????? ???????? Chapter 32 Anesthesia for laparoscopic Surgery ????????? - PowerPoint PPT Presentation

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????? ???????? Chapter 32 Anesthesia for laparoscopic Surgery ?????????

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Title: ????? ???????? Chapter 32 Anesthesia for laparoscopic Surgery ?????????


1
????? ????????
Chapter 32 Anesthesia for
laparoscopic Surgery ?????????
2
  • The field of abdominal surgery has been radically
    changed with the introduction of laparoscopy.

3
  • Recent advance in robotic and video technology
    have made the use of laparoscopic procedures more
    widely applicable.
  • With the evolution of laparoscopy,a substantial
    number of abdominal procedures are being
    performed using this approach, including
    cholecystectomy, myomectomy, and so on.

4
  • Compared with the traditional open abdominal
    approach.the laparoscopic approach is
  • less postoperative pain.
  • shorter hospital stay.
  • fewer overall adverse event.
  • more rapid return to normal activity
  • significant cost savings.

5
  • However, it is important that the benefits of
    laparoscopic procedures be weighed against
    associated complications.
  • A thorough knowledge of potential perioperative
    complications is necessary to provide optimal
    patient care

6
Part I Physiological changes
during laparoscopic surgery
  • The first step in laparoscopy is establishment of
    pneumoperitoneum.
  • The ideal insufflating gas would be colorless,
    nonexplosive, Physiologically inert
  • and readily soluble
  • in plasma.

7
Part I Physiological changes
during laparoscopic surgery
  • CO2 is used extensively in clinic. The speed and
    pressure of the pneumoperitioneum effect the
    absorption of CO2.
  • Positioning changes will effect the physiological
    function.

8
I. Cardiovascular system
  • The pressure of pneumopertioneum effect
    three aspects .
  • systemic vascular resistance (SVR.
    Afterloail).
  • venous return (preload ).
  • cardiac function.

9
I. Cardiovascular system
  • During laparoscopic cholecystectomy
  • If intraabdominal pressure (IAP) gt10mmHg
  • CVP ?PAWP? SVR? CO and MAP?
  • If intraabdominal pressure (IAP) gt20mmHg
  • CVP ? SVR?? CI CO? MAP??or normal

10
I. Cardiovascular system
  • The cause
  • Intraabdominal positive pressure
    intrathoracic pressure cardiac blood flow
    CO
  • IPPV or PEEP intrathoracic pressure
    CO

11
I. Cardiovascular system
  • The arrhythmias during laparoscopy is
    approximately 14, Bradyarrhythemias including
    bradycardia, nodal rhythm are attributed to a
    vagal response due to rapid insufflations.

12
2.The patients were placed in different body
position (Table1)
  • During cholecystectomy , the patient is placed on
    head-up about 10-20.

13
2.The patients were placed in different body
position (Table1)
  • During gynecological surgery, the patient is
    placed on head-down position.

14
Table-1 Hemodynamic measurements before and
during pneumoperitoneum(PP)during
laparoscopic cholecystectomy in
healthy patients
Supine Head-down Head-up Supine with pp Head-down with pp Head-up With pp
Heart rate(beats/min) 617 53 4 66 9 66 16 53 3 70 8
MAP(mmHg) 69 7 76 6 64 9 91 11 87 8 84 13
CVP(mmHg) 6.2 2.9 10.2 3.5 0.8 3.5 10.9 2.7 15.9 4.6 3.1 2.6
MPAP(mmHg) 14.1 1.5 17.4 1.2 8.5 3.5 18.4 3.7 20.0 6.1 10.8 2.5
SVR(dynes/sec/cm5) 1310 302 1381 313 1419 342 1795 444 1577 344 2047 430
15
3. Carbon dioxide absorption
  • The absorption of CO2 is influenced
    significantly by
  • duration of interoperation insufflations
  • IAP and the solubility of CO2 .

16
3. Carbon dioxide absorption
  • Hypercarbia resulting from
  • CO2 insufflations has direct and
  • indirect homodynamic effects.

17
3. Carbon dioxide absorption
  • The direct effects include peripheral
    vasodilatation and depression of myocardial
    contractility.
  • The indirect effects include activation of the
    central nervous system and sympathizes system,
    which increase myocardial contractility and
    causes tachycardia and hypertension

18
II. Pulmonary function
  • Changes in pulmonary function with
  • pneumoperitoneum
  • positioning
  • anesthesia
  • Elevation of diaphragm may be associated
    with reduction in lung
  • volumes.

19
II. Pulmonary function
  • In patients undergoing laparoscopic
  • procedure with 15 degree head-down tilt, the
    total pulmonary compliance
  • decreased by 40.
  • with 20 degree head-up tilt, the total
    pulmonary compliance decreased by 20.

20
II. Pulmonary function
  • Increased IAP and upward
  • displacement of the diaphragm can cause
    alveolar collapse and
  • ventilation/perfusion mismatching,
  • resulting in hypoxemia and
  • hypercarbia.

21
III. The other physiological changes
  • Increased IAP can result in reduction in
    splanchenic and renal perfusion.
  • Hepatic blood flow is decreased .

