Jean L.

Joris

68
Key Points

Anesthesia for Laparoscopic Surgery

1. CO2 pneumoperitoneum results in ventilatory and respiratory changes. Pneumoperitoneum decreases thoracopulmonary compliance. Paco2 increases (15% to 25%) due to CO2 absorption from the peritoneal cavity. Capnography reliably reflects this increase, which plateaus after 20 to 30 minutes. 2. In compromised patients, cardiorespiratory disturbances aggravate the increase in Paco2 and enlarge the gradient between Paco2 and Petco2. 3. Any increase in Petco2 larger than 25% or occurring later than 30 minutes after the beginning of peritoneal CO2 insufflation should suggest CO2 subcutaneous emphysema, the most frequent respiratory complication during laparoscopy. 4. Peritoneal insufflation induces alterations of hemodynamics, characterized by decreases of cardiac output, elevations of arterial pressure, and increases of systemic and pulmonary vascular resistances. Hemodynamic changes are accentuated in high-risk cardiac patients. 5. The pathophysiologic hemodynamic changes can be attenuated or prevented by optimizing preload before pneumoperitoneum and by vasodilating agents, 2adrenergic receptors agonists, high doses of opioids, and -blocking agents.

6. Similar pathophysiologic changes occur during pregnancy and in children. Laparoscopy can be safely managed in pregnant women before the 23rd week of pregnancy provided that hypercarbia is prevented. The open laparoscopy approach should be considered to avoid damaging the uterus. 7. Gasless laparoscopy may be helpful to reduce pathophysiologic changes induced by CO2 pneumoperitoneum but unfortunately increases technical difficulty. 8. Laparoscopy results in multiple postoperative benefits, allowing for quicker recovery and shorter hospital stay. These advantages explain the increasing success of laparoscopy, which is proposed for many surgical procedures. 9. Although no anesthetic technique has proved to be clinically superior to any other, general anesthesia with controlled ventilation seems to be the safest technique for operative laparoscopy. 10. Improved knowledge of the intraoperative repercussions of laparoscopy permits safe management of patients with more and more severe cardiorespiratory disease, who may subsequently benefit from the multiple postoperative advantages offered by this technique.

Surgical procedures have been improved to reduce trauma to the patient, morbidity, mortality, and hospital stay, with consequent reductions in health care costs. The provision of better equipment and facilities, along with increased knowledge and understanding of anatomy and pathology, has allowed the development of endos copy for diagnostic and operative procedures. Starting in the early 1970s, various pathologic gynecologic conditions were diagnosed and treated using laparoscopy. This endoscopic approach was extended to cholecystectomy in the late 1980s. Since the intro duction of the first laparoscopic cholecystectomy procedures,1 laparoscopy has expanded impressively both in scope and volume. It quickly became apparent that laparoscopy results in multiple

benefits compared with open procedures2,3 and was characterized by better maintenance of homeostasis. Overenthusiasm ensued, which explains the effort to use the laparoscopic approach for gastrointestinal (e.g., colonic, gastric, splenic, hepatic surgery), gynecologic (e.g., hysterectomy), urologic (e.g., nephrectomy, prostatectomy), and vascular (e.g., aortic) procedures. The pneumoperitoneum and the patient positions required for laparoscopy induce pathophysiologic changes that complicate anesthetic management. An understanding of the pathophysio logic consequences of increased intraabdominal pressure (IAP) is important for the anesthesiologist who must ideally prevent or, when prevention is not possible, adequately respond to these
2185

2186

Adult Subspecialty Management

changes and who must evaluate and prepare the patient preopera tively in light of these disturbances. The pathophysiologic changes and the complications of laparoscopy are reviewed first. The post operative period is considered next, with examination of the ben efits of laparoscopy and certain specific postoperative problems (e.g., pain, nausea). Practical consequences for the anesthetic management of laparoscopy are presented. Many animal and human studies of the consequences of laparoscopy have been published since the early 1970s. Because much higher IAPs (>20 mm Hg) were previously used and because of potential species differences, we have focused on the human literature published after 1990 using low IAP (<15 mm Hg) and modern anesthesia techniques.

Increase in the Partial Pressure of Arterial Carbon Dioxide

During uneventful CO2 pneumoperitoneum, the partial pressure of arterial carbon dioxide (Paco2) progressively increases to reach a plateau 15 to 30 minutes after the beginning of CO2 insufflation in patients under controlled mechanical ventilation during gyne cologic laparoscopy in the Trendelenburg position14 or during laparoscopic cholecystectomy in the headup position (Fig. 681).15,16 Any significant increase in Paco2 after this period requires a search for a cause independent of or related to CO2 insufflation, such as CO2 subcutaneous emphysema. The increase in Paco2 depends on the IAP.17 During laparoscopy with local anesthesia, Paco2 remains unchanged but minute ventilation sig nificantly increases.18 Capnography and pulse oximetry provide reliable monitor ing of Paco2 and arterial oxygen saturation in healthy patients and in the absence of acute intraoperative disturbances (see Figure 681).15,16 Although mean gradients (aETCO2) between Paco2 and the endtidal carbon dioxide tension (Petco2) do not change significantly during peritoneal insufflation of CO2, individual patient data regularly show variations of this difference during pneumoperitoneum.19,20 Paco2 and aETCO2 increase more in ASA class II and III patients than in ASA class I patients (Fig. 68 2).21,22 These findings have been documented in patients with chronic obstructive pulmonary disease (COPD)23 and in children with cyanotic congenital heart disease.24 These data therefore highlight the lack of correlation between Paco2 and Petco2 in sick patients, particularly those with impaired CO2 excretion capacity, and in otherwise healthy patients with acute cardiopulmonary disturbances. Consequently, hypercapnia can develop, even in the absence of abnormal Petco2. Postoperative intraabdominal CO2 retention results in increased respiratory rate and Petco2 of patients breathing spontaneously after laparoscopic cholecystec tomy as compared with open cholecystectomy.25 During CO2 pneumoperitoneum, the increase of Paco2 may be multifactorial: absorption of CO2 from the peritoneal cavity, impairment of pulmonary ventilation and perfusion by mechanical factors such as abdominal distention, patient posi

Ventilatory and Respiratory Changes During Laparoscopy

Intraperitoneal insufflation of carbon dioxide (CO2), the cur rently routine technique to create pneumoperitoneum for laparos copy, results in ventilatory and respiratory changes and can cause four principal respiratory complications: CO2 subcutaneous emphysema, pneumothorax, endobronchial intubation, and gas embolism.4

Ventilatory Changes
Pneumoperitoneum decreases thoracopulmonary compliance by 30% to 50% in healthy57 and obese patients.8,9 Reduction in functional residual capacity10 and development of atelectasis due to elevation of the diaphragm11 and changes in the distribu tion of pulmonary ventilation and perfusion from increased airway pressure can be expected.11 However, increasing IAP to 14 mm Hg with the patient in a 10 to 20degree headup or headdown position does not significantly modify either physio logic dead space or shunt in patients without cardiovascular problems.12,13

)(mm Hg)

50 48 46 44 42 40 38 36 34 32 30 28 0 5 10 20 15 25 30 Min after insufflation 35 40 45

7.50 7.48

* * * *

* * *

7.46 7.44 7.42 )

Figure 68-1 Ventilatory changes (pH, Paco2, and Petco2) during CO2 pneumoperitoneum for laparoscopic cholecystectomy. For 13 American Society of Anesthesiologists (ASA) class I and II patients, minute ventilation was kept constant at 100 mL/kg/min with a respiratory rate of 12 breaths/min during the study. Intraabdominal pressure was 14 mm Hg. Data are given as the mean SEM.*, P < .05 compared with time 0.

) and PETCO2 (

* *

7.40 7.38 7.36 7.34 7.32 7.30

PaCO2 (

pH (

Anesthesia for Laparoscopic Surgery 2187 39 37 PETCO2(mm Hg) 35 33 31 29 27 25 Before 25 30 35 40 45 50 ASA I ASA IIIII During

68

adjusted in response to the increased dead space, alveolar ventila tion will decrease and Paco2 will rise. In healthy patients, absorp tion of CO2 from the abdominal cavity represents the main (or the only) mechanism responsible for increased Paco2,13 but in patients with cardiorespiratory problems, ventilatory changes also significantly contribute to increasing Paco2.21 Pao2 values and intrapulmonary shunt do not significantly change during laparoscopy.12,13 It is wise to maintain Paco2 within a physiologic range by adjusting the mechanical ventilation. Except in special circum stances, such as when CO2 subcutaneous emphysema occurs (see later), correction of increased Paco2 can be easily achieved by a 10% to 25% increase in alveolar ventilation.

Section V Adult Subspecialty Management

Respiratory Complications
CO2 Subcutaneous Emphysema CO2 subcutaneous emphysema can develop as a complication of accidental extraperitoneal insufflation33 but can also be consid ered as an unavoidable side effect of certain laparoscopic surgical procedures that require intentional extraperitoneal insufflation, such as inguinal hernia repair, renal surgery, and pelvic lym phadenectomy (Fig. 683).14,34,35 During laparoscopic fundoplica tion for hiatal hernia repair, the opening of the peritoneum overlying the diaphragmatic hiatus allows passage of CO2 under pressure through the mediastinum to the cervicocephalic region. In these circumstances, VCO2 , Paco2, and Petco2 increase.14 Any increase in Petco2 occurring after Petco2 has plateaued should suggest this complication. The increase in VCO2 may be such that prevention of hypercapnia by adjustment of ventilation becomes almost impossible. In this case, laparoscopy must be temporarily interrupted to allow CO2 elimination and can be resumed after correction of hypercapnia using a lower insufflation pressure. Indeed, CO2 pressure determines the extent of the emphysema and the magnitude of CO2 absorption. CO2 subcutaneous emphy sema readily resolves once insufflation has ceased. CO2 sub cutaneous emphysema, even cervical, does not counterindicate tracheal extubation at the end of surgery.36 We recommend keeping the patient mechanically ventilated until hypercapnia is corrected, particularly in COPD patients, to avoid an excessive increase in the work of breathing. Pneumothorax, Pneumomediastinum, Pneumopericardium Movement of gas during the creation of a pneumoperitoneum can produce pneumomediastinum,37 unilateral and bilateral pneumothoraces,38 and pneumopericardium.39 Embryonic rem nants constitute potential channels of communication between the peritoneal cavity and the pleural and pericardial sacs, which can open when intraperitoneal pressure increases. Defects in the diaphragm or weak points in the aortic and esophageal hiatus may allow gas passage into the thorax. Pneumothoraces may also develop secondary to pleural tears during laparoscopic surgical procedures at the level of the gastroesophageal junction (e.g., fundoplication for hiatal hernia). Although opening of peritoneo pleural ducts is associated with mainly rightsided pneumo thoraces (in the same way that ascites or peritoneal dialysis may be associated with rightsided pleural effusions40), the pneumo thorax associated with fundoplication is more frequently in the left side of the chest.

PaCO2 (mm Hg)

Figure 68-2 Ventilatory changes as a function of patient physical status. The Paco2 and Petco2 were measured before and during CO2 insufflation. Patients were grouped according to ASA classification: group 1 (green circles), ASA I (n = 20); group 2 (blue circles), ASA II-III (n = 10). (Data from Wittgen CM, Andrus CH, Fitzgerald SD, et al: Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 126:997, 1991.)

tion, and volumecontrolled mechanical ventilation. The observa tion of an increase in Paco2 when CO2, but not nitrous oxide (N2O) or helium, was used as the insufflating gas suggests that the main mechanism of the increased Paco2 during CO2 pneumo peritoneum is absorption of CO2 rather than the mechanical ven tilatory repercussions of increased IAP.26,27 Accordingly, direct measurement of CO2 elimination ( VCO2 ) using a metabolic monitor combined with investigation of gas exchange showed a 20% to 30% increase of VCO2 without significant changes in phy siologic dead space in healthy patients undergoing pelvic lapar oscopy (IAP of 12 to 14 mm Hg) in the headdown position14,28 or laparoscopic cholecystectomy in the headup position.14,29 The time courses of the increase in VCO2 and Paco2 are similar. The absorption of a gas from the peritoneal cavity depends on its dif fusibility, the absorption area, and the perfusion of the walls of that cavity. Because CO2 diffusibility is high, absorption of large quantities of CO2 into the blood and the subsequent marked increases in Paco2 would be expected to occur. The limited rise of Paco2 actually observed can be explained by the capacity of the body to store CO230 and by impaired local perfusion due to increased IAP.17 During deflation, CO2 that accumulated in col lapsed peritoneal capillary vessels reaches the systemic circula tion, leading to transient increases in Paco2 and VCO2 .31 Respiratory changes during the laparoscopic procedure may contribute to increasing CO2 tension. Mismatched ventila tion and pulmonary perfusion can result from the position of the patient and from the increased airway pressures associated with abdominal distention.18,32 Lister and colleagues17 investigated the relationship between VCO2 and intraperitoneal CO2 insufflation pressure in pigs. For an IAP up to 10 mm Hg, increased VCO2 accounts for the increased Paco2. At higher IAPs, the continued rise of Paco2 without a corresponding increase in VCO2 results from an increase in respiratory dead space, as reflected by a wid ening of the aETCO2 gradient.17 If controlled ventilation is not

2188

Adult Subspecialty Management Capnography Increased PETCO2 Decreased PETCO2

No

Yes

Yes

Yes

Yes

Pulse oximetry

Desaturation

No change

Desaturation

Desaturation

Desaturation

Airway pressure Clinicial examination a) Reduced air entry b) Hyperresonance c) Swelling and crepitus Presumptive diagnosis

Increased Paw No change

Increased Paw

Increased Paw

No change

Yes No No

No No Yes

Yes Yes Possibly

Yes Yes Possibly

Murmur Hypotension ECG changes

Endobronchial Subcutaneous Capnothorax intubation emphysema

Pneumothorax

Massive CO2 embolism

Figure 68-3 Diagnosis of respiratory complications during laparoscopy. ECG, electrocardiographic; Paw, airway pressure; Petco2, end-tidal carbon dioxide tension. (Data from Wahba RW, Tessler MJ, Kleiman SJ: Acute ventilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 43:77, 1996.)

