Abdominal Laparoscopy

Procedures

General: diagnosis, cholecystectomy, hernia repair, appendectomy, bowel resection, splenectomy

Gynecologic: diagnosis, lysis of adhesions, ovarian cyst, hysterectomy

Urologic: nephrectomy

Thoracoscopic: lobectomy, pneumonectomy, wedge resection, etc.

Cardiac surgery

Orthopedics

Advantages

Better aesthetic results due to smaller incisions

Earlier postop mobility

Shorter hospital stays

Less postop pulmonary impairment

Improved pain control

Reduction in postop ileus

Faster return to normal activities

Decreased stress response, reduced hyperglycemia

Avoidance of manipulation and exposure of abdominal contents

Disadvantages

Technical difficult

High risk with CO₂ insufflation

Operative visualization dependent on CO₂ insufflation

Decreased PaO₂ due to atelectasis, decreased FRC, V/Q mismatch, pulmonary shunting

Pneumoperitoneum/CO₂ insufflation

Provides a view of the surgical area, room for instruments to move

There is a high risk for complications as the inferior vena cava, aorta, iliac arteries, and veins, as well as bladder, bowel, and uterus are close to the infraumbilical site

Gas embolism symptoms: hypotension, dysrhythmias, cyanosis, pulmonary edema, Millwheel murmur

• Release the pneumoperitoneum, place the patient on the left side, and aspirate air if possible

Risk of pneumothorax due to barotrauma (increased PIP due to decreased pulmonary compliance)

Left shoulder pain (CO₂): Alleviate with 3 big breaths after CO₂ is released before closing the abdominal wall

Anesthetic considerations

Increased intraabdominal pressure, which predisposes to passive gastric regurgitation, possible NG to decompress and minimize the risk of aspiration

Decreased hepatic blood flow

High risk of PONV - ZRA and Zofran and Decadron

Try to keep intra-abdominal pressure <15 mmHg

Increased risk of atelectasis, decreased FRC, increased PIP

Risk of hypercarbia from absorbed CO₂, monitor ETCO₂ and decreased PaO₂

Avoid Nitrous oxide as it can diffuse into CO₂-containing intraabdominal space and increase distension

Decreased venous return, decreased CO, and increased SVR

Increased MAP, increased HR

Bradycardia due to the distension of the Vagus nerve

Trendelenburg position increases intrathoracic pressures (cephalad displacement of abdominal contents), which activates baroreceptor reflex through CNIX in the carotid and CN X in the aortic arch, leading to increased PNS and decreased SNS activity

Trendelenburg with increased risk of R main stem intubation

Reverse Trendelenburg with increased FRC and decreased work of breathing

Neuromuscular blockade: Lower insufflation pressures, better visualization, prevent movement