatients and for
long laparoscopic procedures. During pneumoperitoneum, controlled ventilation must be adjusted to maintain PETCO2 between
35 and 40 mm Hg. In our experience, this requires no more than
a 15% to 25% increase of minute ventilation, except when CO2
subcutaneous emphysema develops. Increase of respiratory rate
rather than of tidal volume may be preferable in patients
with COPD and in patients with a history of spontaneous pneumothorax or bullous emphysema to avoid increased alveolar
inflation and reduce the risk of pneumothorax. Infusion
of vasodilating drugs, such as nicardipine,89,132 2-adrenergic

Section V Adult Subspecialty Management

provided with unidirectional valve resistant to IAPs used during


pneumoperitoneum. In case of glaucoma, the eects on intraocular pressure do not seem to be clinically significant but deserve
further confirmation.122
In patients with heart disease, cardiac function should be
evaluated in light of the hemodynamic changes induced by pneumoperitoneum and patient position, particularly in case of compromised ventricular function (Table 68-1). Patients with severe
congestive heart failure and terminal valvular insuciency are
more prone to develop cardiac complications than patients with
ischemic cardiac disease during laparoscopy. Whether laparoscopy is more dangerous than laparotomy in these patients has not
yet been explored directly but deserves careful consideration. For
these patients, the postoperative benefits of laparoscopy must be
balanced against the intraoperative risks when the choice of
laparoscopy versus laparotomy is discussed. Gasless laparoscopy
may represent an alternative for these patients.
Because of the side eects of increased IAP on renal function, patients with renal failure deserve special care to optimize
hemodynamics during pneumoperitoneum, and the concomitant
use of nephrotoxic drugs should be avoided.
In patients with respiratory disease, laparoscopy appears
preferable to laparotomy because of reduced postoperative respiratory dysfunction. This positive eect counterbalances the risk
of pneumothorax during pneumoperitoneum and the risk of
! mismatching.
! Q
inadequate gas exchange from V
Because of venous stasis in the legs during laparoscopy,
prophylaxis of deep vein thrombosis should be the same as for
laparotomy.
Premedication should be adapted to the duration of
the laparoscopy and to the necessity for quick recovery in the
outpatient setting. Preoperative administration of NSAIDs may
be helpful in reducing postoperative pain and opiate requirements. Preoperative clonidine and dexmedetomidine decrease

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Adult Subspecialty Management

receptor agonists,71,95-97 and remifentanil66 reduces the hemodynamic repercussions of pneumoperitoneum and may facilitate
management of cardiac patients (see Table 68-1). The actual contribution of N2O to PONV is probably less than previously considered.206 Although N2O does not seem to be contraindicated for
laparoscopic cholecystectomy,208 omission of N2O improves surgical conditions for intestinal and colonic surgery.274 The choice
of anesthetic technique does not seem to play a major role in
patient outcome.275-277 Propofol, nevertheless, results in fewer
postoperative side eects.278-280 Propofol anesthesia for laparoscopic fertility procedures involving genetic material transfers,
however, is associated with lower clinical and ongoing pregnancy
rates compared with isoflurane.281 IAP should be monitored, kept
as low as possible to reduce hemodynamic and respiratory
changes, and not allowed to exceed 20 mm Hg. Increases in IAP
can be avoided by ensuring a deep plane of anesthesia. Whether
profound muscle relaxation is necessary for laparoscopy is not
clear.282 Liberal perioperative intravenous fluid therapy decreases
hemodynamic changes from pneumoperitoneum77,84 and PONV
and improves postoperative recovery.216-218 Because of the potential for reflex increases of vagal tone during laparoscopy, atropine
should be available if necessary.
The laryngeal mask airway results in fewer cases of sore
throat and may be proposed as an alternative to endotracheal
intubation283-287 (also see Chapter 50) even if this device does
not protect the airway from aspiration of gastric contents.288,289
It allows controlled ventilation and accurate monitoring of
PETCO2. However, decreased thoracopulmonary compliance
during pneumoperitoneum frequently results in airway pressures
exceeding 20 cm H2O. The ProSeal laryngeal mask airway may
be an alternative to guarantee an airway seal up to 30 cm
H2O.290,291
General anesthesia in patients breathing spontaneously
without intubation can be performed safely and avoids tracheal
irritation as well as administration of muscle relaxant. This anesthetic technique must be restricted to short procedures performed
using low IAP and small degrees of tilt.292 In these conditions, the
laryngeal mask airway might improve the safety of anesthesia283,286,293 and is therefore recommended.
Local and Regional Anesthesia
Local anesthesia oers several advantages: quicker recovery,
decreased PONV, early diagnosis of complications, and fewer
hemodynamic changes (see Chapters 30, 51, and 52).294,295
However, this anesthetic approach requires precise and gentle
surgical technique and may result in increased patient anxiety,
pain, and discomfort during the manipulation of pelvic and
abdominal organs. For these reasons, local anesthesia is routinely
supplemented with intravenous sedation. The combined eect of
pneumoperitoneum and sedation can lead to hypoventilation and
arterial oxygen desaturation.296 Complex laparoscopic procedure
must not be managed with local anesthesia.
Regional anesthesia, including epidural and spinal techniques, combined with the head-down position can be used for
gynecologic laparoscopy without major impairment of ventilation.18,297,298 Laparoscopic cholecystectomy has been successfully
performed using epidural anesthesia in COPD patients.299,300 The
metabolic response is reduced by regional anesthesia.301 Globally,
epidural and local anesthesia share the same benefits and disadvantages. Regional anesthesia reduces the need for sedatives and