These complications are potentially serious and may lead to respiratory and hemodynamic disturbances. Capnothorax (CO2 causing a pneumothorax) reduces thoracopulmonary compliance and increases airway pressures. VCO2 , Paco2, and Petco2 also increase.41 In effect, the absorption surface of CO2 is increased and the absorption from the pleural cavity is greater than from the peritoneal cavity. When a pneumothorax occurs secondary to alveolar rupture, the Petco2 decreases because of decreased cardiac output. Hemodynamic changes and oxygen desaturation should suggest the presence of a tension pneumothorax. The laparoscopist may observe abnormal motion of one hemidiaphragm when a tension pneumothorax has occurred. It should be noted that cervical and upper thoracic subcutaneous emphysema can develop without the presence of a pneumothorax. When a pneumothorax is caused by highly diffusible gas such as N2O or CO2 without associated pulmonary trauma, spon taneous resolution of the pneumothorax occurs within 30 to 60 minutes without thoracocentesis.42 When capnothorax develops during laparoscopy, treatment with positive endexpiratory pres sure (PEEP) is an alternative to chest tube placement.41 In con trast, if the pneumothorax is secondary to rupture of preexisting bullae, PEEP must not be applied and thoracocentesis is mandatory. Endobronchial Intubation Cephalad displacement of the diaphragm during pneumoperito neum results in cephalad movement of the carina in children43 and adults,44 potentially leading to an endobronchial intubation. Cases of endobronchial intubation associated with laparoscopy are reported during procedures in the headdown position45 and in the headup position.44,46 This complication results in a decrease in the oxygen saturation as measured by pulse oximetry (Spo2) associated with an increase in plateau airway pressure (see Fig. 683).

Gas Embolism Although rare, gas embolism is the most feared and dangerous complication of laparoscopy. Intravascular injection of gas may follow direct needle or trocar placement into a vessel, or it may occur as a consequence of gas insufflation into an abdominal organ. This complication develops principally during the induc tion of pneumoperitoneum,47,48 particularly in patients with pre vious abdominal surgery.49 Gas embolism may also occur later during surgery.50,51 CO2 is used most frequently for laparoscopy because it is more soluble in blood than either air, oxygen, or N2O.30 Rapid elimination also increases the margin of safety in case of intravenous injection of CO2. All these characteristics explain the rapid reversal of the clinical signs of CO2 embolism with treatment. Consequently, the lethal dose of embolized CO2 is approximately five times greater than that of air. The pathophysiology of gas embolism is also determined by the size of the bubbles and the rate of intravenous entry of the gas.52,53 During laparoscopy, the rapid insufflation of gas under high pressure probably causes a gas lock in the vena cava and right atrium; obstruction to venous return with a fall in cardiac output or even circulatory collapse can result. Acute right ven tricular hypertension may open the foramen ovale, allowing para doxical gas embolization.50,54 Paradoxical embolism, however, may occur without patent foramen ovale.55 Volume preload diminishes the risk of gas embolism56 and of paradoxical embo lism.57 Ventilationperfusion ( V Q) mismatching develops with increases in physiologic dead space and hypoxemia. The diagnosis of gas embolism depends on the detection of gas emboli in the right side of the heart or on recognition of the physiologic changes from embolization. Early events, occur ring with 0.5 mL/kg of air or less, include changes in Doppler sounds and increased mean pulmonary artery pressure. The low incidence of gas embolism during laparoscopy precludes the routine use of invasive or expensive monitors to detect emboliza tion of small quantities of gas. When the size of the embolus

Anesthesia for Laparoscopic Surgery 2189

68

increases (2 mL/kg of air), tachycardia, cardiac arrhythmias, hypotension, increased central venous pressure, alteration in heart tones (i.e., millwheel murmur), cyanosis, and electrocardiog raphic changes of rightsided heart strain can develop; all these changes are rarely consistently positive.58 Pulmonary edema can also be an early sign of gas embolism.54 Although pulse oximetry is helpful in recognizing hypoxemia, capnometry and capnog raphy are more valuable in providing early diagnosis of gas embo lism and determining the extent of the embolism. Petco2 decreases in the case of embolism owing to the fall in cardiac output and the enlargement of the physiologic dead space. Con sequently, aETCO2 increases. The decrease in Petco2 may be preceded by an initial increase secondary to pulmonary excretion of the CO2, which has been absorbed into the blood.53 Aspiration of gas or foamy blood from a central venous line establishes the diagnosis. Routine preoperative insertion of a central venous line, however, does not appear justified for these procedures. Treatment of CO2 embolism consists of immediate cessa tion of insufflation and release of the pneumoperitoneum. The patient is placed in steep headdown and left lateral decubitus (Durant) position. The amount of gas that advances through the right side of the heart to the pulmonary circulation is less if the patient is in this position because the buoyant foam is displaced laterally and caudally away from the right ventricular outflow tract. Discontinuing N2O will allow ventilation with 100% O2 to correct hypoxemia and reduce the size of the gas embolus and its consequences.53 Hyperventilation increases CO2 excretion and is made necessary by the increase in the physiologic dead space. If these simple measures are not effective, a central venous or pul monary artery catheter may be introduced for aspiration of the gas. Cardiopulmonary resuscitation must be initiated if necessary. External cardiac massage may be helpful in fragmenting CO2 emboli into small bubbles. The high solubility of CO2 in blood, resulting in rapid absorption from the bloodstream, accounts for the rapid reversal of the clinical signs of CO2 embolism with treatment.48 CO2 embolism, however, may be fatal. Cardiopul monary bypass has been used successfully to treat massive CO2 embolism.50 Hyperbaric oxygen treatment should be strongly considered if cerebral gas embolism is suspected.54 Risk of Aspiration of Gastric Contents Patients undergoing laparoscopy might be considered to be at risk for acid aspiration syndrome (see also Chapter 50). However, the increased IAP results in changes of the lower esophageal sphincter that allow maintenance of the pressure gradient across the gastroesophageal junction and that may therefore reduce the risk of regurgitation.59,60 Furthermore, the headdown position should help to prevent any regurgitated fluid from entering the airway.

Hemodynamic Repercussions of Pneumoperitoneum in Healthy Patients

Peritoneal insufflation to IAPs higher than 10 mm Hg induces significant alterations of hemodynamics.61,62 These disturbances are characterized by decreases in cardiac output, increased arte rial pressures, and elevation of systemic and pulmonary vascular resistances. Heart rates remain unchanged or increased only slightly. The decrease in cardiac output is proportional to the increase in IAP.63 Cardiac output has also been reported to be increased64 or unchanged during pneumoperitoneum.65,66 These discrepancies might be caused by differences in rates of CO2 insufflation, IAP,67 steepness of patient tilt, time intervals between insufflation and collection of data, techniques used to assess hemodynamics, and anesthetic techniques. However, most studies have shown a fall of cardiac output (10% to 30%) during perito neal insufflation whether the patient was placed in the head down68,69 or headup position.70,71 These adverse hemodynamic effects of pneumoperitoneum have been confirmed by studies using pulmonary artery catheterization,69,71 thoracic electrical bioimpedance,68,70 esophageal echoDoppler,72 and transesopha geal echocardiography.7375 Normal intraoperative values of venous oxygen saturation (SvO2 ) and lactate concentrations suggest that changes in cardiac output occurring during pneu moperitoneum are well tolerated by healthy patients.71,76 Cardiac outputs, which decrease shortly after the beginning of the perito neal insufflation, subsequently increase, probably as a result of surgical stress.70,71 Hemodynamic perturbations occur mainly at the beginning of peritoneal insufflation. The mechanism of the decrease of cardiac output is multi factorial (Fig. 684). A decrease in venous return is observed after a transient increase in venous return at low IAPs (<10 mm Hg).77,78 Increased IAP results in caval compression,79 pooling of blood in the legs,80 and an increase in venous resistance.77,78 The decline in venous return, which parallels the decrease in cardiac output,63 is confirmed by a reduction in left ventricular enddiastolic volume measured using transesophageal echocardiography.74 Cardiac filling pressures, however, rise during peritoneal insufflation.69,71 The paradoxical increase of these pressures can be explained by the increased intrathoracic pressure associated with pneumoperi toneum.70,81,82 Right atrial pressure and pulmonary artery occlu sion pressure can no longer be considered reliable indices of cardiac filling pressures during pneumoperitoneum. The fact that atrial natriuretic peptide concentrations remain low despite increased pulmonary capillary occlusion pressure during pneu moperitoneum further suggests that abdominal insufflation interferes with venous return.83 The reduction in venous return and cardiac output can be attenuated by increasing circulating volume before the pneumoperitoneum is produced (Fig. 685).77,84 Increased filling pressures can be achieved by fluid loading or tilting the patient to a slight headdown position before peritoneal insufflation, by preventing the pooling of blood with intermittent sequential pneumatic compression device,85 or by wrapping the legs with elastic bandages.86 The ejection fraction of the left ventricle, assessed by echocardiography, does not appear to decrease significantly when IAP increases to 15 mm Hg.73,74 However, all studies describe an increase in systemic vascular resistance during the existence of the pneumoperitoneum. This increase in afterload is not a reflex sympathetic response to the decreased cardiac output.73,82

Section V Adult Subspecialty Management

Hemodynamic Problems During Laparoscopy

Hemodynamic changes observed during laparoscopy result from the combined effects of pneumoperitoneum, patient position, anesthesia, and hypercapnia from the absorbed CO2. In addition to these pathophysiologic changes, reflex increases of vagal tone and arrhythmias can also develop.

2190

Adult Subspecialty Management

Intra-abdominal pressure

Pooling of blood in the legs

Caval compression

Venous resistance

Intrathoracic pressure

Stimulation of peritoneal receptor?

Vasc. resistance of intraabd. organs

Release of neurohumoral factor(s) (vasopressin, catechol )

Venous return

Inotropism??

Systemic vascular resistance

Cardiac output

Arterial pressure

Figure 68-4 Schematic representation of the different mechanisms leading to decreased cardiac output during pneumoperitoneum for laparoscopy.

Systemic vascular resistance was reported to be increased in studies where no decrease in cardiac output was found.73,76 Although the normal heart tolerates increases in afterload under physiologic conditions, the increases in afterload produced by the presence of a pneumoperitoneum can be deleterious to patients with cardiac disease.87 The increase in systemic vascular resistance is affected by patient position. The Trendelenburg position attenuates this increase; the headup position aggravates it.65,69,76,83 The increase in systemic vascular resistance can be corrected by the administration of vasodilating anesthetic agents, such as isoflu rane,82 or direct vasodilating drugs, such as nitroglycerin88 or nicardipine.89
Cardiac index 4

The increase in systemic vascular resistance is thought to be mediated by mechanical and neurohumoral factors.90 The return of hemodynamic parameters to baseline values is gradual, taking several minutes, suggesting the involvement of neuro humoral factor(s).68,82,87 Catecholamines, the reninangiotensin system, and especially vasopressin are all released during the pres ence of the pneumoperitoneum and may contribute to increasing the afterload.70,71,81,83,91,92 However, only the time course of vaso pressin release parallels that of the increase in systemic vascular resistance.70,71,92 Increases in plasma vasopressin concentrations correlate with changes in intrathoracic pressure and transmural right atrial pressure.81 Mechanical stimulation of peritoneal recep tors also results in increased vasopressin release,93 systemic vas
Systemic vascular resistance

Control Volume loaded

3000 2500 2000 1500 1000

(L/min/m2)

1 Post induct 5 min 15 min 30 min Pneumoperitoneum

(dynesseccm-5)

500 Post induct 15 min 5 min 30 min Pneumoperitoneum

Figure 68-5 Changes in the cardiac index and systemic vascular resistance during laparoscopy in two groups of patients. For group 1 (controls, n = 10, yellow bars), pneumoperitoneum was induced with patients in a 10-degree head-up position. Group 2 (volume loaded, n = 10, blue bars) patients received 500 mL of lactated Ringers solution before anesthesia induction and were insufflated in the supine position. Data are presented as the mean SEM.

Anesthesia for Laparoscopic Surgery 2191

68

cular resistance, and arterial pressure.94 However, whether increasing IAP to 14 mm Hg is sufficient to stimulate these recep tors is unknown. The increase in systemic vascular resistance also explains why the arterial pressure increases but the cardiac output falls.62,90 Use of 2adrenergic agonists such as clonidine71,95 or dexmedetomidine96,97 and of blocking agents98 significantly reduces hemodynamic changes and anesthetic requirements. Use of high doses of remifentanil almost completely prevents the hemodynamic changes.66

