Mohammad Said Maani Takrouri MB. CHB. FFARCS(I)

* Based on a lecture delivered at the 5^th Pan Arab Congress on Anaesthesia, Intensive Care and Pain relief. Cairo. Egypt 9-12^th Dec. 1997.

Also appeared in abstract form in Newsletter of Saudi Anaesthetic Association vol. 8, (1): 5-7,1998

Address for correspondence:

Dr. M.S.M. Takrouri, MB. ChB. FFARCS (I)

Professor of Anesthesia

Department of Anesthesia, King Khalid University Hospital (KKUH)

Riyadh 11461 P.O. Box 2925

Tel 009661 4671595

Fax 0096614679463

E-mail: takrouri@ksu.edu.sa

Key words: Laparoscopy, General surgery, Anaesthesia, pain relief, monitoring.

Anaesthesia during the procedure is more technically demanding, this is due to many factors. On one hand the technique itself introduces some trespassing on the respiratory and cardiovascular systems of the patients, and on the other it was introduced as safe and simple surgery which may be performed on outpatient basis hence demanding extreme caution in regard the anaesthetic technique which may respond positively to this expectation ¹⁹.

The procedure employs highly technical equipment, needs special training and special knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all the surgeon must adhere rigidly to guidelines for appropriate techniques. Deviation will most assuredly result in complications and even death. ¹⁷.

Early experience with laparoscopy 1949-1977 has been reported in a study conducted through questionnaire. This included 263900 laparo-pelviscopies performed in Germany and information was gathered from 380 respondents. There were 949 (3.56%) complications. 690 (2.59%) laparotomy. 24 (0.09%) burn or injury. Mortality was one death/11000 pelviscopy. 13 death (0.09) in 140977 (53%) diagnostic procedures. 3 death (0.08%) in 37639 (14.2%) diagnostic-operative. 8 death (0.09%) in 87284 (32.8%) sterilisation's operations. Since 1974 no mortality has been registered ²⁰.

Risk of laparoscopy was addressed in a survey of 100000 gynaecological cases. It was found that there were 194 severe complications over 20 years. 53 cardio-respiratory complications of which 15 were fatal. 122 instrument’s injuries or burns of which 4 were fatal. 18 variable complications. No statistical conclusion is possible because the figures are an approximation ²¹.

Open cholecystectomy mortality rate was reported to be 1.8% just before laparoscopy era in urban hospital. 1.53% mean mortality between 1952-1990 is quoted in a review of published series ²².

European experience with laparoscopic cholecystectomy reported in a review of 1236 cases in 7 centres involving 20 surgeons. It showed that 1191 procedures were completed. 45 converted to open procedures (3.6%) either due to technical difficulties n=33, onset of complication n=11 or instrument failure n=1. No death was reported in these series. Postoperative complications were 20 of 1203 (1.6%). Of which 9 cases requiring laparotomy. The incidence of bile duct damage was 4 of 1203. Median hospital stay 3 days (range 1-27). Median time to return to full activity after discharge 11 days (range 7-42 days) ²³.

The advantages can be summarised as follow: Reduction of post-operative pain. Better cosmetic results. Quicker return to normal activities. Hospital stay is reduced resulting in overall reduction in medical cost ^24,25. Less post operative pneumonia and wound infection ²⁶. Other studies confirmed the reduced metabolic derangement after laparoscopic cholecystectomy ²⁷ , interleukin-6 level ²⁸ and better respiratory function. The plasma cortisol and catecholamine concentrations were not significantly different from open cholecystectomy ^28-30. But the post operative pulmonary function tests are better after laparoscopic cholecystectomy ³¹.

It is performed on older patients and patients with acute surgical conditions as compared to minor gynaecological laparoscopic procedures and it is likely to be associated with higher incidence of peri-operative complications. This should be in mind when interpreting the results of the studies on this group of young fit women The major problems in general surgery patients are related to cardiovascular effect of pneumoperitonium, systemic carbon dioxide absorption, extra-peritoneal gas insufflation, venous gas embolism and unintentional injuries to intra-abdominal structures ²⁵.

