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Anaesthesiology
Anesthesia for Laparoscopic and Robotic Surgeries
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
10 sections · 169 slides
Overview
- Scope of this presentation
- Terms used throughout
Laparoscopic Surgery
- Rise of laparoscopy as a standard approach
- Benefits driving the shift from laparotomy
- Technical challenges for the surgeon
- Trade-offs of laparoscopy
- Benefits of laparoscopic surgery
- Reading the disadvantages table
- Disadvantages of laparoscopic surgery
- Basic laparoscopic technique
- Laparoscopic operating room layout
- Disposable laparoscopic trocars
- Choice of insufflation gas
- Creating the pneumoperitoneum
- Pressure limits during insufflation
- Abdominal wall lift as an alternative
- Positions used for surgical exposure
- Reverse Trendelenburg position on the operating table
- Growth of day-case laparoscopy
- Ambulatory bariatric laparoscopy
- Causes of readmission after day-case bariatric surgery
- Screening patients for ambulatory laparoscopy
Robotic Laparoscopic Surgery
- Purpose of robotic assistance
- Approved fields for robotic surgery
- Examples of robotic-assisted laparoscopic surgery
- Components of the robotic system
- Robotic operating room setup
- Robot cart with numbered instrument arms
- Sequence of a robotic case
- Advantages of remote instrument control
- Footprint of the robot beside the operating table
- Limited patient access during robotic surgery
- Emergency response with a docked robot
- Face and eye protection in steep Trendelenburg
Cardiovascular Effects
- Forces behind the physiologic changes
- Net cardiovascular effect of pneumoperitoneum
- Modifiable factors affecting hemodynamics
- Causes of hemodynamic changes during laparoscopy
- Causes of hemodynamic changes during laparoscopy (continued)
- Absorption of insufflated carbon dioxide
- Effects of severe hypercarbia and acidosis
- Neurohormonal response to peritoneal stretch
- Consequences of a rise in systemic vascular resistance
- Role of intravascular volume status
- Effect of table position on preload
- Hemodynamics in obese patients
- Hemodynamics in geriatric patients
- Recovery after desufflation in geriatric patients
- Right ventricular strain during laparoscopy
- Patients with pulmonary hypertension
- Influence of the type of operation
Respiratory Effects
- Three routes to respiratory change
- Diaphragm displacement and carina shift
- Lung base compression and shunting
- Change in lung compliance
- Causes of pulmonary changes during laparoscopy
- Origin of intraoperative hypercarbia
- Extraperitoneal versus intraperitoneal insufflation
- Time course of carbon dioxide elimination
- Clinical significance in healthy patients
- Causes of severe hypercarbia during laparoscopy
- Mechanism of hypoxia during laparoscopy
- Hypoxic pulmonary vasoconstriction during insufflation
- Causes of hypoxia during laparoscopy
- Ventilation problems in morbid obesity
- Benefits and limits of mild hypercarbia
- Capnography in advanced COPD
Regional Perfusion
- Regional perfusion changes in context
- Splanchnic blood flow during pneumoperitoneum
- Risk of mesenteric ischemia
- Renal effects of pneumoperitoneum
- Vasopressin and free water handling
- Risk factors for acute kidney injury
- Causes of regional perfusion changes during laparoscopy
- Cerebral effects of Trendelenburg and pneumoperitoneum
- Cerebral risk in vulnerable patients
- Intraocular pressure in steep Trendelenburg
- Uncertainty about pressure and visual loss
Intraoperative Management
- Choice of anesthetic technique
- Monitoring during laparoscopic surgery
- Inhaled anesthetics and propofol
- Antiemetic mechanism of propofol
- Nitrous oxide in laparoscopy
- Nausea risk and fire risk with nitrous oxide
- Pharmacologic adjuncts
- Local anesthetic infiltration strategies
- Role of neuromuscular blockade
- Safety risks of deep neuromuscular blockade
- Judging blockade when the arms are tucked
- Modes of mechanical ventilation
- Behaviour of each mode in steep Trendelenburg
- Correcting hypercarbia and hypoxia on the ventilator
- Hemodynamic cost of positive end-expiratory pressure
- Position, preload and ventilator interaction
- Lung-protective ventilation settings
- Trade-offs of a high inspired oxygen fraction
- Temperature management
- Insufflated gas and heat loss
- Fluid loading in ambulatory laparoscopy
- Fluid management in major laparoscopic surgery
- Unreliable indicators of volume status
Intraoperative Complications
- Sources of perioperative complications
- Vascular injury during abdominal entry
- Managing a major vascular injury
- Gastrointestinal and urologic injuries
- Recognising urologic injury
- Hemodynamic sequence during insufflation
- Vagal bradyarrhythmia during insufflation
- Treating hypotension and hypertension
- Managing hypercarbic and hypoxemic events
- Subcutaneous emphysema
- Risk factors for subcutaneous emphysema
- Detecting and treating subcutaneous emphysema
- Postoperative care after gas extravasation
- Capnothorax
- Anatomic routes and risk factors for capnothorax
- Signs of capnothorax
- Diagnosing capnothorax intraoperatively
- Treatment of capnothorax
- Deciding how far to escalate in capnothorax
- Capnomediastinum and capnopericardium
- Mechanism of venous carbon dioxide embolism
- Frequency of gas embolism
- Entry points for gas into the venous system
- Effect of position on gas entrainment
- Clinical signs of venous gas embolism
- Gas embolus in the right atrium on echocardiography
- Treatment of carbon dioxide gas embolism
- Patient shifting and table falls
- Devices for securing the patient
- Peripheral nerve and brachial plexus injuries
- Team watching the laparoscopic video monitor
- Ocular injuries during laparoscopy
- Airway edema after prolonged head-down positioning
Postoperative Course
- Postoperative respiratory dysfunction
- Other causes of respiratory failure after laparoscopy
- Venous thromboembolism after laparoscopy
- Thrombosis risk in specific groups
- Postoperative pain after laparoscopy
- Multimodal analgesia strategy
- Postoperative nausea and vomiting
Summary
- Key physiologic points
- Key practice points
- Emergency actions worth memorising
- Conclusion of the chapter
- References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition