This document provides an overview of anesthesia for laparoscopic surgery. It begins with a brief history of laparoscopy and then discusses the advantages and disadvantages, common procedures, equipment used, physiological changes caused by pneumoperitoneum, and anesthesia considerations and management. Key points include the respiratory, cardiovascular and renal effects of increased intra-abdominal pressure from carbon dioxide insufflation. Close monitoring is needed to prevent complications like gas embolism, pneumothorax, and arrhythmias that can potentially occur during laparoscopic procedures.

1. ANESTHESIA FOR LAPAROSCOPIC
SURGERY
PRESENTER- DR
SHABBIR

2. Today’s Seminar
1. History
2. What is laparoscopy and its applications
3. Adv. and disadv.
4. Contraindications
5. Physiological changes
6. Choice of anaesthesia
7. Anaesthetic management for laparoscopy
8. Complications
9. Laparoscopy for special groups (children, preg,
cardiac ds)

3. HISTORY
 George Kelling used cystoscope to
observe abd organs of dogs—
CYSTOSCOPY
 Laparoscopy introduced in 20 th
Century
 1975 : first laparoscopic salpingectomy
 1970 -- 80 : used for gyne procedures
 1981: Semm, from Germany,1st lap
appendectomy
 1989: laparoscopic cholecystectomy

4. HISTORY
 1980: 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.

5. HISTORY
 1987: 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.

6. DEFINATION
• It 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.
TYPES
1 Intraperitoneal
2 Extraperitoneal
3 Abd wall retraction (gasless laproscopy)
4 Hand assisted (Hassans tech.)

7. ADVANTAGES
1 Minimal pain & illeus
2 Improved cosmesis
3 Shorter hospital stay , faster recovery & rapid
return to work
4 Non muscle splinting incision & less blood loss
5 Post op respiratory muscle function returns to
normal more quickly
6. Wound complications i.e. infection & dehiscence
are less
7 Lap surgery can be done as day care surgery

8. DISADVANTAGES
◦ More expensive
◦ More operating time
◦ Difficult in complicated cases
◦ Potential for major complications in
inexperienced hand

9. LAPROSCOPIC PROCEDURES
 Cholecystectomy
 Vagotomy
 Appendectomy
 Colectomy
 Inguinal hernia
repair
 Adrenalectomy
 Nephrectomy
 Prostatectomy
 Pancreatectomy
 Bariatric surgery
 Nissen
fundoplication
 Para-esophageal
hernia repair
 Splenectomy
 Liver resection
 Cystectomy with
ileal conduit

10. LAPAROSCOPIC SURGERY
[GYNAC]
 Ectopic
pregnancy
 Ovarian
cystectomy
 Reversal of
ovarian torsion
 Salpingo-
oophorectomy
 Hysterectomy
 Myomectomy
 Sacrocolpopexy
 Lymphadenectom
y
 Lymphadenectom
y, staging
 Ablation of
endometriosis

12. LAPROSCOPY EQUIPMENTS
Camera
Light Source
Insufflator
TV Monitor
Telescopes
Light 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

14. 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

15. PNEUMOPERITONEUM
Created by insufflations of gas in peritoneal cavity to
provide sufficient space to ensure adequate
visualization and manipulation
 Ideal gas for pneumo-peritoneum
◦ Limited systemic absorption
◦ Limited systemic effects if absorbed
◦ Rapid excretion
◦ High solubility in blood
◦ Should not support combustion
◦ Colourless, inert, non-explosive
◦ Readily available, non explosive, nontoxic

16.  Helium
Insoluble, gas embolism
 Argon
 N2O: Supports combustion, diffuses into the bowel, PONV
 N2
 Air
 CO2:
◦ Safe during electrocautery
◦ Can be easily eliminated through the lungs
◦ Rapidly absorbed into the bloodstream

17. CARBON DIOXIDE
 -Advantages
◦ does not support combustion
◦ High solubility, eliminated by lungs
◦ low risk of gas embolism, readily available
,less expensive
 -Disadvantages
◦ Hypercarbia and acidosis
◦ Sympathetic stimulation

18. OTHER GASES
 NITROUS OXIDE
◦ Advantage-biologically inert,highly soluble,insignificant
change in acid base balance,less post operative pain
◦ Disadvantages-supports combustion,hazardous for
operative team
 HELIUM
◦ -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 absorbed
 ARGON
◦ Advantage-non combustible,chemically inert,stable AB
balance.
◦ Disadvantage-cardiac depressant

20. CONTRAINDICATIONS
◦ Diaphragmatic hernia
◦ Acute or recent MI
◦ Severe obstructive lung disease
◦ Increased ICP
◦ Hypovolemia
◦ CCF
◦ Severe Valvular heart diseases

21. POSITIONING
1 Lap cholecystectomy rTn & Tn
2 Urology Tn,supine & lateral
3 OBG Dorsolithotomy
4 Upper GIT & biliary Head up
5 Thoracoscopy lateral decubitus
Nephrectomy
Adrenalectomy

22. Laparoscopy – Anesthetic issues
CO2 pneumo peritoneum
Due to patient positioning
Cardiovascular effects
Respiratory effects
Gastro intestinal effects
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR

23. Respiratory & Ventilatory
Changes
Increased Intra-abdominal pressure
Upward displacement of diaphragm/Impaired
diaphragmatic excursion
Reduced lung compliance, FRC
Increased airway pressure & barotrauma
V/Q mismatch with hypoxemia & hypercarbia
Compression of basilar lung segments &
atelectasis

24. CAUSES OF PaCO 2

27. PHYSIOLOGICAL EFFECTS
Cardiovascular effects depends on
 Patient’s preexisting cardiopulmonary
status
 the anesthetic technique
 intra-abdominal pressure (IAP)
 carbon dioxide (CO2) absorption
 patient position
 duration of the surgical procedure

28. HEMODYNAMIC CHANGES
↑IAP
↓Venous return & ↑SVR
↓ Cardiac Output & Cardiac Index

30. - There is biphasic response on CO
- If IAP <10mmHg, milking effect on veins
CO
- If IAP >15mmHg, 10%-30% reduction in
CO
◦ increase in systemic vascular resistance,
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

32. RENAL
 Decrease in renal blood flow when
IAP >15 mmHg
◦ Decrease in GFR
◦ Decrease in urine output
◦ Decrease in creatinine clearance
◦ Decrease in sodium excretion
◦ Potential for volume overload in the face
of excessive fluid administration.

33. LOWER LIMB
1) ↓ Femoral venous blood flow
2) Pooling of blood (Reverse
Trendelenberg position)
↑DVT

34. 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)

35. Neurohumoral Responses
 RAA system activation (↑ renin,
↑ angiotensin, and ↑ aldosterone)
 Sympathetic system activation
(↑ catecholamines)

37. 1. CO2 s/c emphysema
Cause 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

38. Treatment 1. stop CO2 insufflation, interrupt lap temporarily
2. CMV continued till hypercapnia resolves
3. resume lap at low insufflation P thereafter

39. Pneumothorax /
pneumomediastinum
Cause 1. pleuroperitoneal communications (R>L)
2. Diaph defects( aortic, esophageal, GE jn
surg)
3. Rupture of preexisting bullae
4. Perf falciform ligament
Diagnosis –
 airway P,
sudden ↓Sp O2 ,
sudden ↓/  ETco2,
Abnormal motion of hemidiaph
by laparoscopist

40. CO2 embolism (rare but
potentially fatal)
Risk factors - hysteroscopies, previous abd surg, needle/Trocar in vsl
Consequences- GAS LOCK in vena cava ,RA → ↓ VR →© collapse
- Ac RV HTN → opens foramen ovale → paradoxical
gas embolism
Diagnosis
 HR, ↓BP,  CVP, hypoxia, cyanosis,
ET CO2 biphasic change,  Δa ETco2
ECG- Rt heart strain, TEE,  pulm art.
aspiration of gas/ foamy bld from CVP line

41. Treatment
1. Release source (stop co2 + release pneumoperit)
2. position – steep head low + durant position
3. stop N2O + 100%O2
4. Hyperventilation
5. CVP/PA catheter to aspirate CO2
6. Cardiac massage may break embolus- rapid
absorption
7. Hyperbaric o2 - cerebral embolism

42. Endobronchial intubation
Due to cephalad movement of diaph with
head down tilt and  IAP
Diagnosis - Sp O2 ↓
 airway P
Treatment – Repositioning of ETT

43. Aspiration
 Mendelson syndrome
 At IAP>20 mmHg
Changes in LES due to  IAP
that maintain transsphincteric P
gradient + head down position
protect against entry of gastric
content in airways

44. Nerve injuries
Prevented by
 avoid overextension of arms
 padding at P points

45. ARRHYTHMIA’S IN
LAPAROSCOPIC SURGERY
 Hypercapnia is the major cause
 hypoxia , hemodynamic changes
 Vagal reflexes [ stretching of
peritoneum and fallopian tube
clamping ]
 Depth of anesthesia
 Halothane
 Arrythmia may be first sign of gas
embolism

46. LAPROSCOPY IN CHILDREN
1. Physiological changes = adults
2. Paco2 ETco2 increase but ETco2 overestimates
Paco2
3. Co2 abs more rapid and intense due to larger
peritoneal SA / body wt.
4. More chances of trauma to liver during trocar
insertion
5. More chances of bradycardia , maintain IAP to as
low as possible