The respiratory system can be affected by the following mechanisms: Effects of pneumoperitonium i.e. insufflation of the peritoneum by CO₂. Effects of CO₂ absorption. Diaphragmatic movement impairment. The effect of Trendelenberg or anti-Trendelenberg position needed during the procedure. Studies of the respiratory system during the procedure indicated many changes in normal function.

Creation of Pneumoperitoneum

Pneumoperitoneum creation involves the intraperitoneal insufflation of CO₂ through a Veress needle while the patient is in Trendelenburg position. The potential physiological difficulties during creation of pneumoperitoneum are mainly cardiovascular and respiratory function derangement.

Respiratory Function. The available data suggest that the respiratory function changes occurring during laparoscopic cholecystectomy may differ from those reported during gynecologic laparoscopic procedures. In a study compared the ventilatory effects of laparoscopic cholecystectomy in 20 patients with normal cardiopulmonary status (ASA physical status I) to the ventilatory effects in 10 patients with documented cardiac and pulmonary disease (ASA status II and III). Although the patients without cardiopulmonary disease had increased end-tidal and PaCO₂ and decreased arterial pH values after CO₂ insufflation, these changes were not statistically significant. Similarly, no significant changes occurred in minute volume and peak inspiratory pressure after CO₂ insufflation. In contrast, significant decreases in arterial pH and increases in PaCO₂ were observed in patients with cardiopulmonary disease after CO₂ insufflation. These patients also had minute ventilation and peak inspiratory pressures which were significantly higher than the baseline values after CO₂ insufflation ³².

Early reports of laparoscopy during halothane anesthesia emphasised the dangers of hypercarbia when patients were allowed to breathe spontaneously. It was reported that the CO₂ output (VCO₂) increased from 135.4 1 2.5 ml.min^-1 before, to 150.9 1 6.9 ml.min^-1 after, the start of CO₂ insufflation. This increased VCO₂ was associated with end-tidal CO₂ concentrations which increased from 4.7% to 5.4%. It was also observed the presence of tachypnea, increased minute ventilation, and respiratory acidosis in a study of 10 patients spontaneously breathing nitrous oxide/oxygen and 0.5% -1.0% halothane. The hypo- ventilation induced by the steep Trendelenburg position and the pneumoperitoneum-induced splinting of the diaphragm during halothane anesthesia which is potentially hazardous due to hypercarbia, acidosiss and cardiac arrhythmia. ¹⁸. In a trial using spontaneous respiration via mask and via endotracheal tubes compared to intubated ventilated patient, laparoscopy using isoflurane as the inhalational anaesthetic, it was found there were no significant hypercarbia, acidosis or cardiac arrhythmia ^33,34.

A reduction in FRC relative to closing volume may be associated with the development of intraoperative atelectasis and intrapulmonary shunting. These changes may occur during general anesthesia because of a variety of factors: a) cephalad shift of the diaphragm associated with supine position; b) loss of inspiratory muscle tone; c) appearance of end-expiratory muscle tone in the abdominal expiratory muscles; d) changes in intrathoracic blood volume associated with induction of anesthesia; and e) influence of muscle relaxants on diaphragmatic excursion. The reduction in FRC associated with general anesthesia may be compounded by the CO₂-induced pneumoperitoneum during laparoscopic cholecystectomy. A reduced cardiac output secondary to reduction in venous return or drug-induced myocardial depression may reduce mixed-venous O₂ tension. Hypoxemia may be present when these changes are accompanied with reduction in the cardiac output ¹⁸.

Respiratory minute volume increased in spontaneously breathing patients by 30-40% to maintain normo-carbia. CO₂ output increased by 38% for 60 minutes after insufflation. D(a-A) CO₂ showed no changes ³⁹.

