GASTROINTESTINAL TRACT

Anaesthesia for Laparoscopic Surgery

Michael W Platt

pneumomediastinum, subcutaneous emphysema, retroperitoneal carbon dioxide (CO2), venous stasis, bradycardia, increased vagal tone, cardiac arrest, fatal venous CO2 embolism, regurgitation and aspiration. Many of these complications are the result of peritoneal insufflation (pneumoperitoneum). Pneumoperitoneum, the insufflation of the peritoneal cavity, is required to enable a gas milieu for visualization through the laparoscope (the operating telescope). CO2 is used for laparoscopy because it is highly soluble in blood. Blood can carry large quantities of CO2 as bicarbonate, carboxyhaemoglobin, and in plasma proteins. Carbon dioxide is eliminated rapidly and the lethal dose as an embolus is five times that of air. Usually a CO2 gas embolism resolves rapidly, but if it is large, it can be fatal. Pneumoperitoneum is achieved by insufflating the peritoneal cavity with CO2 to a pressure of 1018 mm Hg. The intraperitoneal insufflation of CO2 to these pressures causes respiratory and haemodynamic changes. Respiratory changes that occur as a result of pneumoperitoneum consist of a reduction of chest compliance by 3050%. Airway pressures to maintain tidal volume rise to counter the reduction of chest compliance and the elevation of the diaphragm. Functional residual capacity of the lungs decreases and there is an increase in physiological dead space and shunt because of basal compression by the diaphragm and increased ventilation/perfusion mis-matching, which may result in a reduced arterial partial pressure of oxygen. Basal atelectasis may persist into the postoperative period. If minute volume is kept constant, end-tidal CO2 increases due to absorption of CO2 from the peritoneal cavity. The latter changes are usually countered by increasing the tidal volume and applying positive end-expiratory pressure (PEEP). Haemodynamic changes also occur as a result of the pneumoperitoneum. Compression of the inferior vena cava leads to a reduction in venous return, potentially followed by a fall in cardiac output. However, a reflex tachycardia and a massive increase in peripheral vascular resistance tends to maintain cardiac output at near-normal levels, by pulling blood centrally from the periphery, but with a concomitant increase in mean arterial blood pressure. This increase in myocardial work can result in myocardial ischaemia in those at risk and can lead to infarction, which may not occur until the postoperative period. Active vasodilatation and blockade are often required to counter these effects. Compression of the inferior vena cava causes reduced venous flow from the legs, resulting in venous stasis and an increased risk of venous thrombosis. Prophylactic anticoagulation and elastic stockings or pneumatic calf compressors should be used, especially in the elderly. Respiratory and haemodynamic changes are affected by the patient's position. For example, head-up tilt, used for upper abdominal operations (e.g. cholecystectomy, Nissens fundoplication) further inhibits venous return. Head-down tilt, used for colonic and pelvic surgery, promotes venous return, but aggravates respiratory changes, further reducing chest compliance and functional residual capacity and increasing basal compression. Other complications of pneumoperitoneum include surgical emphysema, which can affect most tissues, including the conjunctivae and the scrotal sack. Cardiac arrhythmias can be

Laparoscopic surgery is a revolution in modern surgical techniques and has reduced postoperative pain, respiratory complications and hospital stay considerably. However, it produces extra stresses on the heart and lungs, therefore patients should be screened carefully and the risks explained fully as part of obtaining consent for the procedure. Anaesthetists should consult their surgical colleagues about the relative risks in those with cardiac and respiratory disease and should be prepared to cope with complications as they arise.

History
The earliest recorded references to endoscopy are from Hippocrates in Greece (460375 BC), who made reference to a rectal speculum. It was only in the 1970s that the problems of transmitting light, insufflation technology and optical technology were surmounted sufficiently for gynaecologists to embrace laparoscopic surgery. Laparoscopic techniques were not supported whole-heartedly by general surgeons until after 1987, when Mouret performed the first laparoscopic cholecystectomy in France. Following this, the rapid development of solid state video camera technology has further broadened the field of laparoscopic surgery. The advantages of minimally invasive surgery are less ileus, the greatly reduced stress response to surgery and trauma, reduced acute phase reaction, reduced pain, reduced postoperative pulmonary dysfunction and reduced hospital stay. These also have economic advantages. More procedures are being developed for laparoscopic surgery, including extraperitoneal inguinal hernia repair and retroperitoneal nephrectomy and adrenalectomy. Routine general surgical laparoscopic procedures now include: oesophagectomy, Nissens fundoplication, gastric banding, oversewing of peptic ulcer, intestinal resections, including hemicolectomy and colectomy, rectopexy and hernia repair.

Pathophysiology and complications of laparoscopy

The complications of laparoscopy include: haemorrhage, hypotension, decreased cardiac output, acidosis, pneumothorax,

Michael W Platt is Consultant in the Department of Anaesthesia, St Mary's Hospital, London. He qualied in Western Australia. His research interests include anaesthesia and pain relief in the elderly, ethical issues at the end of life and aspects of neuropathic pain.

