Site hosted by Build your free website today!











A special review

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


Department of Anesthesia ,


King Khalid University Hospital (KKUH)








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



ABSTRACT: Laparoscopy employs highly technical equipment, and the surgeon needs special training in the technique. He masters in-depth 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 technique. deviation will most assuredly result in complications and even death. General surgery application of laparoscopy followed a wealth of medical experience from gynaecological laparoscopies, which declared the technique as safe, reduce hospital stay with little pain and disfigurement and laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy. Soon many procedures were done using this new technique in adult and children. Anesthesia for laparoscopy has been established with a broad usage of agents an techniques. General anesthesia using balanced anesthesia technique including intravenous induction agents like: thiopentone, propofol, etomidate, and inhalational agents like: nitrous oxide, isoflurane, desflurane has been reported. variety of muscle relaxants including succinyl choline, mivacurium, atracurium, vecuronium aiming at rapid recovery and cardiovascular stability. Total intravenous anesthesia using agents like propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy. Epidural anesthesia was considered as safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression. As for pain relief is concerned, many methods have been used. The pain mechanism is variable and analgesia requirment is less than those of open surgery. Cited complications include pneumothorax, cardiovascular collapse, surgical emphysema and pneumo-peritoneum complications. Among the implication for anaesthesia care, the importance of preoperative monitoring, careful positioning and observation during the insufflation of carbon dioxide. The drive to have short term admission to hospital would make it imperative to use short acting rapidly eliminated anaesthetic drugs, avoidance of vomiting and pain by proper use of modern anti-emetics and NSAID to help in avoidance of narcotics or reduction of the requirement.

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










1. Introduction

Laparoscopy (Greek: l a p a r a = flank or l a p a r o s = soft; s k o p h i n = to look). It is a relatively modern procedure, it involves the insufflation of the abdomen by a gas, so the endoscope can visualise the intra-abdominal contents without being in direct contact with the viscera or tissues 1. It started as a gynaecological procedure in the mid fifties of the present century and developed into other surgical specialities and targeted more sick patients 2. General surgery application of laparoscopy followed a wealth of medical experience from gynaecological laparoscopies, which declared the technique as safe, reduce hospital stay with little pain and disfigurement and laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy 3,4. Soon many procedures were done using this new technique in adult and children 5-7, hiatal hernia repair8, cervical dissection of oesophagus 9, diaphragmatic repair 10, gastroplasty 11, pheochromocytoma 12,13 and adrenalectomy 14 and others. More sick and older patients are subjected to this technique. Even laparascopy for cholecystectomy in patient with mythenia gravis and transplanted heart were reported 15,16. Many reviews discussed the issue we can indicate in particular those of Cali RW (1980)17 which dealt with technique, Cunningham AJ (1993)18 which dealt with the anaesthetic management and Alexander JI (1997)1 on pain relief in laparoscopic surgery. The aim of this review is to give an update and to summarise the current issue of laparoscopic surgery.

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.

Open versus laparoscopic cholecystectomy argument was reported in an Irish study. In a 50 consecutive patients. It was stated in this study that laparoscopy took longer anesthesia time mean (sd) 155 ± (61) min. versus open cholecystectomy anesthesia time of 102 ± (31) min. P<0.001. Laparoscopy took shorter mean postoperative hospital stay mean ± (sd) 3.5 ± (1.5) versus open cholecystectomy hospital stay of 8.8 ± (3.2) days. P<0.001. Reduced mean cost mean ± (sd) Irish pounds 895 ± (376) versus open cholecystectomy cost of 2210 ± (822) pounds. P<0.001 24.


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.


In a study conducted on patients under total intravenous anaesthesia using propofol, and constant minute ventilation, the following changes were noted: Peak airway pressure increased by 50% during insufflation, and during exsufflation goes down to 37% of resting values. Plateau airway pressure increased by 81% - exsufflation 27%. Compliance of the respiratory system decreased by 47% - exsufflation 14% 35 . In another study on seven patients undergoing gynecological laparoscopy the effect of CO2 pneumo-peritonium and Trendelengburg was decreased total lungs capacity (TLC). And increased Pa CO2 and PACO2 36 . In another study comparing N2O and CO2 as insufflating gas in the group who received CO2 there were sharp rise in Pa CO2 and fall in pH, while no changes in those who received N2O (Mango R et al 1979)37. Although in a study, an increased physiological dead space, arterial to end tidal carbon dioxide partial pressure difference and high arterial partial pressure of carbon dioxide was found, it was not statistically significant 38.