Effect of Pneumoperitoneum on Regional Hemodynamics

Increased IAP and the headup position result in lower limb venous stasis.80,85,99 Femoral vein blood flow decreases progres sively with increasing IAP, and no adaptation to the reduced femoral venous outflow occurs, even during prolonged proce dures.100 These changes may predispose to the development of thromboembolic complications. Although cases of thromboem bolism have been reported in the literature, their actual incidence does not seem to be increased by laparoscopy.101103 The effect of CO2 pneumoperitoneum on renal function has also been investigated.104106 Urine output, renal plasma flow, and glomerular filtration rate decrease to less than 50% of base line values during laparoscopic cholecystectomy and are signifi cantly lower than those during open cholecystectomy.104 Urine output significantly increases after deflation. Controversy exists regarding the effect of the CO2 pneu moperitoneum on splanchnic and hepatic blood flow. A signifi cant reduction was reported in animals107 and humans.108110 However, others have not observed any significant changes.111114 Blobner and coworkers,112 comparing CO2 pneumoperitoneum and air pneumoperitoneum in pigs, observed a reduction in splanchnic blood flow during air pneumoperitoneum but not during CO2 pneumoperitoneum. They suggest that the direct splanchnic vasodilating effect of CO2 may counteract the mechan ical effect of increased IAP. Cerebral blood flow velocity increases during CO2 pneu moperitoneum in response to the increased Paco2.115,116 When normocarbia is maintained, pneumoperitoneum combined with the headdown position does not induce harmful changes in intracranial dynamics.117 Intracranial pressure nevertheless rises during CO2 pneumoperitoneum, independently of changes in Paco2, in pigs with preoperative induced intracranial hyperten sion or normal intracranial pressure118,119 and in children with ventriculoperitoneal shunts.120 Intraocular pressure is not affected by pneumoperitoneum in women with no preexisting eye disease.121 In an animal model of glaucoma, pneumoperitoneum only slightly increases intraocular pressure.122

with mild to severe cardiac disease, the pattern of change in mean arterial pressure, cardiac output, and systemic vascular resistance is qualitatively similar to that in healthy patients.87,88,123126 Quan titatively, these changes appear to be more marked. In a initial study including ASA class III or IV patients, SvO2 decreased in 50% of patients despite preoperative hemodynamic optimization using a pulmonary artery catheter.124 Patients who experienced the most severe hemodynamic changes with inadequate oxygen delivery were patients with low preoperative cardiac outputs and central venous pressures and high mean arterial pressures and systemic vascular resistancesa profile suggesting depleted intra vascular volume. The investigators suggest preoperative preload augmentation to offset the hemodynamic effect of pneumoperi toneum. Intravenous nitroglycerin, nicardipine, or dobutamine has been used to manage the hemodynamic changes induced by increased IAP in selected patients with heart disease.88,126 Nitro glycerin was chosen to correct the reduction in cardiac output associated with increased pulmonary capillary occlusion pres sures and systemic vascular resistance. The administration of nicardipine may be more appropriate than that of nitroglycerin. Right atrial and pulmonary capillary occlusion pressures are not reliable indices of cardiac filling pressure during pneumoperito neum. Increased afterload is a major contributor to the altered hemodynamics seen during pneumoperitoneum in cardiac patients. Nicardipine acts selectively on arterial resistance vessels and does not compromise venous return.127 This drug is beneficial in case of congestive heart failure.128 Because normalization of hemodynamic variables does not occur for at least 1 hour post operatively in certain patients,87,125 congestive heart failure can develop in the early postoperative period. Dhoste and associ ates129 did not observe impaired hemodynamics in elderly ASA class III patients, but they used low IAP (10 mm Hg) and slow insufflation rates (1 L/min). The hemodynamic consequences of pneumoperitoneum are minor in heart transplant recipients who have good ventricular function.130,131 Laparoscopic adrenalectomy in patients with pheochromocytoma can be successfully managed using a continuous infusion of nicardipine.89,132 Several studies suggest that hemodynamic changes during pneumoperitoneum are well tolerated by morbidly obese patients.8,133,134

Section V Adult Subspecialty Management

Cardiac Arrhythmias During Laparoscopy

Arrhythmias during laparoscopy have several causes. The increased Paco2 may not be the cause of the arrhythmias occur ring during laparoscopy. Arrhythmias do not correlate with the level of the Paco2 and may develop early during insufflation, when high Paco2 is not present. Reflex increases of vagal tone may result from sudden stretching of the peritoneum and during electrocoagulation of the fallopian tubes.135 Bradycardia, cardiac arrhythmias, and asystole can develop. Vagal stimulation is accentuated if the level of anesthesia is too superficial or if the patient is taking blocking drugs. These events are easily and quickly reversible. Treatment consists of interruption of insufflation, atropine administration, and deepening of anesthesia after recovery of the heart rate. Cardiac irregularities occur most often early, during insuf flation, when pathophysiologic hemodynamic changes are the most intense. For this reason, arrhythmias may also reflect intol erance of these hemodynamic disturbances in patients with

Hemodynamic Repercussions of Pneumoperitoneum in High-Risk Cardiac Patients

The demonstration of significant hemodynamic changes during pneumoperitoneum raises the question of tolerance of these changes in cardiac patients (see Chapters 35 and 60). In patients

2192

Adult Subspecialty Management

known or latent cardiac disease. Gas embolism can also result in cardiac arrhythmias.

Nerve Injury
Nerve compression is a potential complication during the head down position. Overextension of the arm must be avoided. Shoul der braces should be used with great caution and must not impinge on the brachial plexus. Lower extremity neuropathies (e.g., peroneal neuropathy, meralgia paresthetica, femoral neu ropathy) have been reported after laparoscopy.137,138 The common peroneal nerve is particularly vulnerable and must be protected when the patient is placed in the lithotomy position. Prolonged lithotomy position, such as required for some operative laparos copies, can result in lower extremity compartment syndrome.

Problems Related to Patient Position

Patient positioning (see Chapter 36) depends on the site of surgery; whereas headdown tilt is used for pelvic and lower abdominal surgery, the headup position is preferred for upper abdominal surgery. The patient is often placed in the lithotomy position. These positions may be responsible for, or contribute to, the development of pathophysiologic changes or injury during laparoscopy. The steepness of the tilt also affects the magnitude of these changes.

Postoperative Benefits and Consequences of Laparoscopy

Implicit in the decision to use the laparoscopic approach is the assumption that the intraoperative consequences of pneumoperi toneum described in the previous sections are counterbalanced by multiple postoperative benefits. In contrast to laparotomy, improved and more rapid recovery, reduced postoperative fatigue,139,140 and a heightened feeling of wellbeing are commonly reported and reflect better maintenance of homeostasis.3,139

Cardiovascular Effects
In normotensive subjects, the headdown position results in an increase in central venous pressure and cardiac output. The baroreceptor reflex response to increased hydrostatic pressure consists of systemic vasodilation and bradycardia. Although these different reflexes may be impaired during general anesthesia, the hemodynamic changes induced by this position during laparos copy remain insignificant.69,76 However, central blood volume and pressure changes are greater in patients with coronary artery disease, particularly with poor ventricular function, leading to potentially deleterious increased myocardial oxygen demand.32 The Trendelenburg position may also affect the cerebral circula tion, particularly in case of low intracranial compliance,136 and result in elevation of the intraocular venous pressure (which can worsen acute glaucoma).121 Although the intravascular pressure increases in the upper torso, the headdown position decreases transmural pressures in the pelvic viscera, reducing blood loss but increasing the risk of gas embolism.32,56 With the headup position, a decrease in cardiac output and mean arterial pressure results from the reduction in venous return.69,76,82 This decrease in cardiac output compounds the hemodynamic changes induced by pneumoperitoneum. The steeper the tilt, the greater the fall in cardiac output. Venous stasis in the legs occurs during the headup posi tion and may be aggravated by the lithotomy position with knees flexed.32 Because pneumoperitoneum further increases blood pooling in the legs,80,99 any additional factor contributing to cir culatory dysfunction should be avoided. The legs must be freely supported and not tightly strapped, and pressure on the popliteal space must be prevented.

Stress Response
In patients undergoing cholecystectomy, the laparoscopic approach allows for a reduction of the acute phase reaction seen after open cholecystectomy. Plasma concentrations of Creactive protein and interleukin6, which reflect the extent of tissue damage, are significantly lower after laparoscopy as compared with laparotomy.3,139,141143 The metabolic response (e.g., hypergly cemia, leukocytosis) is also reduced after laparoscopy. As a con sequence, nitrogen balance and immune function might be better preserved.144147 Laparoscopy avoids prolonged exposure and manipulation of the intestines and decreases the need for perito neal incision and trauma. Consequently, postoperative ileus and fasting, duration of intravenous infusion, and hospital stay are significantly reduced after laparoscopy.2,3,141,147149 The duration of postoperative ileus is less shortened when compared with laparot omy than previously reported.150 The economic implications of these factors are selfevident and beneficial.151153 Surprisingly, whereas laparoscopy allows for a reduction of surgical trauma, the endocrine response to laparoscopic and open cholecystectomy does not differ significantly; plasma concentra tions of cortisol and catecholamines,3,139,154,155 urinary concentra tions of cortisol and catecholamine metabolites,141 and anesthetic requirements3 are similar after both procedures. Combined general and epidural anesthesia for laparoscopic cholecystectomy does not result in a decreased stress response compared with general anesthesia alone.154 Several hypotheses can be invoked to explain these observations. Pain and discomfort from peritoneal stretch ing, hemodynamic disturbances, and ventilatory changes induced by pneumoperitoneum may contribute to the stress response of laparoscopy. Although parietal afference, which is markedly reduced by laparoscopy, appears to be an important stimulus for postoperative hyperglycemia, visceral nociception, which is less

Respiratory Changes
The headdown position facilitates the development of atelectasis. Steep headdown tilt results in decreases in the functional resid ual capacity, the total lung volume, and the pulmonary compli ance. These changes are more marked in obese, elderly, and debilitated patients. In healthy patients no major changes are seen.32 The headup position is usually considered to be more favorable to respiration.30,32

Anesthesia for Laparoscopic Surgery 2193

68

affected by laparoscopy, may contribute more to adrenocortical stimulation.139 The intraoperative stress response, however, can be reduced by preoperative administration of 2agonists.71,96,97

Postoperative Pain
Surgical trauma contributes to pain and pulmonary dysfunction. Laparoscopy allows a significant reduction in postoperative pain and analgesic consumption (see Chapter 87).3,141,154,156160 Never theless, pain intensity may be significant.161163 The nature of pain varies depending on the surgical technique; after laparotomy, patients complain more of parietal pain (e.g., abdominal wall), whereas after laparoscopic cholecystectomy, patients report also visceral pain (e.g., biliary colic [cholecystectomy], pelvic spasm [tubal ligation]), and shouldertip pain resulting from diaphrag matic irritation.162,163 Pain after laparoscopy is multifactorial, and different treatments have been proposed to provide pain relief.164,165 Local anesthetic infiltration (e.g., intraperitoneal, portsite infil tration) for postoperative pain relief after laparoscopic chole cystectomy produces contradictory results.166170 Benefits of intraperitoneal local anesthetic are greater after gynecologic laparoscopy.166,171 Mesosalpinx block decreases postoperative pain and analgesic consumption after laparoscopic sterilization.166 Residual CO2 pneumoperitoneum contributes to postoperative pain. Careful evacuation of residual CO2 after desufflation was shown to be effective.164,172,173 Preoperative administration of nonsteroidal antiinflammatory drugs (NSAIDs) and of cyclooxygenase2 inhibitors decreases pain, as does opiate con sumption after gynecologic laparoscopy174177 and laparoscopic cholecystectomy.178182 However, others have failed to demonstrate any significant effect of preoperative NSAID on pain after laparo scopic sterilization more severe than after diagnostic gynecologic laparoscopy.183186 Dexamethasone is also effective in reducing postoperative pain.187 Multimodal analgesia is now recommended to prevent and treat postlaparoscopy pain.188190

cantly delay discharge of outpatients.200 In addition to post operative pain of various types, one of the main complaints is postoperative nausea and vomiting (PONV) (40% to 75% of patients).201203 Whereas perioperative opioids increase the inci dence of PONV,204206 propofol anesthesia can markedly reduce the high incidence of these side effects.206,207 The effect of N2O on the incidence of nausea is still controversial.206,208,209 Intraoperative drainage of gastric contents also reduces PONV.210 Intraoperative administration of droperidol and a 5hydroxytryptamine type 3 antagonist appears to be helpful in the prevention and treatment of these side effects.206,211215 Transdermal scopolamine reduces nausea and vomiting after outpatient laparoscopy.201 Perioperative liberal intravenous fluid therapy can contribute to decreasing these symptoms and to improve postoperative recovery.216218

Section V Adult Subspecialty Management

Alternatives to CO2 Pneumoperitoneum

New approaches have been investigated to reduce pathophysio logic consequences of CO2 pneumoperitoneum.

Inert Gases
Insufflation of inert gas (e.g., helium, argon) instead of CO2 avoids the increase in Paco2 from absorption.219,220 Consequently, hyper ventilation is not required.27,221223 Also, the ventilatory conse quences of the increased IAP persist. The hemodynamic changes produced by pneumoperitoneum using inert gas are similar to those observed with CO2. However, the use of these gases accen tuates the decrease in cardiac output, whereas the increase in arterial pressure is attenuated.27,90,223,224 Unfortunately, the low blood solubility of the inert gases raises the issue of safety in the event of gas embolism.225,226

Pulmonary Dysfunction
Upper abdominal surgery results in postoperative changes in pulmonary function (see also Chapter 93). Respiratory dysfunc tion is less severe and recovery is quicker after laparo scopy.3,90,141,154,156,157,191193 Nevertheless, diaphragmatic function remains significantly impaired after laparoscopy.194196 Thoracic epidural analgesia does not improve lung function after laparo scopic cholecystectomy.154 Greater reductions in expiratory volumes and slower recovery of pulmonary function after laparo scopy are reported in older patients,197 obese patients,159,198 smokers, and patients with COPD198 than in healthy patients. Postoperative pulmonary function of these patients, however, is improved after laparoscopy as compared with laparotomy.159,160,198 Postoperative pulmonary function is less impaired after gyneco logic laparoscopy than after upper abdominal laparoscopic surgery.199

Gasless Laparoscopy
Another alternative is gasless laparoscopy. The peritoneal cavity is expanded using abdominal wall lift obtained with a fan retrac tor. This technique avoids the hemodynamic and respiratory repercussions of increased IAP and the consequences of the use of CO2.227231 Renal and splanchnic perfusion is not altered.108,232 Portsite metastases after laparoscopic surgery for cancer are reduced after gasless laparoscopy.233,234 This technique, therefore, is appealing for patients with severe cardiac or pulmonary disease. However, gasless laparoscopy compromises surgical exposure and increases technical difficulty.229,233,234 Combining abdominal wall lifting with low pressure CO2 pneumoperitoneum (5 mm Hg) may improve surgical conditions.

Postoperative Nausea and Vomiting

Laparoscopy is frequently associated with minor postoperative sequelae that can persist more than 48 hours and that can signifi

Laparoscopy During Pregnancy and in Children

The most common nonobstetric surgical procedures during preg nancy are adnexal surgery, appendectomy, and cholecystectomy,

2194

Adult Subspecialty Management

and they are amenable to laparoscopic surgery (see Chapter 69).235 Laparoscopy during pregnancy raises several concerns. Abdomi nal surgery increases the risk of miscarriage or premature labor. However, all the reports in the literature of laparoscopy carried out between 4 and 32 weeks of estimated gestational age have resulted in uncomplicated pregnancies.236240 Another concern is the risk of damaging the gravid uterus. This can be avoided by alternative entry sites for the Veress needle and trocars. CO2 pneumoperitoneum induces significant fetal acidosis. Fetal heart rate and arterial pressure increase, but these changes are minimal.241 Provided maternal Paco2 is maintained at normal levels, fetal placental perfusion pressure and blood flow, pH, and blood gas tensions are unaffected by insufflation or desufflation.242 Capnography is adequate to guide ventilation during laparoscopy in pregnant patients.243 Hemodynamic changes induced by pneu moperitoneum are similar in pregnant and nonpregnant women.244 The following recommendations are for safe laparoscopy in preg nant patients236: 1. The operation should occur during the second trimester, ideally before the 23rd week of pregnancy, to minimize the risk of preterm labor and to maintain adequate intra abdominal working room. 2. Tocolytics are beneficial to arrest preterm labor, but their prophylactic use is debatable. 3. Open laparoscopy should be used for abdominal access to avoid damaging the uterus. 4. Fetal monitoring may be performed using transvaginal ultrasonography. 5. Mechanical ventilation must be adjusted to maintain a physiologic maternal alkalosis. Gasless laparoscopy is an alternative to avoid the potential side effects of CO2 pneumoperitoneum and can sometimes be managed using epidural anesthesia.245,246 Laparoscopy is frequently performed in infants and chil dren (see Chapter 82). Knowledge of the pathophysiologic changes induced by laparoscopy in children is necessary to adapt their monitoring and anesthetic technique.247 CO2 pneumoperi toneum induces the same changes in respiratory mechanics to those reported in adults.248250 Paco2 and Petco2 increase during pneumoperitoneum, but Petco2 may sometimes overestimate Paco2.251 The profile of CO2 absorption and the magnitude of CO2 absorption compared with metabolic VCO2 are similar in infants and children to those recorded in adults.252 The hemodynamic changes observed in children are similar to those reported in adults.253257 Pneumoperitoneum results in oliguria or anuria in children, reversible after desufflation.258 Controversy concerning the benefits (improved analgesia and postoperative recovery) of laparoscopy for appendectomy, the most frequent indication for laparoscopy in children, persists.259261

The experience of gynecologic laparoscopists extends over a relatively long time and, as a result, large surveys are availa ble.262,263 Mortality rates have varied from 1 per 10,000 to 1 per 100,000 cases. The number of serious complications requiring laparotomy was 2 to 10 per 1000 cases. Intestinal injuries accounted for 30% to 50% of these and remained undiagnosed during laparoscopy in one half of the cases. Vascular complica tions also accounted for 30% to 50%. Burns were responsible for 15% to 20% of the reported complications. Although the death rate decreased, the complication rate was slightly higher in the most recent surveys, probably because of the increased complex ity of the laparoscopies performed over the past few years. Large surveys of complications after laparoscopic cholecys tectomy are available.152,264268 The overall mortality rate is 0.1 to 1 per 1000 cases.268 Conversion to laparotomy was necessary in approximately 1% of patients. Bowel perforation occurred in about 2 per 1000 cases, common bile duct injury in 2 to 6 per 1000 cases, and significant hemorrhage in 2 to 9 per 1000 cases. Laparoscopic cholecystectomy was accompanied by a greater frequency of minor operative complications, whereas open cholecystectomy had a more frequent rate of minor general com plications. A learning curve was demonstrated for laparoscopic cholecystectomy; experience was associated with decreased oper ative times and rates of minor or moderate complications. Some of these complications might be prevented by open laparoscopy.269 Although large vessel injury (e.g., aorta, inferior vena cava, iliac vessels) caused emergency situations, retroperitoneal hematoma can develop insidiously and result in significant blood loss without major intraperitoneal effusion, leading to delayed diagnosis. During gynecologic laparoscopy, complications occur more frequently during the creation of pneumoperitoneum and the introduction of trocars, whereas during gastrointestinal surgery they are more closely related to the surgical procedure itself.152,270,271 Injuries provoked by the Veress needle are usually less severe than those by trocars and may even remain undiag nosed. Unrecognized gastrointestinal tract injury and subhepatic abscess formation can lead to potentially lethal septic complica tions.272 The rate of postoperative infections (e.g., surgical site, respiratory) seems to be significantly lower after laparoscopy than after laparotomy.273 Although all these events are surgery related, the anesthesiologist must be aware of the complications and timing of their occurrence. He or she must be ready to respond promptly and adequately to these mishaps and to help the surgeon diagnose a complication.

Anesthesia for Laparoscopy

Preoperative Evaluation of the Patient and Premedication
Without regard to surgical contraindications, absolute contrain dications to laparoscopy and pneumoperitoneum are rare, and some still require characterization (see Chapter 34). Pneumoperi toneum is undesirable in patients with increased intracranial pressure (e.g., tumor, hydrocephalus, head trauma) and hypovo lemia. Laparoscopy can be performed safely in patients with ven tricular peritoneal shunt and peritoneojugular shunt that are

Complications of Laparoscopy
With the development of more sophisticated endoscopic opera tions, it is important to consider the risks and benefits of laparos copy. Although the benefits of the laparoscopic approach are well documented, knowledge of the incidence of complications is more imprecise and is frequently based on retrospective studies.

Anesthesia for Laparoscopic Surgery 2195

68

provided with unidirectional valve resistant to IAPs used during pneumoperitoneum. In case of glaucoma, the effects on intraocu lar pressure do not seem to be clinically significant but deserve further confirmation.122 In patients with heart disease, cardiac function should be evaluated in light of the hemodynamic changes induced by pneu moperitoneum and patient position, particularly in case of com promised ventricular function (Table 681). Patients with severe congestive heart failure and terminal valvular insufficiency are more prone to develop cardiac complications than patients with ischemic cardiac disease during laparoscopy. Whether laparos copy is more dangerous than laparotomy in these patients has not yet been explored directly but deserves careful consideration. For these patients, the postoperative benefits of laparoscopy must be balanced against the intraoperative risks when the choice of laparoscopy versus laparotomy is discussed. Gasless laparoscopy may represent an alternative for these patients. Because of the side effects of increased IAP on renal func tion, patients with renal failure deserve special care to optimize hemodynamics during pneumoperitoneum, and the concomitant use of nephrotoxic drugs should be avoided. In patients with respiratory disease, laparoscopy appears preferable to laparotomy because of reduced postoperative respi ratory dysfunction. This positive effect counterbalances the risk of pneumothorax during pneumoperitoneum and the risk of inadequate gas exchange from V Q mismatching. Because of venous stasis in the legs during laparoscopy, prophylaxis of deep vein thrombosis should be the same as for laparotomy. Premedication should be adapted to the duration of the laparoscopy and to the necessity for quick recovery in the outpatient setting. Preoperative administration of NSAIDs may be helpful in reducing postoperative pain and opiate require ments. Preoperative clonidine and dexmedetomidine decrease

the intraoperative stress response and improve hemodynamic stability.71,9597

Patient Positioning and Monitoring

Patients must be positioned (see Chapter 36) with great care to prevent nerve injuries; padding should protect from nerve com pression, and shoulder braces, if needed, should be placed overly ing the coracoid process. Patient tilt should be reduced as much as possible and should not exceed 15 to 20 degrees. Tilting must be slow and progressive to avoid sudden hemodynamic and res piratory changes. The position of the endotracheal tube must be checked after any change in patient position. Induction and release of the pneumoperitoneum must be smooth and progres sive. Mask ventilation before intubation can inflate the stomach with gas, which must be aspirated before trocar placement to avoid gastric perforation, particularly for supramesocolic laparos copy. The bladder should be emptied before pelvic laparoscopy or prolonged procedures. During laparoscopy, arterial blood pressure, heart rate, electrocardiography, capnometry, and pulse oximetry must be continuously monitored. Although this level of monitoring is valuable for detection of cardiac arrhythmias, gas embolism, CO2 subcutaneous emphysema, and pneumothorax, it provides only indirect evidence of the hemodynamic changes induced by the pneumoperitoneum. Although more invasive hemodynamic monitoring may be necessary in patients with cardiac diseases, increased intrathoracic pressure complicates the interpretation of measured central venous and pulmonary artery pressures. Trans esophageal echocardiography may be more helpful in patients with severe cardiac disease (see Table 681). Petco2 and Spo2 reliably reflect Paco2 and arterial oxygen saturation (Sao2). However, the aETCO2 may vary from patient to patient and during the course of laparoscopy in the same patient. Petco2 must be monitored carefully to avoid hypercapnia and to detect gas embolism. Because aETCO2 may increase more in patients with cardiac and pulmonary diseases, cannulation of a radial artery may be helpful to allow direct measurement of Paco2 from an arterial blood sample.

Section V Adult Subspecialty Management

Table 68-1 Management of Patients with Cardiac Disease for Laparoscopy Preoperative Evaluation: Echocardiography If left ventricular ejection fraction < 30%: Intraoperative monitoring Intra-arterial line Pulmonary artery catheter? Transesophageal echocardiography Continuous ST-segment analysis? Gasless laparoscopy? Laparotomy? Intraoperative Management Slow insufflation Low intra-abdominal pressure Hemodynamic optimization before pneumoperitoneum (preload augmentation) Patient tilt after insufflation Anesthesia: remifentanil, vasodilating anesthetic and drugs (nicardipine, nitroglycerin), cardiotonic agents Experienced surgeon Postoperative Care Slow recovery from anesthesia (benefit of clonidine)

Anesthetic Techniques
General, local, and regional anesthesia have all been used success fully and safely for laparoscopy. General Anesthesia General anesthesia with endotracheal intubation and controlled ventilation is certainly the safest and most commonly used technique and therefore is recommended for inpatients and for long laparoscopic procedures. During pneumoperitoneum, con trolled ventilation must be adjusted to maintain Petco2 between 35 and 40 mm Hg. In our experience, this requires no more than a 15% to 25% increase of minute ventilation, except when CO2 subcutaneous emphysema develops. Increase of respiratory rate rather than of tidal volume may be preferable in patients with COPD and in patients with a history of spontaneous pneu mothorax or bullous emphysema to avoid increased alveolar inflation and reduce the risk of pneumothorax. Infusion of vasodilating drugs, such as nicardipine,89,132 2adrenergic

2196

Adult Subspecialty Management

receptor agonists,71,9597 and remifentanil66 reduces the hemody namic repercussions of pneumoperitoneum and may facilitate management of cardiac patients (see Table 681). The actual con tribution of N2O to PONV is probably less than previously con sidered.206 Although N2O does not seem to be contraindicated for laparoscopic cholecystectomy,208 omission of N2O improves sur gical conditions for intestinal and colonic surgery.274 The choice of anesthetic technique does not seem to play a major role in patient outcome.275277 Propofol, nevertheless, results in fewer postoperative side effects.278280 Propofol anesthesia for laparo scopic fertility procedures involving genetic material transfers, however, is associated with lower clinical and ongoing pregnancy rates compared with isoflurane.281 IAP should be monitored, kept as low as possible to reduce hemodynamic and respiratory changes, and not allowed to exceed 20 mm Hg. Increases in IAP can be avoided by ensuring a deep plane of anesthesia. Whether profound muscle relaxation is necessary for laparoscopy is not clear.282 Liberal perioperative intravenous fluid therapy decreases hemodynamic changes from pneumoperitoneum77,84 and PONV and improves postoperative recovery.216218 Because of the poten tial for reflex increases of vagal tone during laparoscopy, atropine should be available if necessary. The laryngeal mask airway results in fewer cases of sore throat and may be proposed as an alternative to endotracheal intubation283287 (also see Chapter 50) even if this device does not protect the airway from aspiration of gastric contents.288,289 It allows controlled ventilation and accurate monitoring of Petco2. However, decreased thoracopulmonary compliance during pneumoperitoneum frequently results in airway pressures exceeding 20 cm H2O. The ProSeal laryngeal mask airway may be an alternative to guarantee an airway seal up to 30 cm H2O.290,291 General anesthesia in patients breathing spontaneously without intubation can be performed safely and avoids tracheal irritation as well as administration of muscle relaxant. This anes thetic technique must be restricted to short procedures performed using low IAP and small degrees of tilt.292 In these conditions, the laryngeal mask airway might improve the safety of anesthe sia283,286,293 and is therefore recommended. Local and Regional Anesthesia Local anesthesia offers several advantages: quicker recovery, decreased PONV, early diagnosis of complications, and fewer hemodynamic changes (see Chapters 30, 51, and 52).294,295 However, this anesthetic approach requires precise and gentle surgical technique and may result in increased patient anxiety, pain, and discomfort during the manipulation of pelvic and abdominal organs. For these reasons, local anesthesia is routinely supplemented with intravenous sedation. The combined effect of pneumoperitoneum and sedation can lead to hypoventilation and arterial oxygen desaturation.296 Complex laparoscopic procedure must not be managed with local anesthesia. Regional anesthesia, including epidural and spinal tech niques, combined with the headdown position can be used for gynecologic laparoscopy without major impairment of ventila tion.18,297,298 Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia in COPD patients.299,300 The metabolic response is reduced by regional anesthesia.301 Globally, epidural and local anesthesia share the same benefits and disad vantages. Regional anesthesia reduces the need for sedatives and

narcotics, produces better muscle relaxation, and can be proposed for laparoscopic procedures other than sterilization. Shouldertip pain from diaphragmatic irritation and discomfort from abdomi nal distention are incompletely alleviated using epidural anesthe sia alone.302 Extensive sensory block (T4L5) is necessary for surgical laparoscopy and may also lead to discomfort. The epi dural administration of opiates or clonidine, or both, may help to provide adequate analgesia.302 The hemodynamic effects of pneu moperitoneum under epidural anesthesia have not been studied. Regional anesthesia can provide adequate relief of pain and dis comfort in case of gasless laparoscopy, thus avoiding most of the side effects of CO2 pneumoperitoneum.246,303

Recovery and Postoperative Monitoring

Hemodynamic monitoring should be continued in the PACU (see Chapter 85). Hemodynamic changes induced by the pneumo peritoneum, and more particularly the increased systemic vascu lar resistance, outlast the release of the pneumoperitoneum. The hyperdynamic state developing after laparoscopy could conceiv ably lead to a precarious hemodynamic situation in patients with cardiac disease.87,125 Despite the reduction in postoperative pulmonary dys function, Pao2 still decreases after laparoscopic cholecystec tomy.3,156,192 Increased oxygen demand is observed after laparoscopy. Although laparoscopy tends to be considered a minor surgical procedure, oxygen should be administered post operatively, even to healthy patients.304 Finally, prevention and treatment of nausea, vomiting, and pain are important, particularly after outpatient laparoscopic procedures.

