Anesthesia for Laparoscopic Surgery: Anesthetic Management and Complications

Laparoscopic surgery results in physiologic changes that encompass multiple organ systems, with respiratory, cardiovascular and neurologic and splanchnic effects. Insufflation of the peritoneum results in reduced lung volumes, atelectasis, and endobronchial migration of the endotracheal tube. Pneumoperitoneum can result in changes to venous return, cardiac output and blood pressure. Hypercapnia due to carbon dioxide gas used in insufflation can reduce cerebral perfusion pressure. Complications during laparoscopic surgery often occur during port placement and creation of the pneumoperitoneum. Problems include injury to blood vessels during trocar entry, vascular injury in the pneumoperitoneum with limited surgical access, severe bradycardia and arrhythmias due to vagal stimulation from peritoneal stretching, subcutaneous emphysema, pneumothorax, gas embolism, and complications associated with steep Trendelenburg positioning. A thorough understanding of the physiologic changes associated with laparoscopic procedures and recognition of potential complications will facilitate in optimal patient care. This review contains 4 figures, 1 table and 52 references Keywords: Laparoscopy; laparoscopic surgery; carbon dioxide; pneumoperitoneum; capnothorax; general anesthesia; subcutaneous emphysema; insufflation

Evaluation of blood electrolyte alterations in cats during elec-tive laparoscopic ovariectomy

In a clinical setting, we tested the hypothesis of whether hypercapnia developed during carbon dioxide pneumoperitoneum is associated with changes in blood electrolytes. This prospective study involved ten female cats that underwent elective laparoscopic ovariectomy. Venous blood samples for assessment of electrolytes were collected in the following sequence: T1- before anaesthesia induction, T2 - 10 minutes after anaesthesia induction, T3 - 30 minutes of pneumoperitoneum and T4 - at the end of pneumoperitoneum. Statistical analysis revealed AB disturbances associated with general anaesthesia and pneumoperitoneum, manifested with decreased blood pH, whereas blood PvCO2, PO2 and BE were increased. A constant increase of K+ concentration was recorded in all animals during pneumoperitoneum (P<0.05), whereas iMg registered a significant increase only at T3 (P<0.05). Correlations were recorded between blood pH and Na+, iCa, iMg, as well as between Na+ and Cl¯ at different time points during anaesthesia. No correlations were noted between pH and K+ or PvCO2 and K+. In conclusion, electrolyte imbalance represents a possible complication associated with laparoscopic surgery in healthy cats. However, further studies should investigate the causes involved in K+ concentration elevation.

Effects of different plasma target concentrations of remifentanil on the MACBAR of sevoflurane in children with laparoscopic surgery

Background To investigate the effects of different plasma target concentrations of remifentanil on the minimum alveolar concentration (MAC) for blocking adrenergic response (BAR) of sevoflurane in children with laparoscopic herniorrhaphy. Methods Seventy-five children with 3-7 years old scheduled for laparoscopic herniorrhaphy were randomly divided into group R0, group R1, and group R2 according to different remifentanil plasma target concentration (0, 1, and 2 ngml-1), respectively. The MACBAR of sevoflurane was determined by the up-and-down and sequential method in each group. The concentrations of epinephrine and noradrenaline were also determined at corresponding time points. Results A total of 52 child patients were used among the anticipated 75 patients. In groups R0, R1, and R2, the MACBAR of sevoflurane was (3.29 ± 0.17) %, (2.12 ± 0.10) % and (1.29 ± 0.11) %, respectively, and a significant difference was found among the three groups (P<0.05). The changes of epinephrine and noradrenaline concentrations in each group before and after insufflation of carbon dioxide pneumoperitoneum showed no significant differences. Conclusion Remifentanil by target-controlled infusion can effectively reduce the MACBAR of sevoflurane during laparoscopic surgery in children. At a similar effect of MACBAR, both the changes of epinephrine and noradrenaline concentrations are not affected by the infusion of different remifentanil target concentrations. Trial registration The trial was registered at http://www.chictr.org.cn(ChiCTR1800019393, 8, Nov, 2018).

Safe laparoscopy during COVID-19 pandemic by SARS-CoV-2: bio innovation of the closed-circuit system

Background: Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) transmission during laparoscopy while using energy devices through the carbon dioxide pneumoperitoneum is a big concern in operation theatre. So, we had to alter the way we vent carbon dioxide through a closed-circuit system (CCS) to avoid contamination.Methods: We did a prospective study in the safety of the CCS during elective laparoscopic surgeries. We had recruited 184 patients from a single unit in three quarters. The first quarter had 52 patients where the SARS-CoV-2 status was unknown as rapid antigen test (RAT) and reverse transcription polymerase chain reaction (RT- PCR) was not done as per government guidelines. So, we presumed all patients to be potential carriers. Later in the 2nd and 3rd quarter we had recruited 132 patients; all were tested by RAT/RT-PCR and positive patients were excluded from our study. Postoperatively we observed for COVID-19 symptoms in our health care workers (HCW) and confirmed by RT-PCR.Results: Of the total 184 laparoscopic surgeries performed during this period, only 2 (1.09%) patients developed COVID-19 symptoms and this was in the 1st quarter when routine testing by RT-PCR was not done. None (100%) of our HCW developed symptoms of COVID-19.Conclusions: Closed circuit system is an innovative and safe technique during laparoscopy. We strongly recommend RT-PCR for COVID-19 before elective surgery.