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 8-10th 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.

5.1.6 Postoperative pulmonary function tests changes in 24 h form the pre-operative values:

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.

5.2 Cardiovascular Effects.

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 volume18, 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.

The effects of general anesthetics and intravascular volume on hemodynamic function during creation of pneumoperitoneum also have been investigated and reported : A 35% reduction in inferior vena caval blood flow and cardiac output of dogs when intraperitoneal insufflation of N2, N2O, and CO2 produced an IAP of 40 mm Hg during basal pentobarbital anesthesia. The combination of 1.0 minimum alveolar anesthetic concentration (MAC) of halothane plus hypovolemia (resulting from 15% blood volume loss) decreased the preinduction cardiac output more than either halothane anesthesia alone, or the induction of hypovolemia alone. Also in a study compared the hemodynamic effects of 2 kPa (15 mm Hg) IAP pressure to those due to a 30° Trendelenburg tilt in a prospective study of 16 mechanically ventilated patients, randomized to receive either halothane anesthesia or balanced anesthesia with meperidine and thiopental. Regardless of anesthetic technique, an IAP of 15 mm Hg or a 30° head-down tilt produced similar reductions in cardiac index which were accompanied by significant elevations in systemic vascular resistance. In addition to the above-mentioned mechanical effects induced by the pneumoperitoneum, other chemically induced cardiovascular effects of CO2 (such as arrhythmogenesis) has been observed 18, 48- 51.


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-pericardium73,74 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.


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.


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.


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.