Summary
Laparoscopy results in multiple postoperative benefits including less trauma, less pain, less pulmonary dysfunction, quicker recov ery, and shorter hospital stay. These advantages are regularly emphasized and explain the increasing success of laparoscopy, which is now proposed for many surgical procedures. Intraopera tive cardiorespiratory changes occur during pneumoperitoneum. Paco2 increases because of CO2 absorption from the peritoneal cavity. In compromised patients, cardiorespiratory disturbances aggravate this increase in Paco2. Hemodynamic changes are accentuated in highrisk cardiac patients. Improved knowledge of the pathophysiologic hemodynamic changes in healthy patients allows for successful anesthetic management of cardiac patients, by optimizing preload before pneumoperitoneum and through judicious use of vasodilating agents. Alternative insufflating gases (e.g., He, Ar, N2O) do not seem to reduce the hemodynamic changes. Gasless laparoscopy may be more helpful but unfortu nately increases technical difficulty. The incidence of complica tions has now been reported in several large surveys and compares favorably with that of open surgery. The death rate during opera tive laparoscopy is 0.1 to 1 per 1000 cases; the incidence of hem orrhagic complications and visceral injury is 2 to 5 per 1000 cases. Whereas no anesthetic technique has proved to be clinically supe rior to any other, general anesthesia with controlled ventilation

Anesthesia for Laparoscopic Surgery 2197

68

seems to be the safest technique for operative laparoscopy. Improved knowledge of the intraoperative repercussions of lapar oscopy permits safe management of patients with more and more

severe cardiorespiratory disease, who may subsequently benefit from the multiple postoperative advantages offered by this approach.

Section V Adult Subspecialty Management

References
1. Dubois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy: Preliminary report of 36 cases. Ann Surg 211:60, 1990. 2. Grace PA, Quereshi A, Coleman J, et al: Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 78:160, 1991. 3. Joris J, Cigarini I, Legrand M, et al: Metabolic and respiratory changes after cholecystectomy per formed via laparotomy or laparoscopy. Br J Anaesth 69:341, 1992. 4. Wahba RW, Tessler MJ, Kleiman SJ: Acute ven tilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 43:77, 1996. 5. Bardoczky GI, Engelman E, Levarlet M, et al: Ven tilatory effects of pneumoperitoneum monitored with continuous spirometry. Anaesthesia 48:309, 1993. 6. Fahy BG, Barnas GM, Flowers JL, et al: The effects of increased abdominal pressure on lung and chest wall mechanics during laparoscopic surgery. Anesth Analg 81:744, 1995. 7. Fahy BG, Barnas GM, Nagle SE, et al: Changes in lung and chest wall properties with abdominal insufflation of carbon dioxide are immediately reversible. Anesth Analg 82:501, 1996. 8. Dumont L, Mattys M, Mardirosoff C, et al: Changes in pulmonary mechanics during laparoscopic gas troplasty in morbidly obese patients. Acta Anaes thesiol Scand 41:408, 1997. 9. Sprung J, Whalley DG, Falcone T, et al: The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy. Anesth Analg 94:1345, 2002. 10. Mutoh T, Lamm WJ, Embree LJ, et al: Volume infu sion produces abdominal distension, lung compres sion, and chest wall stiffening in pigs. J Appl Physiol 72:575, 1992. 11. Andersson LE, Baath M, Thorne A, et al: Effect of carbon dioxide pneumoperitoneum on develop ment of atelectasis during anesthesia, examined by spiral computed tomography. Anesthesiology 102:293, 2005. 12. OdebergWernerman S: Laparoscopic surgery effects on circulatory and respiratory physiology: an overview. Eur J Surg (Suppl) 585:4, 2000. 13. Andersson L, Lagerstrand L, Thorne A, et al: Effect of CO(2) pneumoperitoneum on ventilation perfusion relationships during laparoscopic chole cystectomy. Acta Anaesthesiol Scand 46:552, 2002. 14. Mullet C, Viale J, Sagnard P, et al: Pulmonary CO2 elimination during surgical procedures using intra or extraperitoneal CO2 insufflation. Anesth Analg 76:622, 1993. 15. Nyarwaya J, Mazoit J, Samii K: Are pulse oximetry and endtidal carbon dioxide tension monitoring reliable during laparoscopic surgery? Anaesthesia 49:775, 1994. 16. Baraka A, Jabbour S, Hammoud R, et al: Endtidal carbon dioxide tension during laparoscopic chole cystectomy: Correlation with the baseline value prior to carbon dioxide insufflation. Anaesthesia 49:304, 1994. 17. Lister DR, RudstonBrown B, Warriner CB, et al: Carbon dioxide absorption is not linearly related to intraperitoneal carbon dioxide insufflation pressure in pigs. Anesthesiology 80:129, 1994. 18. Ciofolo MJ, Clergue F, Seebacher J, et al: Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg 70:357, 1990. 19. Wahba RW, Mamazza J: Ventilatory requirements during laparoscopic cholecystectomy. Can J Anaesth 40:206, 1993. 20. Bures E, Fusciardi J, Lanquetot H, et al: Ventilatory effects of laparoscopic cholecystectomy. Acta Anaesthesiol Scand 40:566, 1996. 21. Wittgen CM, Andrus CH, Fitzgerald SD, et al: Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 126:997, 1991. 22. Wittgen CM, Naunheim KS, Andrus CH, et al: Preoperative pulmonary function evaluation for laparoscopic cholecystectomy. Arch Surg 12:880, 1993. 23. Fitzgerald SD, Andrus CH, Baudendistel LJ, et al: Hypercarbia during carbon dioxide pneumoperito neum. Am J Surg 163:186, 1992. 24. Wulkan ML, Vasudevan SA: Is endtidal CO2 an accurate measure of arterial CO2 during laparo scopic procedures in children and neonates with cyanotic congenital heart disease? J Pediatr Surg 36:1234, 2001. 25. Tolksdorf W, Strang CM, Schippers E, et al: [The effects of the carbon dioxide pneumoperitoneum in laparoscopic cholecystectomy on postoperative spontaneous respiration]. Anaesthesist 41:199, 1992. 26. Rademaker BM, Odoom JA, de Wit LT, et al: Haemodynamic effects of pneumoperitoneum for laparoscopic surgery: a comparison of CO2 with N2O insufflation. Eur J Anaesthesiol 11:301, 1994. 27. Rademaker BM, Bannenberg JJ, Kalkman CJ, et al: Effects of pneumoperitoneum with helium on hemodynamics and oxygen transport: A compari son with carbon dioxide. J Laparoendosc Surg 5:15, 1995. 28. Tan PL, Lee TL, Tweed WA: Carbon dioxide absorp tion and gas exchange during pelvic laparoscopy. Can J Anaesth 39:677, 1992. 29. Kazama T, Ikeda K, Kato T, et al: Carbon dioxide output in laparoscopic cholecystectomy. Br J Anaesth 76:530, 1996. 30. Nunn J: Applied Respiratory Physiology, 4th ed. London, Butterworths Heinemann, 1993. 31. Hirvonen EA, Nuutinen LS, Kauko M: Ventilatory effects, blood gas changes, and oxygen consumption during laparoscopic hysterectomy. Anesth Analg 80:961, 1995. 32. Wilcox S, Vandam LD: Alas, poor Trendelenburg and his position! A critique of its uses and effective ness. Anesth Analg 67:574, 1988. 33. Hall D, Goldstein A, Tynan E, et al: Profound hyper carbia late in the course of laparoscopic cholecys tectomy: Detection by continuous capnometry. Anesthesiology 79:173, 1993. 34. Wolf JS Jr, Monk TG, McDougall EM, et al: Extra peritoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery. J Urol 154:959, 1995. 35. Streich B, Decailliot F, Perney C, et al: Increased carbon dioxide absorption during retroperitoneal laparoscopy. Br J Anaesth 91:793, 2003. 36. Chien GL, Soifer BE: Pharyngeal emphysema with airway obstruction as a consequence of laparo scopic inguinal herniorrhaphy. Anesth Analg 80:201, 1995. 37. Spielman FJ: Laparoscopic surgery. In Kirby DD, Hood RR, Brown DL (eds): Problems in Anesthesia: Anesthesia in Obstetrics and Gynecology. Philadel phia, JB Lippincott 1989, p 151. 38. Whiston RJ, Eggers KA, Morris RW, et al: Tension pneumothorax during laparoscopic cholecystec tomy. Br J Surg 78:1325, 1991. 39. Knos GB, Sung YF, Toledo A: Pneumopericardium associated with laparoscopy. J Clin Anesth 3:56, 1991. 40. McConnell MS, Finn JC, Feeley TW: Tension hydrothorax during laparoscopy in a patient with ascites. Anesthesiology 80:1390, 1994. 41. Joris JL, Chiche JD, Lamy ML: Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive endexpiratory pressure. Anesth Analg 81:993, 1995. 42. Batra MS, Driscoll JJ, Coburn WA, et al: Evanescent nitrous oxide pneumothorax after laparoscopy. Anesth Analg 62:1121, 1983. 43. BottcherHaberzeth S, Dullenkopf A, Gitzelmann CA, Weiss M: Tracheal tube tip displacement during laparoscopy in children. Anaesthesia 62:131, 2007. 44. Morimura N, Inoue K, Miwa T: Chest roentgeno gram demonstrates cephalad movement of the carina during laparoscopic cholecystectomy. Anesthesiology 81:1301, 1994. 45. Burton A, Steinbrook RA: Precipitous decrease in oxygen saturation during laparoscopic surgery. Anesth Analg 76:1177, 1993. 46. Brimacombe J, Orlande H, Graham D: Endobron chial intubation during upper abdominal laparo scopic surgery in the reverse Trendelenburg position. Anesth Analg 78:607, 1997. 47. de Plater RM, Jones IS: Nonfatal carbon dioxide embolism during laparoscopy. Anaesth Intensive Care 17:359, 1989. 48. Ostman PL, PantleFisher FH, Faure EA, et al: Cir culatory collapse during laparoscopy. J Clin Anesth 2:129, 1990. 49. Cottin V, Delafosse B, Viale JP: Gas embolism during laparoscopy: a report of seven cases in patients with previous abdominal surgical history. Surg Endosc 10:166, 1996. 50. Diakun TA: Carbon dioxide embolism: successful resuscitation with cardiopulmonary bypass. Anesthesiology 74:1151, 1991. 51. Greville AC, Clements EA, Erwin DC, et al: Pulmo nary air embolism during laparoscopic laser chole cystectomy. Anaesthesia 46:113, 1991. 52. Couture P, Boudreault D, Derouin M, et al: Venous carbon dioxide embolism in pigs: an evaluation of endtidal carbon dioxide, transesophageal echocar diography, pulmonary artery pressure, and precor dial auscultation as monitoring modalities. Anesth Analg 79:867, 1994. 53. Nyarwaya JB, Pierre S, Mazoit JX, et al: Effects of carbon dioxide embolism with nitrous oxide in the inspired gas in piglets. Br J Anaesth 76:428, 1996. 54. McGrath BJ, Zimmerman JE, Williams JF, et al: Carbon dioxide embolism treated with hyperbaric oxygen. Can J Anaesth 36:586, 1989.

