Laparoscopy

  • Benefits: reduced trauma and stress response
    • Closed abdomen may be a factor
  • Physiologic benefits
    • Less impairment of pulm fxn
    • Less blood loss
    • Less immune suppression
    • Less stress response
    • Less adhesions
  • Clinical benefits
    • Less pain: less narcotic use
    • Quicker resumption of diet
    • Shorter LOS
    • Quicker return to work
    • Less incisional hernia
    • better return of normal lung volumes (FVC and FEV1)
  • Entry Techniques: no advantage in preventing major complications
    • Types: Veress Needle, Hasson: Open direct, Optical Viewing Trocars
  • Physiology: Insufflation
    • Insufflation: CO2 gas: 12-15mmHg
      • Gas exchange: CO2 + H20 = H2CO3 = H + HCO3: resp acidosis
      • Asa 1/2: no effect
      • Asa 3/4: increased map and increased svr with decreased CO leads to hypoxia and dec o2 delivery
    • Altered ventilation
      • Increased IAP: like a severe valsalva
      • Decreased FRC: increased alveolar dead space
      • Increased airway pressure
      • Decreased compliance 2′ decreased diaphragm excursion
      • CO2 rapidly absorbed from the peritoneal cavity
        • Causes hypercapnea and respiratory acidosis
      • Requires an inc in minute/tidal volume to keep pco2 acceptable: up to 16% to maintain normocarbia
        • Anesthesiology increases rate to compensate
    • Altered hemodynamics
      • Increase in catecholamines, angiotensin and vasopressin
      • Venous return (ivc) is decreased
        • Decreases stroke volume and thus decreases cardiac index
      • Response is increased SVR: lasts up to 30 min post procedure
        • SVR = ((MAP-VCP)*80) /CO
      • Increased intrathoracic pressure
      • Increased CVP and PCWP
      • Increased PVR
      • Decreased CI: Caused by decreased SV 2’ to IAP compression of IVC causing decreased venous return
        • CI = HR * SV / BSA
      • Reduced CO: bad for: cardiomyopathy, as, etc
      • Response dependent on volume status of pt
        • Typically pt are low or euvolemic
      • Pt Positioning
        • Trendelenburg: enhances altered hemodynamics
        • Reverse trendelenburg: worsens these effects
    • Immune system response
      • White cells still rise
      • Acute phase reactants: CRP
        • Rises 4-12 hours after surgery, peaks 1-3 days, remains elevated for 2 weeks
        • Less rise with laparoscopy: likely secondary to CO2gas (not just incision size)
      • CD3 down reg
      • Activated lymphocytes down reg
      • Cytokines: Less rise of IL 6, TNFalpha, IL1, granulocytes
    • Neuroendocrine response
      • Less elevation of adrenal hormones: cortisol and epinephrine
      • Less elevation of sympathetic hormones: dopa and norepi
      • Less elevation of pituitary hormones: acth, prolactin, growth hormone
      • All have 20-40% lower peaks
      • Faster return to normal 4 v 9 hours
      • Peak glucose increase 25% less
    • Increased intra-abd pressure stretches diaphragm and irritates nerves
      • No increased risk of DVT
    • Altered Renal Blood flow
      • Decreased RBF during tension pneumoperitoneum
      • Increased renal vein pressure
      • Decreased urine output: usually not clinically relevant
      • Increased renal blood flow after exsufflation: usually no effect on serum creatinine
      • Preserve function with pressure <20mmHg
      • Tx: Increase in fluid administration, dopamine
    • Increased ICP
      • Independent of arterial pH, oxygenation and MAP
      • Mechanism not elucidated
      • Usually without clinical consequence
  • Complications
    • Bradyarrythmia on induction of pneumo:
      • 2’ to vagal stimulation induced by peritoneal stretching on insufflation
      • Tx/ immediate cessation of surgical stimulation
        • Deflate abdomen
        • Glycopyrrolate or atropine
    • CO2 embolism
      • CO2 directly into venous channel: obstruction of R ventricular outflow tract
        • Decreased end tidal co2
      • MC during hepatectomy
      • Cyanosis
      • Increased venous pressure
      • Ventricular arrhythmia
      • Tx
        • Stop insufflation
        • Left Lateral Decubitus: head down
        • Hyperventilate
        • Aspirate gas from R atrium through central venous catheter
    • SubQ emphysema during or after laparoscopy
      • Presents as crepitus
      • Frequent occurrence: leak around abd insufflating port
      • Can be assoc with respiratory acidosis
      • Prolonged postop ventilation
      • Will dissolve in 24-72 hours
      • May bruise
    • Shoulder pain: nerve irritaiton
      • Last up to 3 days
    • Aspiration of gastric contents:
      • increased IAP can increase risk of regurg
      • P/w tachycardia immediately following extubation (tx IS and nebs)
    • Injury to viscera: bladder, bowel
      • Bladder
        • Repair primarily
        • Leave foley 7-10 days
      • Enterotomy 1.8%
        • Immediate:
          • Cx/ Trocar, suture passer, adhesiolysis
          • Primary repair
        • Delayed: 20% missed, 8% mortality
          • Cx/ Thermal burn: cautery ultrasonic shears
      • Bleeding
        • From trocar site: figure of 8 suture or hook cautery: don’t ignore
        • From trocar entry:
          • Convert to open, isolate injury primary repair
  • NB for common procedures
    • Chole: Identify the critical window
    • Colon: Right, Left and LAR
      • Risk: bleeding, infection, visceral/ureteral injury, leaks
      • Minimize risk: medial to lateral dissection, proper visualization, proper identification of anatomy
      • Benefit: less pain, fewer wound complications
    • Hernia
      • TEP: total extraperitoneal rpr
      • TAPP: transabdominal pre peritoneal rpr
      • Risk: chronic pain, recurrence
      • Chronic pain: TEP less than open
      • Lap: more expensive, but can catch b/l hernias
      • Higher recurrence (veterans data)
      • Recurrence do opposite of first: lap/open
      • Recurrence after lap inguinal: inadequate dissection, mesh fixation and pt obesity and smoking
  • Future
    • SILS
      • Growth preceeds clinical benefit
      • Increased hernia’s
      • Body image better, Cost higher
    • NOTES: experimental
    • Robotics: level 5 (expert opinion) evidence:
      • better cosmesis
      • Less pain, shorter LOS, less ebl
      • More expensive, longer OR times

8,658 thoughts on “Laparoscopy


    Fatal error: Allowed memory size of 67108864 bytes exhausted (tried to allocate 72 bytes) in /home/surgeryextra/public_html/wp-includes/class-wp-walker.php on line 283