  1. ALEXANDER JI.: Pain after laparoscopy. Br J Anaesth;79:369-379,1997.
  2. ALEXANDER GD., NOE FE., BROWN EM.: Anesthesia for pelvic laparoscopy. Anesth Analg; 48(1):14-8, 1969.
  3. DUBOIS F.: Laparosscopic cholecyctectomy: Technique and complications, experience of 2636 cases. Saudi Medical Journal;17(2):129-136,1996.
  4. TAKROURI M S M. :Anesthesia implication of laparascopic surgery. Newsletter of Saudi Anesthesia Association. 8(1);5-7,1998.
  5. WALSH M T., VETTEER T R.: Anesthesia for pediatric laparoscopic cholecystectomy. J Clin Anesth 4(5):406-8,1992.
  6. JAWAD A.J., KURBAN K., EL-BAKRY A., AL-SANIE A., AL-FAWAZ I., BAKHAMEES H., BAHAKIM H.: Laparoscopic cholecystectomy: The treatment of choice in infancy and childhood. Annals of Saudi Medicine ;17,4:410—13,1997.
  7. JAWAD AJ., KURBAN K., EL-BAKERY A., AL-RABEEAH A., SERAJ M., AMMAR A.: Lapararoscopic cholecystectomy for cholelithiasis during infancy and childhood: cost analysis and review of current indications. World J. Surg;22,69-74,1998.
  8. BISWAS T K., SMITH J A.: Laparoscopic total fundoplication: anaesthesia and complication (letter). Anesthesia Intensive care; 21(1):127-8,1993.
  9. PEDEN CJ., PRYS-RROBERTS C.: Capno-thorax: implications for anaesthetist. Anaesthesia; 48(8):664-6,1993.
  10. POWER M., MCCOY D., CUNNINGHAM AJ AJ.: Laparoscopic-assisted repair of a traumatic ruptured diaphragm. Anesth Analg; 78(6):1187-9,1994.
  11. JANDALI ST., MOFTI AB., Al-ZOURKANY A., .HUSSEIN N M., TAKROURI M S M.: Anesthesia implications of laparoscopic gastroplasty in morbid obesity. ( in press).
  12. MANN C., MILLAT B., BOCCARA G., ATGER J., COLSON P.: Tolerence of laparoscopy for resection of pheochromocytoma. Br J Anaesth ;77:795-797, 1996.
  13. MICCOLI P., BENDINELLI C., MATERAZZI G., IACCONI P., BUCCIANTI P.: Traditional versus laparoscopic surgery in the treatment of pheochromocytoma: A preliminary study. Journal of Lparoendoscopic & Advanced Surgical Technique;7(3):167-171,1997.
  14. JANDALI ST., MOFTI AB., AL- MUHAYA S., Al-ZOURKANY., A.HUSSEEINN M., Al-GAMAL H., TAKROURI M S M.: Anesthesia implications of laparoscopic adrenalectomy in nephrotic syndrome. ( in press).
  15. JOSHI G P., HEIN H A T., RAMSAY M A E., FOREEMAN M L.: Hemodynamic response to anesthesia and pneumoperitoneum in orthotopic cardiac transplant recipients. Anesthesiology;85:929-33, 1996.
  16. LEVEQUE J P., BENHAMOU D., ZETLAOUI P., PAPELIER Y.: Laparoscopic cholecystectomy in a patient with a transplanted heart (Correspondence). Anesthesiology;86:1425-6,1997.
  17. CALI RW.: Laparoscopy. Surg Clin North Am;60(20:407-24,1980.
  18. CUNNINGHAM AJ., BRULL S J.: Laparoscopic cholecystectomy: anesthetic implications. Anesth Analg; 76(5):1120-33,1993.
  19. ROSE D K., COHEN M M., SOUTTER D I.: Laparoscopic cholecystectomy: the anaesthetist’s point of view. Can J Anaesth.; 39(8):809-15, 1992.
  20. SEMM K.: Statistical survey of gynaecological laparoscopy/pelviscopy in Germany till 1977; Endoscopy; 11(2):101-2,1979.
  21. MINTZ M. : Risk and prevention of complications in gynecologic laparoscopy. Survey of 100000 cases. J Gynecol Obstet Biol Reprod (Paris); 5(5):681-95,1976.
  22. MORGENSTERN L; WONG L; BERCI G.: Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg;127(4):400-3, 1992.
  23. CUSCHIERI A., DUBOIS F., MOUIEL J.., MOURET P., BECKER H., BUESS G., TREDE M., TROIDL H.: The European experience with laparoscopic cholecystectomy. Am J Surg 161(3):385-7,1991.