Elimination of CO₂ was examined in patient subjected to gynaecology laparoscopy, laparoscopic cholecystectomy and pelviscopy under controlled ventilation. It was found that oxygen consumption (VO₂) did not change but pulmonary elimination of CO₂ (VECO₂) and end tidal CO₂ (ETCO₂) continuee to rise from post insufflation till 8-10^th minutes then a plateau was reached in the group of intraperitoneal insufflation, then it will continue to rise slowly throughout CO₂ insufflation. It was concluded that CO₂ diffuse to the body more during extra-peritoneal than intra-peritoneal, and it is not influenced by the duration of intra-peritoneal insufflation ⁴⁰. It was shown to be affected by raising the intraperitoneal pressure above the venous vessels pressure which prevent CO₂ resorption ⁴¹. The rate of CO2 re-absorption is 70 ml.min-1 during the first 30 minutes of pneumoperitoneum and latter of order of 90ml.min-1 ⁴². The remaining CO₂ in the body influence spontaneous respiration for 3 hours post operatively since there will be increase in respiratory rate (RR) to get ride of CO₂ which may be prolonged in the presence of strong narcotics ⁴³.

Impaired diaphragmatic contractile function: This is manifested by the following: Maximal trans-diaphragmatic pressure is reduced by 50%. Maximal sniff manoeuvre pressure does not change. Tidal volume decreased by 30%. Inspiratory time/total cycle time reduced by 13% ^44,45.

Dynamic respiratory pattern study after laparoscopic and open cholecystectomy showed small magnitude changes after laparoscopy, namely: Frequency of resting breathing increased by 29%, abdominal motion decreased by 32%, rib cage tidal volume increased by 70% and abdominal tidal volume decreased by 29%⁴⁶.

In a study on 22 patients undergoing laparoscopic cholecystectomy, pulmonary function tests done before, 24 hours after and 1 week post-operatively showed the following results: FEV₁ reduced to 75%. VC reduced to 73%. FRC reduced to 92%. TLC reduced to 82%. Inspiratory mouth pressure reduced to 66%. Expiratory mouth pressure reduced to 63%. PaO₂ reduction. PaO₂ no changes. Alveolar-arterial gradient increased ⁴⁷.

Studies in healthy gynaecologic patients have consistently shown only minor hemodynamic changes during laparoscopic procedures with CO₂ insufflation when intra-abdominal pressures (IAP) did not exceed 25 cm H₂O (18 mm Hg). However, these short surgical procedures were performed in young, relatively healthy, female patients in the Trendelenburg position. Considering the widespread adoption of the laparoscopic cholecystectomy technique, there is a remarkable paucity of data concerning the hemodynamic changes induced by the CO₂ pneumoperitoneum, both in healthy patients and in those with cardiopulmonary disorders. The initial use of gynecologic laparoscopy was associated with generation of IAP of up to 40 mm Hg (55 cm H₂O). Modern laparoscopic cholecystectomy technology employs an electronic variable-flow insufflator, which automatically terminates flow when a preset IAP of 12 - 15 mm Hg is reached. Despite the relatively low IAP achieved, the volume of gas insufflated may exceed 50 L, because intra-abdominal gas may escape quickly through the multiple trocar/cannla puncture sites ^{18, 48-} 50.

The extent of the cardiovascular changes associated with creation of pneumo-peritoneum will depend on the intra-abdominal pressure attained, the volume of CO₂ absorbed, the patient's intra-vascular volume, the ventilatory technique, surgical conditions, and anesthetic agents employed. In a prospective, observational study of 16 otherwise healthy patients, no significant cardiac output changes, despite an increased mean arterial pressure and end-tidal CO₂ (ETCO₂) during creation of pneumoperitoneum. Similarly, other results reported no significant changes in cardiac output in a series of anesthetized, spontaneously ventilating patients in whom the IAP was 15-20 cm H₂O (11-15 mm Hg). The effects of stepwise increases in IAP up to a maximum of 25 cm H₂O in anesthetized, mechanically ventilated patients. At an IAP of 25 cm H₂O, increases in airway pressure, intrathoracic pressure (ITP), CVP, and femoral venous pressure (FVP) were accompanied by hypertension, tachycardia, and increased (ETCO₂) tension. Other researchers found that moderate increases of IAP (up to 25 cm H₂O) may be accompanied by an increased effective cardiac filling pressure (defined as CVP-ITP), and therefore (according to Starling's law), by an increased cardiac output. When IAP was increased further to 40 cm H₂O, tachycardia, hypotension, reduced CVP, and decreased cardiac output were observed. These changes were most marked in the horizontal compared with the head-down tilt position. It was speculated that increased IAP has two opposite effects on the cardiovascular system: it forces blood out of the abdominal organs and inferior vena cava and into the central venous reservoir, while at the same time it increases peripheral blood pooling and thus tends to decrease the central blood volume^{18, 48-} 50.