narcotics, produces better muscle relaxation, and can be proposed


for laparoscopic procedures other than sterilization. Shoulder-tip
pain from diaphragmatic irritation and discomfort from abdominal distention are incompletely alleviated using epidural anesthesia alone.302 Extensive sensory block (T4-L5) is necessary for
surgical laparoscopy and may also lead to discomfort. The epidural administration of opiates or clonidine, or both, may help to
provide adequate analgesia.302 The hemodynamic eects of pneumoperitoneum under epidural anesthesia have not been studied.
Regional anesthesia can provide adequate relief of pain and discomfort in case of gasless laparoscopy, thus avoiding most of the
side eects of CO2 pneumoperitoneum.246,303

Recovery and Postoperative Monitoring


Hemodynamic monitoring should be continued in the PACU (see
Chapter 85). Hemodynamic changes induced by the pneumoperitoneum, and more particularly the increased systemic vascular resistance, outlast the release of the pneumoperitoneum. The
hyperdynamic state developing after laparoscopy could conceivably lead to a precarious hemodynamic situation in patients with
cardiac disease.87,125
Despite the reduction in postoperative pulmonary dysfunction, PaO2 still decreases after laparoscopic cholecystectomy.3,156,192 Increased oxygen demand is observed after
laparoscopy. Although laparoscopy tends to be considered a
minor surgical procedure, oxygen should be administered postoperatively, even to healthy patients.304
Finally, prevention and treatment of nausea, vomiting, and
pain are important, particularly after outpatient laparoscopic
procedures.

Summary
Laparoscopy results in multiple postoperative benefits including
less trauma, less pain, less pulmonary dysfunction, quicker recovery, and shorter hospital stay. These advantages are regularly
emphasized and explain the increasing success of laparoscopy,
which is now proposed for many surgical procedures. Intraoperative cardiorespiratory changes occur during pneumoperitoneum.
PaCO2 increases because of CO2 absorption from the peritoneal
cavity. In compromised patients, cardiorespiratory disturbances
aggravate this increase in PaCO2. Hemodynamic changes are
accentuated in high-risk cardiac patients. Improved knowledge of
the pathophysiologic hemodynamic changes in healthy patients
allows for successful anesthetic management of cardiac patients,
by optimizing preload before pneumoperitoneum and through
judicious use of vasodilating agents. Alternative insuating gases
(e.g., He, Ar, N2O) do not seem to reduce the hemodynamic
changes. Gasless laparoscopy may be more helpful but unfortunately increases technical diculty. The incidence of complications has now been reported in several large surveys and compares
favorably with that of open surgery. The death rate during operative laparoscopy is 0.1 to 1 per 1000 cases; the incidence of hemorrhagic complications and visceral injury is 2 to 5 per 1000 cases.
Whereas no anesthetic technique has proved to be clinically superior to any other, general anesthesia with controlled ventilation

Anesthesia for Laparoscopic Surgery 2197

seems to be the safest technique for operative laparoscopy.


Improved knowledge of the intraoperative repercussions of laparoscopy permits safe management of patients with more and more

severe cardiorespiratory disease, who may subsequently benefit


from the multiple postoperative advantages oered by this
approach.

18. Ciofolo MJ, Clergue F, Seebacher J, et al: Ventilatory


eects of laparoscopy under epidural anesthesia.
Anesth Analg 70:357, 1990.
19. Wahba RW, Mamazza J: Ventilatory requirements
during laparoscopic cholecystectomy. Can J Anaesth
40:206, 1993.
20. Bures E, Fusciardi J, Lanquetot H, et al: Ventilatory
eects of laparoscopic cholecystectomy. Acta
Anaesthesiol Scand 40:566, 1996.
21. Wittgen CM, Andrus CH, Fitzgerald SD, et al:
Analysis of the hemodynamic and ventilatory
eects of laparoscopic cholecystectomy. Arch Surg
126:997, 1991.
22. Wittgen CM, Naunheim KS, Andrus CH, et al:
Preoperative pulmonary function evaluation for
laparoscopic cholecystectomy. Arch Surg 12:880,
1993.
23. Fitzgerald SD, Andrus CH, Baudendistel LJ, et al:
Hypercarbia during carbon dioxide pneumoperitoneum. Am J Surg 163:186, 1992.
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