2198

Adult Subspecialty Management

75. Branche PE, Duperret SL, Sagnard PE, et al: Left ventricular loading modifications induced by pneu moperitoneum: A time course echocardiographic study. Anesth Analg 86:482, 1998. 76. Odeberg S, Ljungqvist O, Svenberg T, et al: Haemo dynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparo scopic surgery. Acta Anaesthesiol Scand 38:276, 1994. 77. Kashtan J, Green JF, Parsons EQ, et al: Hemody namic effect of increased abdominal pressure. J Surg Res 30:249, 1981. 78. Giebler RM, Behrends M, Steffens T, et al: Intraperi toneal and retroperitoneal carbon dioxide insuffla tion evoke different effects on caval vein pressure gradients in humans: Evidence for the starling resis tor concept of abdominal venous return. Anesthe siology 92:1568, 2000. 79. Takata M, Wise RA, Robotham JL: Effects of abdominal pressure on venous return: Abdominal vascular zone conditions. J Appl Physiol 69:1961, 1990. 80. Goodale RL, Beebe DS, McNevin MP, et al: Hemo dynamic, respiratory, and metabolic effects of laparoscopic cholecystectomy. Am J Surg 166:533, 1993. 81. SolisHerruzo JA, Moreno D, Gonzalez A, et al: Effect of intrathoracic pressure on plasma arginine vasopressin levels. Gastroenterology 101:607, 1991. 82. Joris JL, Noirot DP, Legrand MJ, et al: Hemody namic changes during laparoscopic cholecystec tomy. Anesth Analg 76:1067, 1993. 83. Hirvonen EA, Nuutinen LS, Vuolteenaho O: Hor monal responses and cardiac filling pressures in headup or headdown position and pneumoperi toneum in patients undergoing operative laparos copy. Br J Anaesth 78:128, 1997. 84. Ho HS, Saunders CJ, Corso FA, et al: The effects of CO2 pneumoperitoneum on hemodynamics in hemorrhaged animals. Surgery 114:381, 1993. 85. Alishahi S, Francis N, Crofts S, et al: Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device. Ann Surg 233:176, 2001. 86. Hirvonen EA, Poikolainen EO, Paakkonen ME, et al: The adverse hemodynamic effects of anesthe sia, headup tilt, and carbon dioxide pneumoperito neum during laparoscopic cholecystectomy. Surg Endosc 14:272, 2000. 87. Harris SN, Ballantyne GH, Luther MA, et al: Altera tions of cardiovascular performance during laparo scopic colectomy: A combined hemodynamic and echocardiographic analysis. Anesth Analg 83:482, 1996. 88. Feig BW, Berger DH, Dougherty TB, et al: Pharma cologic intervention can reestablish baseline hemo dynamic parameters during laparoscopy. Surgery 116:733, 1994. 89. Joris JL, Hamoir EE, Hartstein GM, et al: Hemody namic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocy toma. Anesth Analg 88:16, 1999. 90. Wahba RW, Beique F, Kleiman SJ: Cardiopulmonary function and laparoscopic cholecystectomy. Can J Anaesth 42:51, 1995. 91. OLeary E, Hubbard K, Tormey W, et al: Laparo scopic cholecystectomy: Haemodynamic and neu roendocrine responses after pneumoperitoneum and changes in position. Br J Anaesth 76:640,1996. 92. Mann C, Boccara G, Pouzeratte Y, et al: The relation ship among carbon dioxide pneumoperitoneum, vasopressin release, and hemodynamic changes. Anesth Analg 89:278, 1999. 93. Melville RJ, Forsling ML, Frizis HI, et al: Stimulus for vasopressin release during elective intra abdominal operations. Br J Surg 72:979, 1985. 94. Longhurst JC, Spilker HL, Ordway GA: Cardiovas cular reflexes elicited by passive gastric distension in anesthetized cats. Am J Physiol 240:H539, 1981. 95. Laisalmi M, Koivusalo AM, Valta P, et al: Clonidine provides opioidsparing effect, stable hemodynam ics, and renal integrity during laparoscopic chole cystectomy. Surg Endosc 15:1331, 2001. 96. Aho M, Lehtinen AM, Laatikainen T, et al: Effects of intramuscular clonidine on hemodynamic and plasma betaendorphin responses to gynecologic laparoscopy. Anesthesiology 72:797, 1990. 97. Aho M, Scheinin M, Lehtinen AM, et al: Intramus cularly administered dexmedetomidine attenuates hemodynamic and stress hormone responses to gynecologic laparoscopy. Anesth Analg 75:932, 1992. 98. Koivusalo AM, Scheinin M, Tikkanen I, et al: Effects of esmolol on haemodynamic response to CO2 pneumoperitoneum for laparoscopic surgery. Acta Anaesthesiol Scand 42:510, 1998. 99. Jorgensen JO, Lalak NJ, North L, et al: Venous stasis during laparoscopic cholecystectomy. Surg Lapar osc Endosc 4:128, 1994. 100. Jorgensen JO, Gillies RB, Lalak NJ, et al: Lower limb venous hemodynamics during laparoscopy: An animal study. Surg Laparosc Endosc 4:32, 1994. 101. Caprini JA, Arcelus JI: Prevention of postoperative venous thromboembolism following laparoscopic cholecystectomy. Surg Endosc 8:741, 1994. 102. Mayol J, VincentHamelin E, Sarmiento JM, et al: Pulmonary embolism following laparoscopic chole cystectomy: Report of two cases and review of the literature. Surg Endosc 8:214, 1994. 103. Lord RV, Ling JJ, Hugh TB, et al: Incidence of deep vein thrombosis after laparoscopic vs minilaparot omy cholecystectomy. Arch Surg 133:967, 1998. 104. Iwase K, Takenaka H, Ishizaka T, et al: Serial changes in renal function during laparoscopic cholecystectomy. Eur Surg Res 25:203, 1993. 105. Kubota K, Kajiura N, Teruya M, et al: Alterations in respiratory function and hemodynamics during laparoscopic cholecystectomy under pneumoperi toneum. Surg Endosc 7:500, 1993. 106. Chiu AW, Azadzoi KM, Hatzichristou DG, et al: Effects of intraabdominal pressure on renal tissue perfusion during laparoscopy. J Endourol 8:99, 1994. 107. Ishizaki Y, Bandai Y, Shimomura K, et al: Safe intra abdominal pressure of carbon dioxide pneumoperi toneum during laparoscopic surgery. Surgery 114:549, 1993. 108. Koivusalo AM, Kellokumpu I, Ristkari S, et al: Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: A comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method. Anesth Analg 85:886, 1997. 109. Schilling MK, Redaelli C, Krahenbuhl L, et al: Splanchnic microcirculatory changes during CO2 laparoscopy. J Am Coll Surg 184:378, 1997. 110. Sato K, Kawamura T, Wakusawa R: Hepatic blood flow and function in elderly patients undergoing laparoscopic cholecystectomy. Anesth Analg 90: 1198, 2000. 111. Thaler W, Frey L, Marzoli GP, et al: Assessment of splanchnic tissue oxygenation by gastric tonometry in patients undergoing laparoscopic and open cholecystectomy. Br J Surg 83:620, 1996. 112. Blobner M, Bogdanski R, Kochs E, et al: Effects of intraabdominally insufflated carbon dioxide and elevated intraabdominal pressure on splanchnic

55. Butler BD, Hills BA: Transpulmonary passage of venous air emboli. J Appl Physiol 59:543, 1985. 56. Bazin JE, Gillart T, Rasson P, et al: Haemodynamic conditions enhancing gas embolism after venous injury during laparoscopy: a study in pigs. Br J Anaesth 78:570, 1997. 57. Tuppurainen T, Makinen J, Salonen M: Reducing the risk of systemic embolization during gyneco logic laparoscopyeffect of volume preload. Acta Anaesthesiol Scand 46:37, 2002. 58. English JB, Westenskow D, Hodges MR, et al: Comparison of venous air embolism monitoring methods in supine dogs. Anesthesiology 48:425, 1978. 59. Jones MJ, Mitchell RW, Hindocha N: Effect of increased intraabdominal pressure during laparos copy on the lower esophageal sphincter. Anesth Analg 68:63, 1989. 60. Halevy A, Kais H, Efrati Y, et al: Continuous esopha geal pH monitoring during laparoscopic cholecys tectomy. Surg Endosc 8:1294, 1994. 61. Struthers AD, Cuschieri A: Cardiovascular conse quences of laparoscopic surgery. Lancet 352:568, 1998. 62. Koivusalo AM, Lindgren L: Effects of carbon dioxide pneumoperitoneum for laparoscopic chole cystectomy. Acta Anaesthesiol Scand 44:834, 2000. 63. Ivankovich AD, Miletich DJ, Albrecht RF, et al: Car diovascular effects of intraperitoneal insufflation with carbon dioxide insufflation and nitrous oxide in the dog. Anesthesiology 42:281, 1975. 64. Kelman GR, Swapp GH, Smith I, et al: Cardiac output and arterial bloodgas tension during laparos copy. Br J Anaesth 44:1155, 1972. 65. Gannedahl P, Odeberg S, Brodin LA, et al: Effects of posture and pneumoperitoneum during anaesthe sia on the indices of left ventricular filling. Acta Anaesthesiol Scand 40:160, 1996. 66. Lentschener C, Axler O, Fernandez H, et al: Haemo dynamic changes and vasopressin release are not consistently associated with carbon dioxide pneu moperitoneum in humans. Acta Anaesthesiol Scand 45:527, 2001. 67. Dexter SP, Vucevic M, Gibson J, et al: Hemodynamic consequences of high and lowpressure capnoperi toneum during laparoscopic cholecystectomy. Surg Endosc 13:376, 1999. 68. Torrielli R, Cesarini M, Winnock S, et al: Hemody namic changes during celioscopy: A study carried out using thoracic electric bioimpedance. Can J Anaesth 37:46, 1990. 69. Hirvonen EA, Nuutinen LS, Kauko M: Hemody namic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy. Acta Anaesthesiol Scand 39:949, 1995. 70. Walder AD, Aitkenhead AR: Role of vasopressin in the haemodynamic response to laparoscopic chole cystectomy. Br J Anaesth 78:264, 1997. 71. Joris JL, Chiche JD, Canivet JL, et al: Hemodynamic changes induced by laparoscopy and their endo crine correlates: Effects of clonidine. J Am Coll Cardiol 32:1389, 1998. 72. Muchada R, Lavandier B, Cathignol D, et al: [Non invasive hemodynamic monitoring in gynecologic laparoscopy]. Ann Fr Anesth Reanim 5:14, 1986. 73. Cunningham AJ, Turner J, Rosenbaum S, Rafferty T: Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br J Anaesth 70:621, 1993. 74. Dorsay DA, Green FL, Baysinger CL: Hemody namic changes during laparoscopic cholecys tectomy monitored with transesophageal echocar diography. Surg Endosc 9:128, 1995.

Anesthesia for Laparoscopic Surgery 2199

circulation: An experimental study in pigs. Anesthe siology 89:475, 1998. Klopfenstein CE, Morel DR, Clergue F, et al: Effects of abdominal CO2 insufflation and changes of posi tion on hepatic blood flow in anesthetized pigs. Am J Physiol 275:H900, 1998. Makinen MT, Heinonen PO, Klemola UM, et al: Gastric air tonometry during laparoscopic chole cystectomy: A comparison of two Paco2 levels. Can J Anaesth 48:121, 2001. Fujii Y, Tanaka H, Tsuruoka S, et al: Middle cerebral arterial blood flow velocity increases during laparo scopic cholecystectomy. Anesth Analg 78:80, 1994. Huettemann E, Terborg C, Sakka SG, et al: Pre served CO(2) reactivity and increase in middle cerebral arterial blood flow velocity during laparo scopic surgery in children. Anesth Analg 94:255, 2002. Kirkinen P, Hirvonen E, Kauko M, et al: Intracranial blood flow during laparoscopic hysterectomy. Acta Obstet Gynecol Scand 74:71, 1995. Josephs LG, EsteMcDonald JR, Birkett DH, Hirsch EF: Diagnostic laparoscopy increases intracranial pressure. J Trauma 36:815, 1994. Halverson A, Buchanan R, Jacobs L, et al: Evaluation of mechanism of increased intracranial pressure with insufflation. Surg Endosc 12:266, 1998. Uzzo RG, Bilsky M, Mininberg DT, et al: Laparo scopic surgery in children with ventriculoperito neal shunts: Effect of pneumoperitoneum on intracranial pressurepreliminary experience. Urology 49:753, 1997. Lentschener C, Benhamou D, Niessen F, et al: Intra ocular pressure changes during gynaecological laparoscopy. Anaesthesia 51:1106, 1996. Lentschener C, FrediReygrobellet D, Bouaziz H, et al: Effect of CO(2) pneumoperitoneum on early cellular markers of retinal ischemia in rabbits with alphachymotrypsininduced glaucoma. Surg Endosc 14:1057, 2000. Iwase K, Takenaka H, Yagura A, et al: Hemodynamic changes during laparoscopic cholecystectomy in patients with heart disease. Endoscopy 24:771, 1992. Safran D, Sgambati S, Orlando R 3rd: Laparoscopy in highrisk cardiac patients. Surg Gynecol Obstet 176:548, 1993. Portera CA, Compton RP, Walters DN, et al: Benefits of pulmonary artery catheter and transesophageal echocardiographic monitoring in laparoscopic cholecystectomy patients with cardiac disease. Am J Surg 169:202, 1995. Hein HA, Joshi GP, Ramsay MA, et al: Hemody namic changes during laparoscopic cholecystec tomy in patients with severe cardiac disease. J Clin Anesth 9:261, 1997. Pepine CJ, Lambert CR: Cardiovascular effects of nicardipine. Angiology 41:978, 1990. Aroney CN, Semigran MJ, Dec GW, et al: Inotropic effect of nicardipine in patients with heart failure: Assessment by left ventricular endsystolic pressurevolume analysis. J Am Coll Cardiol 14: 1331, 1989. Dhoste K, Lacoste L, Karayan J, et al: Haemody namic and ventilatory changes during laparoscopic cholecystectomy in elderly ASA III patients. Can J Anaesth 43:783, 1996. Joshi GP, Hein HA, Ramsay MA, et al: Hemody namic response to anesthesia and pneumoperito neum in orthotopic cardiac transplant recipients. Anesthesiology 85:929, 1996. Levecque JP, Benhamou D, Zetlaoui P, et al: Laparo scopic cholecystectomy in a patient with a trans planted heart. Anesthesiology 86:1425, 1997. 132. Atallah F, BastideHeulin T, Soulie M, et al: Haemo dynamic changes during retroperitoneoscopic adrenalectomy for phaeochromocytoma. Br J Anaesth 86:731, 2001. 133. Fried M, Krska Z, Danzig V: Does the laparoscopic approach significantly affect cardiac functions in laparoscopic surgery? Pilot study in nonobese and morbidly obese patients. Obes Surg 11:293, 2001. 134. Nguyen NT, Ho HS, Fleming NW, et al: Cardiac function during laparoscopic vs open gastric bypass. Surg Endosc 16:78, 2002. 135. Brantley JC 3rd, Riley PM: Cardiovascular collapse during laparoscopy: A report of two cases. Am J Obstet Gynecol 159:735, 1988. 136. Rosenthal RJ, Hiatt JR, Phillips EH, et al: Intra cranial pressure: Effects of pneumoperitoneum in a largeanimal model. Surg Endosc 11:376, 1997. 137. Johnston RV, Lawson NW, Nealon WH: Lower extremity neuropathy after laparoscopic cholecys tectomy. Anesthesiology 77:835, 1992. 138. Gombar KK, Gombar S, Singh B, et al: Femoral neuropathy: A complication of the lithotomy posi tion. Reg Anesth 17:306, 1992. 139. Jakeways MS, Mitchell V, Hashim IA: Metabolic and inflammatory responses after open or laparoscopic cholecystectomy. Br J Surg 81:127, 1994. 140. Delaunay L, Bonnet F, Cherqui D, et al: Laparo scopic cholecystectomy minimally impairs postop erative cardiorespiratory and muscle performance. Br J Surg 82:373, 1995. 141. Mealy K, Gallagher H, Barry M, et al: Physiological and metabolic responses to open and laparoscopic cholecystectomy. Br J Surg 79:1061, 1992. 142. Karayiannakis AJ, Makri GG, Mantzioka A, et al: Systemic stress response after laparoscopic or open cholecystectomy: A randomized trial. Br J Surg 84:467, 1997. 143. Targarona EM, Pons MJ, Balague C, et al: Acute phase is the only significantly reduced component of the injury response after laparoscopic cholecys tectomy. World J Surg 20:528, 1996. 144. Bessler M, Whelan RL, Halverson A, et al: Is immune function better preserved after laparoscopic versus open colon resection? Surg Endosc 8:881, 1994. 145. Trokel MJ, Bessler M, Treat MR, et al: Preservation of immune response after laparoscopy. Surg Endosc 8:1385, 1994. 146. Glerup H, Heindorff H, Flyvbjerg A, et al: Elective laparoscopic cholecystectomy nearly abolishes the postoperative hepatic catabolic stress response. Ann Surg 221:214, 1995. 147. Senagore AJ, Kilbride MJ, Luchtefeld MA, et al: Superior nitrogen balance after laparoscopic assisted colectomy. Ann Surg 221:171, 1995. 148. McAnema O, Austin O, Hederman WP: Laparo scopic versus open appendicectomy. Lancet 338:693, 1991. 149. Hotokezata M, Combs MJ, Mentis EP, et al: Recov ery of fasted and fed gastrointestinal motility after open versus laparoscopic cholecystectomy in dogs. Ann Surg 223:413, 1996. 150. Basse L, Madsen JL, Billesbolle P, et al: Gastrointes tinal transit after laparoscopic versus open colonic resection. Surg Endosc 17:1919, 2003. 151. McMahon AJ, Russell IT, Baxter JN, et al: Laparo scopic versus minilaparotomy cholecystectomy: A randomised trial. Lancet 343:135, 1994. 152. Kane RL, Lurie N, Borbas C, et al: The outcomes of elective laparoscopic and open cholecystectomies. J Am Coll Surg 180:136, 1995. 153. McLauchlan GJ, Macintyre IM: Return to work after laparoscopic cholecystectomy. Br J Surg 82:239, 1995. 154. Rademaker BM, Ringers J, Odoom JA, et al: Pulmo nary function and stress response after laparoscopic cholecystectomy: Comparison with subcostal inci sion and influence of thoracic epidural analgesia. Anesth Analg 75:381, 1992. 155. Donald RA, Perry EG, Wittert GA, et al: The plasma ACTH, AVP, CRH and catecholamine responses to conventional and laparoscopic cholecystectomy. Clin Endocrinol 38:609, 1993. 156. PutensenHimmer G, Putensen C, et al: Compari son of postoperative respiratory function after laparoscopy or open laparotomy for cholecystec tomy. Anesthesiology 77:675, 1992. 157. McMahon AJ, Russell IT, Ramsay G, et al: Laparo scopic and minilaparotomy cholecystectomy: A randomized trial comparing postoperative pain and pulmonary function. Surgery 115:533, 1994. 158. Wiesel S, Grillas R: Patientcontrolled analgesia after laparoscopic and open cholecystectomy. Can J Anaesth 42:37, 1995. 159. Joris JL, Hinque VL, Laurent PE, et al: Pulmonary function and pain after gastroplasty performed via laparotomy or laparoscopy in morbidly obese patients. Br J Anaesth 80:283, 1998. 160. Nguyen NT, Lee SL, Goldman C, et al: Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial. J Am Coll Surg 192:469, 2001. 161. Ure BM, Troidl H, Spangenberger W, et al: Pain after laparoscopic cholecystectomy: Intensity and locali zation of pain and analysis of predictors in preop erative symptoms and intraoperative events. Surg Endosc 8:90, 1994. 162. Joris J, Thiry E, Paris P, et al: Pain after laparoscopic cholecystectomy: Characteristics and effect of intraperitoneal bupivacaine. Anesth Analg 8:379, 1995. 163. Bisgaard T, Klarskov B, Rosenberg J, et al: Charac teristics and prediction of early pain after laparo scopic cholecystectomy. Pain 90:261, 2001. 164. Alexander JI: Pain after laparoscopy. Br J Anaesth 79:369, 1997. 165. Wills VL, Hunt DR: Pain after laparoscopic chole cystectomy. Br J Surg 87:273, 2000. 166. Moiniche S, Jorgensen H, Wetterslev J, et al: Local anesthetic infiltration for postoperative pain relief after laparoscopy: A qualitative and quantitative systematic review of intraperitoneal, portsite infiltration and mesosalpinx block. Anesth Analg 90:899, 2000. 167. Zmora O, StolikDollberg O, BarZakai B, et al: Intraperitoneal bupivacaine does not attenuate pain following laparoscopic cholecystectomy. JSLS 4:301, 2000. 168. Elhakim M, Elkott M, Ali NM, et al: Intraperitoneal lidocaine for postoperative pain after laparoscopy. Acta Anaesthesiol Scand 44:280, 2000. 169. Lee IO, Kim SH, Kong MH, et al: Pain after laparo scopic cholecystectomy: The effect and timing of incisional and intraperitoneal bupivacaine. Can J Anaesth 48:545, 2001. 170. Labaille T, Mazoit JX, Paqueron X, et al: The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy. Anesth Analg 94:100, 2002. 171. Goldstein A, Grimault P, Henique A, et al: Prevent ing postoperative pain by local anesthetic instilla tion after laparoscopic gynecologic surgery: A placebocontrolled comparison of bupivacaine and ropivacaine. Anesth Analg 91:403, 2000. 172. Fredman B, Jedeikin R, Olsfanger D, et al: Residual pneumoperitoneum: A cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg 79:152, 1994.