The relative roles of the factors which contribute to changes in cardiac output may be difficult to separate, but the increased cardiac output at lower IAP may result from increased cardiac filling pressures, due partly to mechanical factors, and partly to sympathetically mediated constriction of capacitance vessels and hypercarbia-induced effects on cardiac efferent sympathetic activity. It was also reported a reduction in inferior vena caval blood flow and cardiac output of more than 60% when the IAP exceeded 40 mm Hg ^{18, 48-} 50.

5.2.1 CARDIOVASCULAR CHANGES WITH TRENDELENBERG POSITION & PNEUMOPERITONEUM

Cardiac output fall by 60% and there are no changes in heart rate ⁵². Moderate fall in stroke volume ⁵³. Stroke index and cardiac index fall by 42% can be noticed. Total peripheral resistance increased by 100% in balanced anesthesia from 1620 to 2491 dyn.s. cm^-5. M^-2. ⁵⁴.

There is a decrease in mean arterial pressure and cardiac index., as well as increase in peripheral and pulmonary vascular resistance ^49,50. These effects may be blunted by anaesthetic agents. There is also an increase in left ventricular end-systolic wall stress, and decreased left ventricular end-diastolic area but left ventricular ejection fraction was maintained during a study by trans-oesophageal echocardiography ⁵⁵.

On gynaecological patient for infertility the application of PEEP of 0.49 kPa (3.7 mmHg) was used with 25 degrees head down tilt. The intra-abdominal insufflation with CO₂ was done using low pressure 0.7-1.1 kPa (5-8 mmHg). The net cardiac effects were small. But there were reduction in ETCO₂, and there were no net increase in ETCO₂ after CO₂ insufflation ⁵⁶.

Routine intraoperative monitors as in other anaesthetics which includes EKG, pulse oximetry, blood pressure, pulse rate, ventilator performance, anesthetic gases concentration and patient’s temperature, There is need for a urinary bladder catheter and naso-gastric tubes to decompress the viscera and thus avoid injury to intra-abdominal contents during trocar insertion. For haemodynamically unstable or compromised patient and patients with cardio-respiratory chronic diseases careful monitoring of cardiovascular and blood gases is indicated ³². This also apply in case of obese patients ⁵⁷. As for the question of blood gases, ETCO₂ is most commonly used as a non-invasive substitute for PaCO₂ in evaluating the adequacy of ventilation during laparoscopic surgery. However, ETCO₂ may differ considerably from PaCO₂ because of ventilation-perfusion (V/Q) mismatching, and erroneous clinical decisions may be reached if the two values are assumed to be equal, to change proportionally, or even to change in the same direction ⁵⁸. In a study of healthy, mechanically ventilated patients undergoing laparoscopic cholecystectomy, equal and proportional increases in ETCO₂ and PaCO₂ were observed after CO₂ insufflation . In this patient population, ETCO₂ monitoring should suffice. In contrast, patients with preoperative cardiopulmonary disease demonstrated significant increases in PaCO₂ and decreases in pH after CO₂ insufflation, which were not reflected by comparable increases in ETCO₂. The difference between PaCO₂ and ETCO₂ (P[a-ET]CO₂) will increase if there is a greater contribution of ventilation from high V/Q regions. Therefore, radial artery cannulation for continuous blood pressure recording and frequent arterial blood gas analysis should be considered in patients with preoperative cardiorespiratory disease and in situations where intra-operative hypoxemia, high airway pressures, or elevated ETCO₂ are encountered ¹⁸. In an investigation of pre and post CO₂ insufflation on reading of ETCO₂ of healthy patients, there was positive linear relationship between the maximum end-tidal carbon dioxide tension during laparoscopy with baseline value prior to carbon dioxide insufflation ⁵⁹.