  24. GRACE PA., QUEREESHI A., COLEMAN J., KEANE R., MCENTEE G., BROE P., OSBORNE H., BOUCHIER-HAYES D.: reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 78(2):160-2,1991.
  25. CHUI PT., GIN T., OH TE.: Anesthesia for laparoscopic general surgery. Anaseth Intensive Care 21(2):163-71,1993.
  26. LITWIN DE., GIROTTI MJ., POULIN EC., MAMAZZA J., NAGY AG.: Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases.Can J Surg 35(3):291-6,1992.
  27. MCMAHON AJ; BAXTER JN; O’DWYER PJ.: Metabolic effects of cholecystectomy. Br J Anaesth; 70(4):493-4, 1993.
  28. HALL GM; DESBOUROUGH JP.: Interleukin-6 and metabolic response to surgery [editorial]. Br J Anaesth; 69(4):337-8, 1992
  29. JORIS J., CIGARINI I., LEGRAND M JACQUET N., DEGROOTE D., FRANCHIMONT P., LAMY M.: metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparoscopy. Br J Anaesth; 69(4):341-5,1992.
  30. MEALY K., GALLAGHER H., BARRY M., LENNON F., TRAYNOR O., HYLAND J: Physiological and metabolic responses to open and laparoscopic cholecystectomy. Br J Surg;79(10):1061-4, 1992.
  31. FRAZEE RC., ROBERTS JW., OKESON GC., SYMMONDS R E., SNYDER SK., HENDRICKS JC., SMITH R W.: Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function. Ann Surg;213(6):653-4, 1991.
  32. WITTGEN CM., ANDRUS CH., FITZGERALD SD., BAUDENDISTEL LJ., DAHMS TE., KAMINSKI DL.: Analysis of the haemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg; 126(8):997-1000, 1991.
  33. HODGSON C; MCCLELLAND RM; NEWTON JR.: Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia; 25(3):382-90, 1970.
  34. KENEFICK JP., LEADER A., MALTBY JR., TAYLOR PJ.: Laparoscopy: blood-gas values and minor sequelae associated with three techniques based on isoflurane. Br J Anaesth; 59(2):189-94,1987.
  35. BARDOCZKY GI., ENGEKMAN E., LEVARLET M., SIMON P.: Ventilatory effects of pneumoperitoneum monitored with continuous spirometry. Anesthesia,48(4):309-11, 1993
  36. VERSICHELEN L., SERREYN R., ROLLY G., VANDERKERCKHOVE D. :Physiopathologic changes during anesthesia administration for gynecologic laparoscopy. J Reprod Med 29(10):697-700,1984.
  37. MAGNO R., MEDEGARD A., BENGTSSON R., TRONSAD SE.: Acid-base balance during laparoscopy. The effects of intraperitoneal insufflation of carbon dioxide and nitrous oxide on acid-base balance during controlled ventilation. Acta Obstet Gynecol Scand;58(1):81-5,1979.
  38. PURI GD., SINGH H.: Ventilatory effects of laparoscopy under general anaestheesia. Br J Anaesth.; 68(2):211-3,1992.
  39. LUIZ T; HUBER T; HARTUNG HJ.: Ventilatory changes during laparoscopic cholecystectomy. Anaesthesist;41(9):520,1992.
  40. MULLETT CE., VIALE JP., SAGNARD PE., MIELLET CC., RUYNAT LG., COUNIOUX HC., MOTIN JP., BOULEZ JP., DARGENT DM., ANNAT GJ.: Pulmonary CO2 elimination during surgical procedures using intra- or extra-peritoneal CO2 insufflation. Anesth Analg; 76(3):622-6, 1993.
  41. BLOBNER M., FELBER AR; GOGLER S; FEUSSNER H; WEIGL EM; JELEN G; JELEN-ESSELBORN S.: The resorption of carbon dioxide from the pneumoperitoneum in laparoscopic cholecystectomy. Anaestheesist; 42(5):288-94,1993.
  42. WURST H; SCHULTE-STEINBERG H; FINSTERER U.: Pulmonary CO2 elimination in laparoscopic cholecystectomy. A clinical study. Anaesthesist; 42(7):427-34, 1993.
  43. TOLKSDORF W; STRANG CM; SCHIPPERS E; SIMON HB; TRUONG S.: The effects of thhe carbon dioxide pneumoperitoneum in laparoscopic cholecystectomy on post operative spontaneous respiration. Anaesthesist; 41(4):199-203, 1992.
  44. ERICE F; FOX GS; SALIB YM; ROMANO E; MEAKINS JL; MAGDER SA.: Diaphragmatic function before and after laparoscopic cholecystectomy. Anesthesiology;79(5):966-75,1993.
  45. COUTURE JG; CHARTRAND D;GAGNER M; BELLEMAARE F.: Diaphragmatic and abdominal muscle activity after endoscopic cholecystectomy. Anesth Analg;78(4):733-9,1994.
  46. SHULMAN SM; CHUTER T; WEISSMAN C.: Dynamic respiratory patterns after laparoscopic cholecystectomy. Chest; 103(4):1173-7,1993.
  47. FREEMAN JA; ARMSTRONG IR.: Pulmonary function tests before and after laparoscopic cholecystectomy. Anaesthesia; 49(7):579-82,1994.
  48. JOHANNSON G; ANDERSEN M JUHL B.: the effect of general anaesthesia on the haemodynamic events during laparosscopy with CO2 -insufflation. Acta Anaesthesiol Scand; 33(2):132-6,1989.
  49. ODEBERG S., LJUNGQVIST O., SEVENBERG T., GANNEDAHL P., BACKDAHL M., VON ROSEN A., SOLLEVI.: Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthesiol Scand; 38(3):276-83,1994.
  50. JORIS JL., NOIROT DP., LEGRAND MJ., JACQUET NJ., LAMY ML.: Haemodynamics changes during laparoscopic cholecystectomy. Anesth Analg 76(5):1067-71,1993.
  51. CRITCHLEY LA., CRITCHLEY JA., GIN T.: Haemodynamic changes in patients undergoing laparoscopic cholecystectomy: measurement by transthoracic electricical bioimpedance. Br J Anaesth; 70(6):681-3,1993.
  52. MCKENZIE R., WADHWA RK., BEDGER RC.: Non-invasive measurement of cardiac output during laparoscopy. J Reprod Med;24(6):247-50,1980.
  53. LENZ RJ., THOMAS TA., WILKINS DG.,: cardiovascular changes during laparoscopy. Studies of stroke volume and cardiac output using impedence cardiography. Anaesthesia; 31(1)4-12,1976.
  54. TORRIELLI R., CESARINI M., WINNOCK S., CABIRO C., MENE JM.: Hemodynamic changes during celioscopy: a study carried out using thoracic electric bioimpedance. Can J Anaesth;37(1):46-51,1990.
  55. CUNNINGHAM AJ AJ., TURNER J., ROSENBAUM S., RAFFERTY T.: Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br. J Anaesth:70(6t):621-5,1993.
  56. EKMAN LG., ABRAHAMSSON J., BIBER B., FORSSMAN L., MILSOM I., SJOQVIST BA.: haemodynamic changes during laparoscopy with positive end-expiratory pressure ventilation. Acta Anaesthesiol Scand:32(6):447-53,1988.
  57. SCHOEFFLER p., HABERER JP., MANHES H., HENRY C., HABOUZIT JL.: Circulatory and respiratory effects of celioscopy in the obese. Ann Fr Anesth Reanim;3(1):10-5, 1984.
  58. YAMMANAKA MK., SUE DJ.: Comparison of arterial -end tidal PCO2 differeence and dead volume ratio in respiratory failure. Chest; 92:832-5,1987.
  59. BARAKA A., JABBOUR S., HAMMOND R., AOUAD M., NAJJAR F., KHOURY G., SIBI A.: End-tidal carbon dioxide tension during laparoscopic cholecystectomy. Correlation with the baseline value prior to carbon dioxide insufflation. Anaesthesia;49(4):304-6,1994.
  60. CHAPRON C; QQUERLEU D; MAGE G; MADELENAT P; DUBUISSON JB; AUDEBERT A; ERNY R; BRUHAT MA.: Complications of gynecologic laparoscopy. Multicentric study of 7,604 laparoscopies. J Gynecol Obstet Biol Reprod(paris); 21(2):207-13, 1992.
  61. HASEL R; ARORA; HICKEY DR.: Intraoperativce complications of laparoscopic cholecystectomy. Can J Anaesth; 40(5Pt 1):549-64, 1993.
  62. DOYLE DJ., MARK PW.: Reflex bradycardia during surgery. Can j Anaesth; 37(2):219-22,1990.
  63. OSTMAN PL; PANTLE-FISHER FH., FAURE EA., GLOSTEN B.: Circulatory collapse during laparoscopy. J Clin Anesth; 2(2):129-32,1990.