ANAESTHESIA AND INTENSIVE CARE MEDICINE

36

2003 The Medicine Publishing Company Ltd

platt.indd 36

23/01/03, 14:53:27

GASTROINTESTINAL TRACT

secondary to vagal stimulation (bradycardia) or to hypercarbia (tachyarrythmias). Pneumothorax (including tension pneumothorax) may occur, particularly with upper abdominal procedures such as Nissens fundoplication. Gastric reflux can occur because of increased intraperitoneal pressure, although retained gas in the stomach may obstruct the surgeons view for upper abdominal operations. Pressure on the renal veins and arteries may cause a temporary reduction in renal function, due to reduced renal blood flow. Major CO2 gas embolus seldom occurs and is usually the result of accidental direct injection of gas into a major vessel (e.g. the inferior vena cava). This may cause an obstruction to cardiac output when it reaches the heart. The treatment is to turn the patient onto the right side immediately and position them head down, causing the gas embolus to occupy the apex of the right ventricle, relieving the obstruction to ventricular outflow.

Anaesthetic technique
Preoperative assessment Patients should be assessed carefully preoperatively, focussing on their cardiac function and reserve, because of the amount of extra cardiac work required during pneumoperitoneum. Patients with significant cardiac disease and limited cardiac reserve should be assessed by a cardiologist. It may be that an open procedure or even cancelling the procedure would be best for the patient. Patients with added risks of venous thrombosis should be treated prophylactically with fractionated heparin, elastic stockings and calf compressors during surgery. Surgery for patients with previously untreated hypertension should be postponed until treatment has stabilized. Respiratory function should also be assessed. Pulmonary function tests should be performed in those with significant pulmonary disease. Liver and renal function need to be ascertained because these organs may also be affected by pneumoperitoneum. Intercurrent medications (especially antihypertensives) should be given as normal on the morning of operation. A light sedative, such as a short-acting benzodiazepine, may be given before surgery. Perioperative management A routine intravenous induction is appropriate. It is preferable to intubate and ventilate patients undergoing laparoscopic surgery. This ensures a secure airway while ventilating with higher airway pressures and reducing the inherently small risk of aspiration from gastric regurgitation. A large-bore intravenous cannula should be placed to allow ready access for the management of major complications. In upper abdominal procedures a 1216 FG oro- or nasogastric tube is passed to allow egress of gas from the stomach to facilitate the surgeons view. Maintenance may be by total intravenous or inhalational anaesthesia. Intermittent positive-pressure ventilation is preferable, to ensure adequate ventilation in the presence of the reduced compliance and elevated diaphragm caused by the pneumoperitoneum. Opioid supplementation aids analgesia and improves postoperative analgesia. This may be as intermittent morphine and diamorphine or as an infusion of a short-acting agent such as alfentanil or remifentanil. Monitoring should be the minimum standard of non-invasive

blood pressure, electrocardiograph, end-tidal CO2, anaesthetic gases and pulse oximetry. For patients who require laparoscopic surgery, but who have very borderline cardiac function, invasive blood pressure and central venous pressure may be necessary, to allow closer control of cardiac function, in particular myocardial work. A pulmonary artery flotation catheter may be considered if there is concern regarding left heart function. When peritoneal insufflation begins, there is often a reflex tachycardia and significant increase in blood pressure, even at deep levels of anaesthesia. To avoid hypertensive crises, with diastolic blood pressures above 120 mm Hg, it is advisable to have a vasodilator and blocker available. Carefully titrated doses of labetalol can be effective, with its combined and effects. Occasionally, vagally-mediated bradycardia, even to the point of sinus arrest, may be seen. In this case, insufflation should cease immediately, while an appropriate vagolytic (e.g. atropine) is given. Ventilation should be adjusted to increase tidal volume and PEEP applied to counter the reduced compliance, elevated diaphragm and increased CO2 load. At the end of the procedure, it is preferable for the surgeon to infiltrate the small port wounds with long-acting local anaesthetic to reduce postoperative pain. The raw areas of tissue that occur after cholecystectomy can contribute to pain, due to carbonic acid formation by CO2. Spraying the peritoneal cavity with bupivacaine may be effective in these cases.

Recovery
Pain in the immediate postoperative period can be severe, presumably due mainly to stretching of the tissues. Shoulder-tip pain is common, secondary to diaphragmatic irritation. Sitting the patient up and giving systemic analgesia should help this to settle. Occasionally, large doses of intravenous opioid are required for adequate relief. However, once the pain is controlled, recovery is rapid and the patient usually goes home in 23 days.

Postoperative complications
Surgical emphysema is occasionally alarming because it involves much of the trunk. It is advisable to deflate the scrotal sack before recovery. More generalized emphysema settles rapidly with time, but a pneumothorax should be excluded. The main problem with surgical emphysema is pain, which should be controlled systemically. Basal atelectasis with secondary pulmonary infection may also occur. It is more common in those with pre-existing pulmonary disease, and should be treated with antibiotics and physiotherapy. Aspiration may manifest as pleural effusions or rarely as Mendelsons syndrome. These may require the input of a respiratory physician, but are not usually a major problem in fasted patients. The most serious complications are usually haemodynamic. Postoperative myocardial infarction can occur as a result of the increase in myocardial work during the procedure. Deep venous thrombosis may occur due to venous stasis in the legs during surgery. This occasionally presents postoperatively with pulmonary embolus.
FURTHER READING Chui P T, Gin T, Oh T E. Anaesth Intens Care 1993; 21(2): 16371.

ANAESTHESIA AND INTENSIVE CARE MEDICINE

37

2003 The Medicine Publishing Company Ltd

platt.indd 37

23/01/03, 14:53:29