7. COMPLICATIONS DUE TO LAPAROSCOPY: In multi-centre study of complications of gynaecological laparoscopy reporting on 7604 procedures. There were one death, 2.76 per thousand complications requiring laparotomy; 4.46 per thousand for major surgical procedures and 0.42 per thousand for minor surgery and they are either intestinal injuries or less frequently vascular injuries ^60, 61.

Other complications include: Reflex bradycardia due may be due to vagally-mediated reflex, and may be predisposed to by drugs like vecuronium, atracurium, halothane, fentanyl and succinylcholine. It can be overcome by anticholinergic premedication ⁶² and cardiac collapse has been reported during the procedure in case of laparoscopic tubal ligation, during CO₂ insufflation vaginally ⁶³ and during sterilisation in two cases attributed to vagal atypical reaction and to CO₂ embolism ⁶⁴. Most interestingly a report of cardiovascular collapse after CO₂ exsufflation in a patient undergoing laparascopic cholecystectomy, The patient was 75-yr-old male, hypertensive on captopril and nadolol, rapid exsufflation resulted immediately in hypotension, bradycardia and low oxygen saturation, but responded well to treatment. The possible mechanism for this event was explained as a haemodynamic changes simulate the changes after aortic cross-clmping and release of the clamp in aortic surgery. In healthy individuals this may be compensated but the beta blocked and vasodilated patient may be unable to compensate ⁶⁵. The laporoscopic procedure itself is not arrhythmogenic ⁶⁶. Other reported complications are intestinal injuries, surgical emphysema, scrotal, ocular. Carbon dioxide venous embolism : Fatal ^67-69 and non Fatal ^70,71 . Pneumothorax ⁷² , pneumo-pericardium^73,74 and pneumo-mediastinum ⁷⁵. Tension pneumothorax also has been reported during laparoscopic cholecystectomy following trocar insertion and intraperitoneal CO₂ insufflation. A congenital defect of the diaphragm (patent pleuroperitoneal canal through which the insufflated gas passes into the thoracic cavity has been suggested as the underlying mechanism ⁷⁶. Many studies and reports indicated insufflation of CO₂ outside the peritoneum may lead to prolonged hypercarbia and acidosis ^77,78, also acute pulmonary oedama has been reported to occur after laparoscopy ⁷⁹. Gastric regurgitation in 2 of 93 fasting patients undergoing elective gynaecologic laparoscopic procedures ⁸⁰. Similarly, during laparoscopic cholecystectomy there are several factors which increase IAP and which predispose to regurgitation, including the initial steep head-down tilt, insufflation of intraperitoneal gas, and mechanical pressure exerted on the abdomen by the surgical team. or the anaesthetic technique ⁸¹,82. Technical difficulties in insufflation have been reported with the insertion of Veresse needle. Lower extremity neuropathy was reported as well ⁸³. Stray current due to capacitance coupling are possible when the devices used for electro surgical endoscopy. This may add to the previous list of risk ⁸⁴.

. Carbon monoxide (CO) formation during pyrolysis of tissue in hypoxic environment was studdied, it appears that after 5 minutes of electro-cautery use and reached at the end of surgery to the median level of 475 ppm (range 100-1900 ppm), although there were no significant absorption in this study but care in scavenging the gases produced by cautery is well recommended ⁸⁵, and finally nitrous oxide diffusing into the peritoneal cavity insufflated with CO₂ can reach a concentration in the peritoneal cavity which can support combustion of hydrogen part of the bowel gas, while the risk of methane combustion hazard has not been proven ^86,87.