  64. BRANTLEY JC 3D., RILEY PM.: Cardiovascular collapse during laparoscopy: a report of two cases. Am J Obstet Gynecol; 159(3):735-7,1988.
  65. BARAKA A.;: Cardiovascular collapse after carbon dioxide exsufflation in a patient undergoing laparoscopic cholecystectomy [letter]. Anesth Analg; 78(3):603,1994
  66. HARRIS MN., PLANTEVIN OM., CROWTHER A.: Cardiac arrhythmias during anaesthesia for laparoscopy. Br. J Anaesth; 56(11):1213-7,1984.
  67. BECK DH; MCQUILLAAN PJ.: Fatal carbon dioxide embolism and severe haemorrhage during laparoscopic salpingectomy. Br J Anaesth.; 72(2):2443-5,1994.
  68. ROOT B; LEVY MN POLLACK S; LUBERT M; PATHAK K.: Gas embolism death after laparoscopy delaayed by "trapping" in portal circulation. Anesth Analg; 57(2)232-7, 1978.
  69. GOMAR C; FERNANDEZ C; VILLALONGA A; NALDA MA.: Carbon dioxide embolism during laparoscopy and hysteroscopy.. Ann Fr Anesth reanim; 4(4):380-2, 1985.
  70. DEPLATER RM; JONES IS.: Non-fatal carbon dioxide embolism during laparoscopy. Anaesth Intensive care; 17(3):359-6,1989.
  71. MCGRATH BJ; ZIMMERMAN JE; WILLIAMS JF; PARMET J.: Carbon dioxide embolism treated with hyperbaric oxygen. Can J Anaesth; 36(5):586-9, 1989.
  72. GABBOTT DA; DUNKLEY AB; ROBEERTS FL.: Carbon dioxide pneumothorax ocuring during laparoscopic cholecystectomy. Anaesthesia; 47(7):587-8,1992.
  73. NICHOLSON RD; BERMAN ND.: Pneumo-pericardium following laparoscopy. Chest; 76(5):605-607, 1979.
  74. KNOS GB; SUNG YF; TOLEDO A.: Pneumo-pericardium associated with laparoscopy. J Clin anesth; 3(1):56-9, 1991.
  75. CHUI PT; GIN T; CHUNG SC.: Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy. Report of two cases. Anaesthesia; 48(11):978-81, 1993.
  76. WHISTON RJ; EGGERS KA; MORRIS RW; STAMATAKIS JD.: Tension pneumothorax during laparoscopic cholecystectomy. Br J Surg; 78(11):1325, 1991.
  77. HALL D; GOLDSTEIN A ; TYNAN E; BRAUNSTEIN L.: Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry. Anesthesiology; 79(1):173-4, 1993.
  78. PEARCE DJ.: Respiratory acidosis and subcutaneous emphysema during laparoscopic cholecystectomy. Can J Anaesth; 41(4):314-6, 1994.
  79. DESAI S; RAOF E; LIU P.: Acute pulmonary edema during laparoscopy. Anesth Analg; 61(8):699-700, 1982.
  80. DUFFEY BL.: Regurgitation during pelvic laparoscopy. Br J anaesth; 51(11):1089-90, 1979.
  81. WATCHA MF; WHITE PF.: Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology; 77(1):162-84, 1992.
  82. OKUM GS; COLONNA-ROMANO P; HORROW JC: Vomiting after alfentanil anesthesia: effect of dosing method. Anesth Analg; 75(4):558-60,1992.
  83. JOHNSTON RV; LAWSON NW; NEALON WH.: Lower extremity neuropathy after laparoscopic cholecystectomy [letter]. Anesthesiology; 77(4):835, 1992.
  84. TUCKER RD., VOYLES CR., SILVIS SE.: Capacitive coupled stray currents during laparoscopic and endoscopic electrosurgical procedures. Biomed Instrum Technol;26(4):303-11,1992.
  85. BEEBE DS; SWICA H; CARLSON N; PALAHNIUK RJ; GOODALE RL. High levels of carbon monoxide are produced by electro-cautery of tissue during laparoscopic cholecystectomy. Anesth Analg; 77(2):338-41, 1993.
  86. NEUMAN GG; SIDEBOTHAM G; NEGOIANU E; BERNSTEIN J; KOPMAN AF; HICKS RG; WEAT ST; HARING L.: Laparoscopy explosion hazards with nitrous oxide. Anesthesiology; 78(5):875-9, 1993.
  87. RADEMAKER BM; RINGERS J; ODOOM JA; DE WIT L; KALKMAN CJ; OOSTING J. Pulmonary function and stress response after laparoscopic cholecystectomy: comparision with subcostal incision and influence of thoracic epidural analgesia. Anesth Analg; 75(3):381-5, 1992.