68

113.

Section V Adult Subspecialty Management

114.

115.

116.

117.

118.

119.

120.

121.

122.

123.

124.

125.

126.

127. 128.

129.

130.

131.

2200

Adult Subspecialty Management

193. Karayiannakis AJ, Makri GG, Mantzioka A, et al: Postoperative pulmonary function after laparo scopic and open cholecystectomy. Br J Anaesth 77:448, 1996. 194. Shulman SM, Chuter T, Weissman C: Dynamic res piratory patterns after laparoscopic cholecystec tomy. Chest 103:1173, 1993. 195. Erice F, Fox GS, Salib YM, et al: Diaphragmatic function before and after laparoscopic cholecystec tomy. Anesthesiology 79:966, 1993. 196. Sharma RR, Axelsson H, Oberg A, et al: Diaphrag matic activity after laparoscopic cholecystectomy. Anesthesiology 91:406, 1999. 197. Tousignant G, Wiesel S, Laporta D, et al: The effect of age on recovery of pulmonary function after laparoscopic cholecystectomy. Anesth Analg 74(Suppl 2S), S321, 1992. 198. Johnson D, Litwin D, Osachoff J, et al: Postoperative respiratory function after laparoscopic cholecystec tomy. Surg Laparosc Endosc 2:221, 1992. 199. Joris J, Kaba A, Lamy M: Postoperative spirometry after laparoscopy for lower abdominal or upper abdominal surgical procedures. Br J Anaesth 79:422, 1997. 200. Collins KM, Docherty PW, Plantevin OM: Postop erative morbidity following gynaecological out patient laparoscopy: A reappraisal of the service. Anaesthesia 39:819, 1984. 201. Bailey PL, Streisand JB, Pace NL, et al: Transdermal scopolamine reduces nausea and vomiting after outpatient laparoscopy. Anesthesiology 72:977, 1990. 202. Watcha MF, White PF: Postoperative nausea and vomiting: Its etiology, treatment, and prevention. Anesthesiology 77:162, 1992. 203. Beattie WS, Lindblad T, Buckley DN, et al: Men struation increases the risk of nausea and vomiting after laparoscopy: A prospective randomized study. Anesthesiology 78:272, 1993. 204. Okum GS, ColonnaRomano P, et al: Vomiting after alfentanil anesthesia: Effect of dosing method. Anesth Analg 75:558, 1992. 205. Sukhani R, Vazquez J, Pappas AL, et al: Recovery after propofol with and without intraoperative fen tanyl in patients undergoing ambulatory gyneco logic laparoscopy. Anesth Analg 83:975, 1996. 206. Apfel CC, Korttila K, Abdalla M, et al: A factorial trial of six interventions for the prevention of post operative nausea and vomiting. N Engl J Med 350:2441, 2004. 207. Green G, Jonsson L: Nausea: The most important factor determining length of stay after ambulatory anaesthesia. A comparative study of isoflurane and/ or propofol techniques. Acta Anaesthesiol Scand 37:742, 1993. 208. Taylor E, Feinstein R, White PF, et al: Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide con traindicated? Anesthesiology 76:541, 1992. 209. Sukhani R, Lurie J, Jabamoni R: Propofol for ambu latory gynecologic laparoscopy: Does omission of nitrous oxide alter postoperative emetic sequelae and recovery? Anesth Analg 78:831, 1994. 210. Stanton J: Anaesthesia for laparoscopic cholecystec tomy. Anaesthesia 46:317, 1990. 211. Bodner M, White PF: Antiemetic efficacy of ondansetron after outpatient laparoscopy. Anesth Analg 73:250, 1991. 212. Paxton LD, McKay AC, Mirakhur RK: Prevention of nausea and vomiting after day case gynaecological laparoscopy: A comparison of ondansetron, droperidol, metoclopramide and placebo. Anaes thesia 50:403, 1995. 213. McKenzie R, Kovac A, OConnor T, et al: Com parison of ondansetron versus placebo to prevent postoperative nausea and vomiting in women undergoing ambulatory gynecologic surgery. Anesthesiology 78:21, 1993. Grond S, Lynch J, Diefenbach C, et al: Comparison of ondansetron and droperidol in the prevention of nausea and vomiting after inpatient minor gyneco logic surgery. Anesth Analg 81:603, 1995. Sniadach MS, Alberts MS: A comparison of the prophylactic antiemetic effect of ondansetron and droperidol on patients undergoing gynecologic laparoscopy. Anesth Analg 85:797, 1997. Holte K, Klarskov B, Christensen DS, et al: Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: A ran domized, doubleblind study. Ann Surg 240:892, 2004. Magner JJ, McCaul C, Carton E, et al: Effect of intra operative intravenous crystalloid infusion on post operative nausea and vomiting after gynaecological laparoscopy: Comparison of 30 and 10 ml kg(1). Br J Anaesth 93:381, 2004. Maharaj CH, Kallam SR, Malik A, et al: Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg 100:675, 2005. Menes T, Spivak H: Laparoscopy: Searching for the proper insufflation gas. Surg Endosc 14:1050, 2000. Neuhaus SJ, Gupta A, Watson DI: Helium and other alternative insufflation gases for laparoscopy. Surg Endosc 15:553, 2001. Bongard FS, Pianim NA, Leighton TA, et al: Helium insufflation for laparoscopic operation. Surg Gynecol Obstet 177:140, 1993. McMahon AJ, Baxter JN, Murray W, et al: Helium pneumoperitoneum for laparoscopic cholecystec tomy: Ventilatory and blood gas changes. Br J Surg 81:1033, 1994. Rademaker BM, Kalkman CJ, Odoom JA, et al: Intraperitoneal local anaesthetics after laparoscopic cholecystectomy: Effects on postoperative pain, metabolic responses and lung function. Br J Anaesth 72:263, 1994. Eisenhauer DM, Saunders CJ, Ho HS, et al: Hemo dynamic effects of argon pneumoperitoneum. Surg Endosc 8:315, 1994. Wolf JS Jr, Carrier S, Stoller ML: Gas embolism: Helium is more lethal than carbon dioxide. J Laparoendosc Surg 4:173, 1994. Roberts MW, Mathiesen KA, Ho HS, et al: Cardio pulmonary responses to intravenous infusion of soluble and relatively insoluble gases. Surg Endosc 11:341, 1997. Lindgren L, Koivusalo AM, Kellokumpu I: Conven tional pneumoperitoneum compared with abdomi nal wall lift for laparoscopic cholecystectomy. Br J Anaesth 75:567, 1995. McDermott JP, Regan MC, Page R, et al: Cardiores piratory effects of laparoscopy with and without gas insufflation. Arch Surg 130:984, 1995. Rademaker BM, Meyer DW, Bannenberg JJ, et al: Laparoscopy without pneumoperitoneum: Effects of abdominal wall retraction versus carbon dioxide insufflation on hemodynamics and gas exchange in pigs. Surg Endosc 9:797, 1995. Casati A, Valentini G, Ferrari S, et al: Cardiorespira tory changes during gynaecological laparoscopy by abdominal wall elevation: Comparison with carbon dioxide pneumoperitoneum. Br J Anaesth 78:51, 1997. Koivusalo AM, Kellokumpu I, Scheinin M, et al: Comparison of gasless mechanical and conven tional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy. Anesth Analg 86:153, 1998. Koivusalo AM, Kellokumpu I, Scheinin M, et al: Randomized comparison of the neuroendocrine

173. Shrivastav P, Nadkarni P, Craft I: Prevention of shoulder pain after laparoscopy. Lancet 339:744, 1992. 174. Comfort VK, Code WE, Rooney ME, et al: Naproxen premedication reduces postoperative tubal ligation pain. Can J Anaesth 39:349, 1992. 175. Ding Y, White PF: Comparative effects of ketorolac, dezocine, and fentanyl as adjuvants during outpa tient anesthesia. Anesth Analg 75:566, 1992. 176. Gilberg LE, Harsten AS, Stahl LB: Preoperative diclofenac sodium reduces postlaparoscopy pain. Can J Anaesth 40:406, 1993. 177. van Ee R, Hemrika DJ, van der Linden CT: Pain relief following daycase diagnostic hysteroscopy laparoscopy for infertility: A doubleblind random ized trial with preoperative naproxen versus placebo. Obstet Gynecol 82:951, 1993. 178. Liu J, Ding Y, White PF, et al: Effects of ketorolac on postoperative analgesia and ventilatory function after laparoscopic cholecystectomy. Anesth Analg 76:1061, 1993. 179. Wilson YG, Rhodes M, Ahmed R, et al: Intramus cular diclofenac sodium for postoperative analgesia after laparoscopic cholecystectomy: A randomised, controlled trial. Surg Laparosc Endosc 4:340, 1994. 180. Gan TJ, Joshi GP, Viscusi E, et al: Preoperative parenteral parecoxib and followup oral valdecoxib reduce length of stay and improve quality of patient recovery after laparoscopic cholecystectomy sur gery. Anesth Analg 98:1665, 2004. 181. Joshi GP, Viscusi ER, Gan TJ, et al: Effective treat ment of laparoscopic cholecystectomy pain with intravenous followed by oral COX2 specific inhibi tor. Anesth Analg 98:336, 2004. 182. Boccara G, Chaumeron A, Pouzeratte Y, et al: The preoperative administration of ketoprofen improves analgesia after laparoscopic cholecystectomy in comparison with propacetamol or postoperative ketoprofen. Br J Anaesth 94:347, 2005. 183. Shapiro MH, Duffy BL: Intramuscular ketorolac for postoperative analgesia following laparoscopic sterilisation. Anaesth Intensive Care 22:22, 1994. 184. Hovorka J, Kallela H, Korttila K: Effect of intrave nous diclofenac on pain and recovery profile after daycase laparoscopy. Eur J Anaesthesiol 10:105, 1993. 185. Crocker S, Paech M: Preoperative rectal indometh acin for analgesia after laparoscopic sterilisation. Anaesth Intensive Care 20:337, 1992. 186. Green CR, Pandit SK, Levy L, et al: Intraoperative ketorolac has an opioidsparing effect in women after diagnostic laparoscopy but not after laparo scopic tubal ligation. Anesth Analg 82:732, 1996. 187. Bisgaard T, Klarskov B, Kehlet H, et al: Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: A randomized doubleblind placebocontrolled trial. Ann Surg 238:651, 2003. 188. Michaloliakou C, Chung F, Sharma S: Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 82:44, 1996. 189. Mixter CG 3rd, Hackett TR: Preemptive analgesia in the laparoscopic patient. Surg Endosc 11:351, 1997. 190. Bisgaard T: Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evi dence. Anesthesiology 104:835, 2006. 191. Frazee RC, Roberts JW, Okeson GC, et al: Open versus laparoscopic cholecystectomy: A compari son of postoperative pulmonary function. Ann Surg 213:651, 1991. 192. Schauer PR, Luna J, Ghiatas AA, et al: Pulmonary function after laparoscopic cholecystectomy. Sur gery 114:389, 1993.