8. PAIN RELIEF:

This topic was reviewed recently by Alexander JI (1997)¹. The patient may feel pain in the upper abdomen, lower abdomen, back or shoulder which may be evident in 63% of patients. The greatest incidence of pain in the upper abdomen. The reporting of pain by the patients is greater after the operation which it will decrease to a low level within 24 hours, but increases to second and third peak later. Visceral pain after cholecystectomy predominates in the first 24h but subsides from a peak soon after the operation, whereas shoulder pain, minor in the first day, increases and become significant on the following day. The mechanism of the pain is considered as; tearing of the blood vessels and traction on nerves and the release of inflammatory mediators during distension of the peritoneum. phrenic nerve excitation. Peritoneal inflammation. Suxamethonium may produce pain in the shoulder but its avoidance does not reduce the shoulder pain produced by the gas.

Minimal requirements of pain relief has been noticed especially if pneumoperitonium is properly evacuated ⁸⁸. Opioids were used intramuscularly (im) or intravenously (iv) or patient controlled analgesia (PCA). Ibuprofen has been used effectively for outpatient patients ⁸⁹. Diclofenac 50 & 100 mg iv has been used for diagnostic outpatient procedures ^90,91. Local anaesthetics used in rectus muscle sheath block alone was not effective ⁹². Intra-peritoneal local analgesics also was not effective ⁹³.

9. LAPAROSCOPY INPLICATIONS FOR ANESTHEESIA:

Care is indicated during monitoring of respiratory parameters including: Airway pressure plateau and peak airway pressure. End tidal CO2 and pulse oximetry. Tidal volumes and minute volume. Attention to the increased ventilatory requirement. End tidal CO2 is imperfect index of arterial level. The need for proper institution of post-operative oxygen therapy was demonstrated in human⁹⁴, and in animals⁹⁵.

. Most of the prevailing anaesthetic combinations have been employed with the emphasis on short duration, rapid recovery and mobility and freedom from postoperative nausea and vomiting.

Anesthesia for laparoscopy has been established with a broad usage of agents and techniques. General anesthesia using balanced anesthesia technique including intravenous induction agents like: thiopentone, propofol, etomidate, and inhalational agents like: nitrous oxide, isoflurane ^34,96 desflurane ⁹⁷ has been reported. variety of muscle relaxants including succinyl choline, mivacurium⁹⁸ , atracurium ⁹⁹ and vecuronium aiming at rapid recovery and cardiovascular stability ⁹⁶,97. Total intravenous anesthesia using the following agents: propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy ¹⁰⁰. Epidural anesthesia was considered as safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression ¹⁰¹.

9.2 IMPLICATIONS FOR ANESTHESIA:

It is obvious that optimal anesthesia care is needed with the proper understanding of potential problem and to use appropriate anaesthetic techniques with proper monitoring to detect and reduce complications ²⁵.

Due care and monitoring during positioning are needed. A close watch during the insufflation of carbon dioxide to produce pneumo-peritonium, and attention to the peak inspiratory pressure and the adequacy of ventilation, during the procedures with the use of controlled ventilation to avoid hypercarbia using capnography to monitor for it ¹⁰². Oxygen administration and use of pulse oximetry monitoring in the immedate post-operative period will add more safetey for the patients ¹⁰³. Anti-emetics should be used for these kind of procedure to reduce vomiting ¹⁰⁴. Also to reduce the possibility of inhaling gastric contents. Non-steroidal anti-inflammatory drugs NSAIDs can be used for relief of pain for ambulant patients but avoiding its use in patients with history of gastric peptic ulcers. Sicker and older patients are more likely to be subjected for such procedures so a special care can practised to improve the outcome ¹⁸.

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-Total intravenous anesthesia (Bailie et al 1987):

-General Anesthesia (de Grood PM et al 1987):

Anesthesia: Fentanyl, alfentanil.