Risks of anaesthesia in laparoscopic interventions in the abdominal cavity

Laparoscopic surgical technologies in abdominal surgeries strengthen their position every year, especially du­ring planned surgeries, reduce the patient’s trauma and length of stay in the hospital. However, the technique of laparoscopic interventions involves non-physiological position of the patient on the operating table (especially during long operations), the use of pneumoperitoneum with carbon dioxide. Pneumoperitoneum creates increased pressure on the diaphragm, disrupts venous return and can create other unpleasant situations. There is no absolute contraindication to laparoscopic surgery, although we should anticipate possible problems in conditions such as obesity, pregnancy and previous abdominal surgeries. In order to reduce the trauma of surgery, laparoscopic techniques are used, and incorrect assessment of their capabilities in high-risk patients can lead to serious complications. Anaesthesiologists should carefully consider all the risks associated with laparoscopic technique, interact with surgeons to reduce the risk of complications, constantly monitor the patient’s state and use modern approaches to the choice of anaesthesia. The purpose of this work is to summarize the best available evidence and established practice for perioperative management of patients with laparoscopic interventions in the abdominal cavity.

The “Dark Side” of Pneumoperitoneum and Laparoscopy

Laparoscopic surgery has been one of the most common procedures for abdominal surgery at pediatric age during the last few decades as it has several advantages compared to laparotomy, such as shorter hospital stays, less pain, and better cosmetic results. However, it is associated with both local and systemic modifications. Recent evidence demonstrated that carbon dioxide pneumoperitoneum might be modulated in terms of pressure, duration, temperature, and humidity to mitigate and modulate these changes. The aim of this study is to review the current knowledge about animal and human models investigating pneumoperitoneum-related biological and histological impairment. In particular, pneumoperitoneum is associated with local and systemic inflammation, acidosis, oxidative stress, mesothelium lining abnormalities, and adhesion development. Animal studies reported that an increase in pressure and time and a decrease in humidity and temperature might enhance the rate of comorbidities. However, to date, few studies were conducted on humans; therefore, this research field should be further investigated to confirm in experimental models and humans how to improve laparoscopic procedures in the spirit of minimally invasive surgeries.

Effect of Body Posture on Lung Ventilation and Oxygenation During Carbon Dioxide Pneumoperitoneum in Rabbit

This study was conducted to investigate the influence of body position on respiratory compliance and oxygenation during iatrogenic pneumoperitoneum in the rabbit. The peak inspiratory pressure, dynamic compliance, static compliance and arterial gas parameters were calculated and measured 10 min before and 30 min after the creation of pneumoperitoneum with the patient in the horizontal position, 30 min after placing the patient in the Trendelenburg position and 30 min after placing the patient in the reversed Trendelenburg position. Following the creation of pneumoperitoneum and Trendelenburg positioning, there was a significant increase in peak inspiratory pressure while dynamic and static respiratory compliance decreased. Similarly, arterial oxygenation increased during Trendelenburg position while arterial carbon pressure remained within limits during all positions. Overall, the reverse Trendelenburg position did not improve ventilation, neither the oxygenation. However, this position showed to be more appropriate because may reduce the risk of lung injury associated with high-pressure ventilation during pneumoperitoneum.

Abdominal Recurrence after Robotic Nephron-Sparing Surgery for Wilms Tumor in an Adult Patient

A 31-year-old man was referred to an adult urologist for a renal polar mass that measured 7.2 cm in maximum diameter. Robotic assisted complete tumor excision for suspicious renal cell carcinoma was carried out, preserving the rest of the left kidney. Histopathology showed a Wilms tumor (WT) with positive margins. No postoperative therapy was made, and the patient shortly presented an abdominal recurrence. The patient was referred to our pediatric oncology unit; he received preoperative chemotherapy, followed by surgery (completion nephrectomy and removal of neoplastic deposits in the omentum and parietal peritoneum), postoperative chemotherapy, and abdomen radiotherapy. He is well at the 5-year follow-up. Peritoneal dissemination after laparoscopic nephron-sparing surgery (NSS) in a child with a 10-cm WT was previously reported. We suggest open NSS for large WT may be safer than laparoscopic or robotic NSS because carbon dioxide pneumoperitoneum and traumatic handling of tumor may predispose to tumor cell migration. An abdominal WT relapse in adults can be salvaged by multimodal therapy recommended by current pediatric WT guidelines.

Effects of different plasma target concentrations of remifentanil on the MACBAR of sevoflurane in children with laparoscopic surgery

BackgroundTo investigate the effects of different plasma target concentrations of remifentanil on the minimum alveolar concentration (MAC) for blocking adrenergic response (BAR) of sevoflurane in children with laparoscopic herniorrhaphy.MethodsSeventy five children with 3–7 years old scheduled for laparoscopic herniorrhaphy were randomly divided into group R0, group R1, and group R2 according to different remifentanil plasma target concentration (0, 1, and 2 ng/ml), respectively. The MACBAR of sevoflurane was determined by the up-and-down and sequential method in each group. The concentrations of epinephrine and noradrenaline were also determined at corresponding time points.ResultsIn groups R0, R1, and R2, the MACBAR of sevoflurane was (3.29 ± 0.17)%, (2.12 ± 0.10)% and (1.29 ± 0.11)%, respectively, and a significant difference was found among the three groups (P < 0.05). The changes of epinephrine and noradrenaline concentrations in each group before and after insufflation of carbon dioxide pneumoperitoneum showed no significant differences.ConclusionRemifentanil by target-controlled infusion can effectively reduce the MACBAR of sevoflurane during laparoscopic surgery in children. At a similar effect of MACBAR, both the changes of epinephrine and noradrenaline concentrations are not affected by the infusion of different remifentanil target concentrations.Trial registrationThe trial was registered in the China Clinical Trial Center(http://www.chictr.org.cn) in advance (the registry number is ChiCTR1800019393.).