  88. FREDMAN B; JEDEIKIN R; OLSFANGER D; FLOR P; GRUZMAN A.: Residual pneumo-peritoneum; a cause of post operative pain after laparoscopic cholecystectomy. Anesth Analg; 79(1):152-4,1994.
  89. ROSENBLUM M; WELLER RS; CORNARD PL; FFAVEY EA; GROSS JB.: Ibuprofen providees longer lasting analgesia than fentanyl after laparoscopic surgery. Anesth Analg; 73(3):255-9, 1991.
  90. GILLBERG LE; HARSTEN AS; STAHL LB.: Preoperative diclofenac sodium reduces post-laparoscopy pain. Can J Anaesth; 40(5 Pt 1):406-8), 1993.
  91. HOVORKA J; KALLELA H KORTTILA K.: Effect of intravenous diclofenac on pain and recovery profile after day case laparoscopy. Eur J Anaesthesiol; 10(2):105-8,1993.
  92. SMITH BE; SUCHAK M; SIGGINS D; CHALLANDS J.: Rectus sheath block for diagnostic laparoscopy. Anaesthesia; 43(1):947-8,1988.
  93. RADEMAKER BM; KALKMAN CJ; ODOOM JA; DE WIT L; RINGERS J.: Intraperitoneal local anaesthetics after laparoscopic cholecystectomy: effects on posstoperative pain, metabolic responses and lung function. Br J Anaesth; 72(3):263-6, 1994.
  94. WAHBA RW; MAMAZZA J.: Ventilatory requirements during laparoscopic cholecystectomy. Can J Anaesth;40(3):206-10,1993.
  95. LISTER DR; RUDSTOWN-BROWN B; WARRINER CB; MCEWEN J; CHAN M; WALLEY KR.: Carbon dioxide absorption is not linearly related to intraperitoneal carbon dioxide insufflation pressure in pigs. Anestheesiology;80(1):129-36,1994.
  96. DE GROOD P.M., HARBERTS J.B., VAN EGMOND J., CRUL J.F.: Anesthesia for laparoscopy. A comparision of five techniques including propofol, etomidate, thiopentone and isoflurane. Anesthesia 42(8):815-23. 1987.
  97. VAN HEMELRIJCK J., SMITH I., WHITE P.F.: Use of desflurane for outpatient anesthesia. a comparison with propofol and nitrous oxide. Anesthesiology;75(2):197-203,1991
  98. DING Y., FREDMAN B., WHITE P.F.: Use of mivacurium during laparoscopic surgery: effect of reversal drugs on post operative recovery. Anesth Analg;78(3):450-4, 1994
  99. WALDVOGEL H.H., SCHNECK H.J., FELBER A., VON HUNDELSHAUSEN B.: Anesthesia relevant features of laparoscopy- the value of capnograohy (German text). Anaesthesiol Reanim;19(1):4-10,1994.
  100. BAILIE R., CRAIG G., RESTALL J.: Total intravenous anesthesia for laparoscopy. Anesthesia; 44(1):60-3,1987.
  101. CIOFOLO M.J., CLERGUE F., SEEBACHER J., LEFEBVRE G., VIARS P.: Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg;70(4):357-61,1990.
  102. HALL D; GOLDSTEIN A; TYNAN E; BRAUNSTEIN L.: Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry. Anesthesiology; 79(1):173-4, 1993.
  103. VEGFORS M; CEDERHOLM I; LENNMARKEN C; LOFSTROM JB.: Should oxygen be administered after laparoscopy in healthy patients? Acta Anaesthesiol Scand; 32(4):350-2. 1993.
  104. VILA P; VALLES J; CANET J; MELERO A; VIDAL F.: Acid aspiration prophylaxis in morbidly obese patients: famotidine vs ranitidine. Anaesthesia; 46(11):967-9, 1991.




-Total intravenous anesthesia (Bailie et al 1987):

Propofol, Etomidate and Midazolam-ketamine.

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

Induction: Propofol, Etomidate and thiopentone.

Maintenance: Isoflurane-nitrous oxide, Desflurane (Vav Hemelrijck J et al 1991)- nitrous oxide, & halothane.

Anesthesia: Fentanyl, alfentanil.

Muscle relaxant: Vecuronium. Mivacurium (Ding et al 1994), atracurium.

-Epidural anesthesia (Ciofolo MJ et al 1990).