22
III. The other physiological changes
  • Reduction in urine output.
  • the compression of renal vessel
  • increased plasma renin activity .
  • Increased IAP can result in
  • aspiration and regurgitation.

23
Part II Anesthesia for
laparoscopic surgery
24
?. Preoperative evaluation and preparation for
anesthesia.
  • 1. Evaluation
  • Elderly, obesity, hypertension, coronary
    artery disease.
  • Serious hypertension , cardiac dysfunction
    , COPD .
  • The open surgery (open cholecystectomy)
    duo to medical problem (serious hypercarbia).

25
?. Preoperative evaluation and
preparation for anesthesia.
  • 2. Preparation and premedication
  • Same as general surgery.
  • Meperidine and opioid is thought to cause
    sphincter of oddi spasm.
  • Atropine may help decease spasm.
  • H2 antagonist (ranitidine) may be given
    (the patient being at risk for gastric
    aspiration).
  • To open upper extremity vein.

26
?.The choice of anesthesia
  • 1.The principle of choice
  • The principle is rapidly, shorter, safety
    comfortable and return to a normal activity
    early.
  • General anesthesia is may be more
  • suitable than other anesthesia.

27
?.The choice of anesthesia
  • 2.Method of anenthesia
  • A. General anesthesia
  • Advantage
  • ? Proper depths of anesthesia.
  • ? Effective ventilation.
  • ? To control the relax of muscle.
  • ? Adjusting MVV.

28
?.The choice of anesthesia
  • Anesthetic Management
  • The endotracheal intubation is suggested.
  • An oral gastric tube should be inserted to
    ensure that gastric distension does not exist.

29
?.The choice of anesthesia
  • Anesthetic agents.
  • Propofol, Etomidate, Midazolam.
  • Fentanyl, Remifentanyl,
  • Succinyicholine Vecuronium Atracurium.
  • Isoflurane, desflurane.
  • The use of N2O is controversial.
  • It increases bowel distention, and
    produce
  • conflicting results on the rate of N2O on
  • postoperative nausea.

30
?.The choice of anesthesia
  • B.Epidural anesthesia?
  • A high level is required for complete
    muscle relaxation?
  • 70prevent diaphragmatic irritation caused
    by gas insufflation and surgical manipulations.

31
?.The choice of anesthesia
  • B.Epidural anesthesia?
  • Serious respiratorg depression is possible
  • a high regional block
  • the use of opioid
  • the diaphragm is rised during
    insufflation.
  • The occasional occurrence of referred shoulder
    pain

32
?.The choice of anesthesia
  • C. General Aesthesia and Epidural
  • anesthesia.
  • D. Regional anesthesia.

33
?.Perioprative monitoring
  • Cardiovascular function
  • Respiratory function
  • Urinary volume
  • Neuromuscular transmission

34
?.Special considerations in the anesthesia
  • Control of intra-abdominal pressure
  • laparoscopic cholecystetomy, IAP10-15mmHg
  • Prevention of aspiration of gastric contents.
  • Gynecologic laparoscopy,IAP20- 40mmHg
  • obesity,abdominal wall lift is used

35
?.Special considerations in the anesthesia
  • Position
  • Laparoscopic cholecystetomy ,supine is
    placed,reverse trendelenburg with right side
    elevates.
  • Gynecologic laparoscopy, head-down and
    feet-up.

36
?.Special considerations in the anesthesia
  • Enhance respiratory management during
    operation
  • The use of neuromuscular blockers and
    complete muscle relaxation are required

37
?.Special considerations in the anesthesia
  • If it is not possible to complete the
    laparoscopic procedure, for example a major
    abdominal vessel lacerated ,peritonitis and
    hemorrhage, a open surgery will be performed.

38
?.Special considerations in the anesthesia
  • Epidural anesthesia represent alternative for
    laparoscopic surgery. But a high level is
    required. A disadvantage is the occurrence of
    referred shoulder pain.

39
?.Special considerations in the anesthesia
  • After operation, the residual pheumoperitoneum
    should be discharged.
  • Prevention of the regurgitation of gastric
    contents

40
PART ?.COMPLICATION
  • 1.Cardiovescular system
  • hypertention
  • bradycardia
  • tachycardia

41
PART ?.COMPLICATION
  • 2. Hypoxemia, Hypercarbia and Acidosis
  • High LAP
  • Head-down position
  • morbid obesity
  • COPD (chronic obstructive
  • pulmonary disease)
  • mechanical ventilation

42
PART ?.COMPLICATION
  • 3.CO2 embolism
  • The most common cause of clinically apparent
    co2 embolism is inadvertent intravascular
    placement of the needle
  • An open vein has a lower pressure than the
    surrounding pressure

43
PART ?.COMPLICATION
  • 4.Regurgitation and aspiration
  • High LAP
  • Change of position
  • Epidural and spinal aneasthesia

44
PART ?.COMPLICATION
  • 5.Nausea and vomiting
  • They are common following laparoscopic
    procedures.
  • Pharmacologic prophylaxis is recommended,
    for example Renitidine, Droperidol,ondansetron.

45
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