47. LAPROSCOPY IN PREGNANCY
Indications- appendicectomy
cholecystectomy
Risk – preterm labour, miscarriage, fetal acidosis
Timing – II trimester (< 23 wk)
Lap technique – HASSANS tech
Special considerations
1.prophylactic- antithrombolytic measures + tocolytics
2.operating time to be minimised
3.IAP as low as possible
4.Continous fetal monitoring (TVS)
5.Lead shield to protect foetus if intraop cholangiography needed

50. Trendelenberg
Rev Trendelenberg
 15-20˚ head down
  VR,CBV,CO,MAP
↓VC,FRC,Compliance
Paw (atelectasis)
 Endobronchial intubation
 20-30˚ head up
 ↓ VR,CBV,CO,MAP
 Improves diaph function
 Predisposition to DVT

51. ANESTHESIA IN LAP
PAE
Done in usual manner with special attention to
cardiac & pulmonary system
Investigations
1. Complete hemogram
2. RBS
3. Na, K
4. BUN, Creatinine
5. Coagulation profile
6. CXR, ECG
7. BG, CM
Special investigations
1. ECHO
2. PFT

52. PREMEDICATION
1. NPO
2. Complete bowel preparation
3. Antibiotics as per surgical team
4. Awareness about post op shoulder tip pain
5. Written informed consent for laparotomy
6. Anxiolytics/antiemetics/H2 receptor
antagonist/analgesic
7. 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

53. MONITORING
1. HR
2. NIBP
3. Continous ECG
4. Pulse oximetry
5. Capnography
6. Temperature
7. Airway pressure
8. IAP
If required, ABG, precordial doppler,TEE may be
instituted.

54. ANESTHESIA FOR LAP GA
1. Preloading- 5-10 ml/kg to prevent hemodynamic
changes during pneumoperitoneum
2. Induction- propofol, thiopentone Na, TIVA
(propofol+fentanyl)
3. Msl relaxation – Scoline (RSI) for
antireflux surg.
NDMR
4. Maintainence – O2 +? N2O + sevo/iso

55. 4. Folleys catheter and NG tube insertion to avoid
bladder/bowel injury (↓PONV, improve surgical
view)
5. 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<15 mm Hg (10-12)
check ETT position

56. 8. Prevent hypothermia
9. Analgesic / antiemetic
10. Postop recovery- monitor vitals
O2 supplementation

57.  1. provides good msl
relaxation & ventilation
to compensate for resp
acidosis & hypercarbia
 2. adq. field of exp.
decreasing risk of
perforation by instruments
 3. Protection against
aspiration
 4. Trendelenburg position
may cause resp
compromise & dyspnoea in
awake spon breathing pts
with abd contents under
pressure esp obese pts
GA RA
CONTROLL
ED
VENTILATIO
N
SPONTANEO
US
VENTILATION
ADVANTA
GES
DISADVAN
TAGES
For lower
abd
short duration
Surg
1. Pt is awake
→easier c/c
detection
2. Excellent postop.
analgesia
3. Less PONV
4. No IPPV induced
cardiovasc.
changes
1.Extensive and dense
block (T4-L5)needed to
abolish discomfort d/t
handling →may cause
dyspnoea
2. Sedation and
pneumoperitoneum→hyp
ovent→hypercarbia and
desaturation
3. Symp block may
exagerate
pneumoperitoneum
induced vagal reflexes
4. Pain at shoulder tip
remains unrelieved intraop
as well.

58. WHEN TO DO ABG ??
 After 30 minutes of pneumoperitoneum???
◦ During laparoscopy an unsteady sate of CO2
level exists between body compartments.
◦ Rate of rise of PCO2 is greatest during the first
20 – 30 minutes.
◦ After 20 – 30 minutes, new equilibrium levels are
reached between the different compartments,
and the rate of PCO2 rise is slower.

59. Protocol For Postoperative Pain
Relief
 Preoperative administration of a non-
opioid analgesic (e.g. NSAID,
Paracetamol)
 Pre-incisional infiltration of trocar
insertion sites with local anesthetics (e.g.
40 ml bupivacaine 0.25%, lidocaine
0.5%)
 Rescue medication with small doses of
an opioid (e.g. morphine)
 Treat postoperative shivering with
clonidine or pethidine.

60. PONV
 Incidence as high as 42%.
 Inj Dexamethasone 4 mg iv at the time of
induction.
 Inj Ondansetron 4 mg iv at the end of
surgery.
 Third anti-emetic for rescue therapy.
 Adequate pain control.

61. Gasless Laparoscopy

62. GASLESS LAPROSCOPY
 Peritoneal lift is optained using fan
retractor
 Avoids hemodynamic and respiratory
percussions
 Renal and splanchnic perfusion is not
altered
 Port site metastases reduced

64. EXPET OPINION !!!!!!!!!!!