214.

215.

216.

217.

218.

219. 220.

221.

222.

223.

224.

225.

226.

227.

228.

229.

230.

231.

232.

Anesthesia for Laparoscopic Surgery 2201

response to laparoscopic cholecystectomy using either conventional or abdominal wall lift tech niques. Br J Surg 83:1532, 1996. Bouvy ND, Marquet RL, Jeekel H, et al: Impact of gas(less) laparoscopy and laparotomy on peritoneal tumor growth and abdominal wall metastases. Ann Surg 224:694, 1996. Watson DI, Mathew G, Ellis T, et al: Gasless laparo scopy may reduce the risk of portsite metastases following laparoscopic tumor surgery. Arch Surg 132:166, 1997. Visser BC, Glasgow RE, Mulvihill KK, et al: Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg 18:409, 2001. Lemaire BM, van Erp WF: Laparoscopic surgery during pregnancy. Surg Endosc 11:15, 1997. Affleck DG, Handrahan DL, Egger MJ, et al: The laparoscopic management of appendicitis and cholelithiasis during pregnancy. Am J Surg 178:523, 1999. Barone JE, Bears S, Chen S, et al: Outcome study of cholecystectomy during pregnancy. Am J Surg 177:232, 1999. Carter JF, Soper DE: Operative laparoscopy in preg nancy. JSLS 8:57, 2004. Oelsner G, Stockheim D, Soriano D, et al: Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc 10:200, 2003. Hunter JG, Swanstrom L, Thornburg K: Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endosc 9:272, 1995. Barnard JM, Chaffin D, Droste S, et al: Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 85:669, 1995. BhavaniShankar K, Steinbrook RA, Brooks DC, et al: Arterial to endtidal carbon dioxide pressure difference during laparoscopic surgery in preg nancy. Anesthesiology 93:370, 2000. Steinbrook RA, BhavaniShankar K: Hemody namics during laparoscopic surgery in pregnancy. Anesth Analg 93:1570, 2001. Topel HC: Gasless laparoscopy under epidural anesthesia in a woman with a 14week gestation. J Am Assoc Gynecol Laparosc 2:S79, 1995. Pelosi M: Gasless laparoscopy under epidural anesthesia during pregnancy. J Am Assoc Gynecol Laparosc 2:S75, 1995. Veyckemans F: Celioscopic surgery in infants and children: The anesthesiologists point of view. Pae diatr Anaesth 14:424, 2004. Bergesio R, Habre W, Lanteri C, et al: Changes in respiratory mechanics during abdominal laparo scopic surgery in children. Anaesth Intensive Care 27:245, 1999. Manner T, Aantaa R, Alanen M: Lung compliance during laparoscopic surgery in paediatric patients. Paediatr Anaesth 8:25, 1998. Bannister CF, Brosius KK, Wulkan M: The effect of insufflation pressure on pulmonary mechanics in infants during laparoscopic surgical procedures. Paediatr Anaesth 13:785, 2003. Laffon M, Gouchet A, Sitbon P, et al: Difference between arterial and endtidal carbon dioxide pres sures during laparoscopy in paediatric patients. Can J Anaesth 45:561, 1998. Pacilli M, Pierro A, Kingsley C, et al: Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric tech nique. Br J Anaesth 97:215, 2006. Gueugniaud PY, Abisseror M, Moussa M, et al: The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: Assessment by continuous esophageal aortic blood flow echo Doppler. Anesth Analg 86:290, 1998. 254. Sakka SG, Huettemann E, Petrat G, et al: Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhaphy in small children. Br J Anaesth 84:330, 2000. 255. De Waal EE, Kalkman CJ: Haemodynamic changes during lowpressure carbon dioxide pneumoperito neum in young children. Paediatr Anaesth 13:18, 2003. 256. Gentili A, Iannettone CM, Pigna A, et al: Cardiocir culatory changes during videolaparoscopy in chil dren: An echocardiographic study. Paediatr Anaesth 10:399, 2000. 257. Huettemann E, Sakka SG, Petrat G, et al: Left ven tricular regional wall motion abnormalities during pneumoperitoneum in children. Br J Anaesth 90:733, 2003. 258. Gomez Dammeier BH, Karanik E, Gluer S, et al: Anuria during pneumoperitoneum in infants and children: A prospective study. J Pediatr Surg 40:1454, 2005. 259. Lejus C, Delile L, Plattner V, et al: Randomized, singleblinded trial of laparoscopic versus open appendectomy in children: Effects on postoperative analgesia. Anesthesiology 84:801, 1996. 260. Lintula H, Kokki H, Vanamo K: Singleblind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg 88:510, 2001. 261. Little DC, Custer MD, May BH, et al: Laparoscopic appendectomy: An unnecessary and expensive pro cedure in children? J Pediatr Surg 37:310, 2002. 262. LehmannWillenbrock E, Riedel HH, et al: Pelvis copy/laparoscopy and its complications in Germany, 19491988. J Reprod Med 37:671, 1992. 263. Hulka JF, Peterson HB, Phillips JM, et al: Operative laparoscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 38:569, 1993. 264. Deziel DJ, Millikan KW, Economou SG, et al: Com plications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 165:9, 1993. 265. VincentHamelin E, Pallares AC, Felipe JA, et al: National survey on laparoscopic cholecystectomy in Spain: Results of a multiinstitutional study con ducted by the Committee for Endoscopic Surgery (Associacion Espanola de Cirujanos). Surg Endosc 8:770, 1994. 266. Schlumpf R, Klotz HP, Wehrli H, et al: A nations experience in laparoscopic cholecystectomy: Pro spective multicenter analysis of 3722 cases. Surg Endosc 8:35, 1994. 267. Croce E, Azzola M, Golia M, et al: Laparocholecys tectomy: 6,865 cases from Italian institutions. Surg Endosc 8:1088, 1994. 268. Keus F, de Jong JA, Gooszen HG, et al: Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Data base Syst Rev 4:CD006231, 2006. 269. McMahon AJ, Baxter JN, ODwyer PJ: Preventing complications of laparoscopy. Br J Surg 80:1593, 1993. 270. Club TSS: A prospective analysis of 1518 laparo scopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 324:1073, 1991. 271. Strasberg S, Sanabria J, Clavien P: Complications of laparoscopic cholecystectomy. Can J Surg 35:275, 1992. 272. Wolfe BM, Gardiner BN, Leary BF, et al: Endoscopic cholecystectomy: An analysis of complications. Arch Surg 126:1192, 1991. 273. Boni L, Benevento A, Rovera F, et al: Infective complications in laparoscopic surgery. Surg Infect (Larchmt) 7(Suppl 2):S109, 2006. 274. Akca O, Lenhardt R, Fleischmann E, et al: Nitrous oxide increases the incidence of bowel distension in patients undergoing elective colon resection. Acta Anaesthesiol Scand 48:894, 2004. 275. Jensen AG, Prevedoros H, Kullman E, et al: Perop erative nitrous oxide does not influence recovery after laparoscopic cholecystectomy. Acta Anaesthe siol Scand 37:683, 1993. 276. Oikkonen M: Propofol vs isoflurane for gynaeco logical laparoscopy. Acta Anaesthesiol Scand 38:110, 1994. 277. Jakobsson J, Rane K, Ryberg G: Anaesthesia during laparoscopic gynaecological surgery: A comparison between desflurane and isoflurane. Eur J Anaesthe siol 14:148, 1997. 278. de Grood PM, Harbers JB, van Egmond J, et al: Anaesthesia for laparoscopy: A comparison of five techniques including propofol, etomidate, thiopen tone and isoflurane. Anaesthesia 42:815, 1987. 279. Bailie R, Craig G, Restall J: Total intravenous anaes thesia for laparoscopy. Anaesthesia 44:60, 1989. 280. Marshall CA, Jones RM, Bajorek PK, et al: Recovery characteristics using isoflurane or propofol for maintenance of anaesthesia: A doubleblind con trolled trial. Anaesthesia 47:461, 1992. 281. Vincent RD Jr, Syrop CH, Van Voorhis BJ, et al: An evaluation of the effect of anesthetic technique on reproductive success after laparoscopic pronuclear stage transfer: Propofol/nitrous oxide versus isoflu rane/nitrous oxide. Anesthesiology 82:352, 1995. 282. Chassard D, Berrada K, Tournadre J, et al: The effects of neuromuscular block on peak airway pressure and abdominal elastance during pneu moperitoneum. Anesth Analg 82:525, 1996. 283. Goodwin AP, Rowe WL, Ogg TW: Day case laparo scopy: A comparison of two anaesthetic techniques using the laryngeal mask during spontaneous breathing. Anaesthesia 47:892, 1992. 284. Swann DG, Spens H, Edwards SA, et al: Anaesthesia for gynaecological laparoscopya comparison between the laryngeal mask airway and tracheal intubation. Anaesthesia 48:431, 1993. 285. Brimacombe J: Laparoscopy and the laryngeal mask airway. Br J Anaesth 73:121, 1994. 286. Tobias JD, Holcomb GW 3rd, Brock JW 3rd, et al: General anesthesia by mask with spontaneous ven tilation during brief laparoscopic inspection of the peritoneum in children. J Laparoendosc Surg 4:379, 1994. 287. Maltby JR, Beriault MT, Watson NC, et al: Gastric distension and ventilation during laparoscopic cholecystectomy: LMAclassic vs. tracheal intuba tion. Can J Anaesth 47:622, 2000. 288. Barker P, Langton JA, Murphy PJ, et al: Regurgita tion of gastric contents during general anaesthesia using the laryngeal mask airway. Br J Anaesth 69:314, 1992. 289. Skinner HJ, Ho BY, Mahajan RP: Gastro oesophageal reflux with the laryngeal mask during daycase gynaecological laparoscopy. Br J Anaesth 80:675, 1998. 290. Hohlrieder M, Brimacombe J, Eschertzhuber S, et al: A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery. Anaesthesia 62:913, 2007. 291. Miller DM, Camporota L: Advantages of ProSeal and SLIPA airways over tracheal tubes for gyneco logical laparoscopies. Can J Anaesth 53:188, 2006. 292. Vegfors M, Engborg L, Gupta A: Changes in end tidal carbon dioxide during gynecologic laparos copy: Spontaneous versus controlled ventilation. J Clin Anesth 6:199, 1994.

68

233.

Section V Adult Subspecialty Management

234.

235.

236. 237.

238.

239. 240.

241.

242.

243.

244.

245.

246.

247.

248.

249.

250.

251.

252.

253.

2202

Adult Subspecialty Management

Characteristics of three hypobaric solutions. Can J Anaesth 48:256, 2001. Lennox PH, Vaghadia H, Henderson C, et al: Small dose selective spinal anesthesia for shortduration outpatient laparoscopy: Recovery characteristics compared with desflurane anesthesia. Anesth Analg 94:346, 2002. Pursnani KG, Bazza Y, Calleja M, et al: Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease. Surg Endosc 12:1082, 1998. Gramatica L Jr, Brasesco OE, Mercado Luna A, et al: Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc 16:472, 2002. Lehtinen AM, Laatikainen T, Koskimies AI, et al: Modifying effects of epidural analgesia or general anesthesia on the stress hormone response to laparoscopy for in vitro fertilization. J In Vitro Fert Embryo Transf 4:23, 1987. 302. Chilvers CR, Vaghadia H, Mitchell GW, et al: Small dose hypobaric lidocainefentanyl spinal anesthesia for short duration outpatient laparoscopy: II. Optimal fentanyl dose. Anesth Analg 84:65, 1997. 303. Topel HC: Gasless laparoscopic assisted hysterec tomy with epidural anesthesia. J Am Assoc Gynecol Laparosc 1:S36, 1994. 304. Vegfors M, Cederholm I, Lennmarken C, et al: Should oxygen be administered after laparoscopy in healthy patients? Acta Anaesthesiol Scand 32:350, 1988.

293. Verghese C, Brimacombe JR: Survey of laryngeal mask airway usage in 11,910 patients: Safety and efficacy for conventional and nonconventional usage. Anesth Analg 82:129, 1996. 294. Peterson HB, Hulka JF, Spielman FJ, et al: Local versus general anesthesia for laparoscopic steriliza tion: A randomized study. Obstet Gynecol 70:903, 1987. 295. MacKenzie IZ, Turner E, OSullivan GM, et al: Two hundred outpatient laparoscopic clip sterilizations using local anaesthesia. Br J Obstet Gynaecol 94: 449, 1987. 296. Brady CE 3rd, Harkleroad LE, Pierson WP: Altera tions in oxygen saturation and ventilation after intravenous sedation for peritoneoscopy. Arch Intern Med 149:1029, 1989. 297. Vaghadia H, Viskari D, Mitchell GW, et al: Selective spinal anesthesia for outpatient laparoscopy: I.

298.

299.

300.

301.