Journal of Clinical Anesthesia (2006) 18, 67 – 78

Review article

Anesthesia for laparoscopy: a review Frederic J. Gerges MD (Chief Resident), Ghassan E. Kanazi MD (Associate Professor), Samar I. Jabbour-khoury MD (Associate Professor)* Department of Anesthesiology, American University of Beirut-Medical Center, Beirut 1107-2020, Lebanon Received 7 June 2004; accepted 27 January 2005

Keywords: Laparoscopy; Patophysiological changes; Anesthesia; General; Regional; Recovery; Complications

Abstract Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbon dioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This article considers the pathophysiological changes during laparoscopy using carbon dioxide for intraabdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, and discusses recovery and postoperative complications after laparoscopic abdominal surgery. D 2006 Elsevier Inc. All rights reserved.

1. Introduction Laparoscopy started in the mid 1950s when gynecologists declared this technique as a safe way to diagnose pelvic pain while reducing hospital stay and postoperative pain. Thereafter, laparoscopy for general surgery followed and proved to be advantageous in reduction of postoperative pain, better cosmetic results, quicker return to normal activities, reduction in hospital stay resulting in overall reduction in * Corresponding author. Tel.: +961 1 350 000x6380; fax: +961 1 744 464. E-mail address: [email protected] (S.I. Jabbour-khoury). 0952-8180/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2005.01.013

medical cost, less intraoperative bleeding, less postoperative pulmonary complications, less postoperative wound infection, reduced metabolic derangement, and better postoperative respiratory function [1]. In recent years, advanced laparoscopic surgery has targeted older and sicker patients, rendering anesthesia during laparoscopy more technically demanding. On one hand, laparoscopy can compromise the cardiovascular and respiratory function of the patients, whereas on the other, it was introduced as a safe and simple procedure that may be performed on an outpatient basis hence demanding extreme caution regarding the anesthetic technique. Furthermore, the application of laparoscopy has expanded and is currently

68 used safely and effectively in children [2], in vascular cases such as total laparoscopic aortomesenteric bypass [3], in complicated urology cases such as laparoscopic nephrectomy for large renal arteriovenous malformation [4], for radical prostatectomy, in hand assisted laparoscopic radical cystectomy [5], in advanced general surgery for distal pancreatectomy [6], and in hepatic resection [7,8]. Consequently, laparoscopic surgery presents several new challenges for the anesthesiologist where an appraisal of the potential problems is essential for optimal anesthetic care, allowing early detection and reduction of complications.

2. The choice of insufflated gas The ideal gas for insufflation would have the following properties: minimal peritoneal absorption, minimal physiological effects, rapid excretion of any absorbed gas, inability to support combustion, minimal effects from intravascular embolization, and high blood solubility [9]. Air and oxygen cannot be used for insufflations during laparoscopy because they support combustion whenever bipolar diathermy or lasers are used. Helium and nitrogen are relatively insoluble, as compared with carbon dioxide, and can result in more serious cardiovascular sequelae whenever an intravascular gas embolization occurs. Furthermore, concerns about helium cost effectiveness in laparoscopy have been raised. Argon may have unwanted hemodynamic effects, especially on hepatic blood flow. Although nitrous oxide is advantageous for procedures requiring local/ regional anesthesia and, in some cases, of depressed pulmonary function, it does not suppress combustion [9]. Carbon dioxide approaches the ideal insufflating gas and maintains its role as the primary insufflation gas in laparoscopy. Residual carbon dioxide pneumoperitoneum is cleared more rapidly than that created with other gases, minimizing the duration of postoperative discomfort [9]. However, the chief drawback of carbon dioxide is its significant vascular absorption across the peritoneum, leading to hypercapnia and intravascular embolization [10]. The gasless laparoscopic technique avoids using any gas for insufflation, relying instead on an abdominal wall lift to create an intra-abdominal space at atmospheric pressure, consequently eliminating the problems attributed to increased intra-abdominal pressure (IAP), hypercapnia, and carbon dioxide embolization. Furthermore, it provides a better cardiovascular condition with a resultant higher heart performance and lower preload and afterload, as compared with carbon dioxide laparoscopy [11]. Alijani et al [12] have demonstrated that the abdominal wall lift approach avoids fall in cardiac output associated with carbon dioxide pneumoperitoneum and is associated with a more rapid recovery of postoperative cognitive function. Hence, abdominal walllifting approach in laparoscopic cholecystectomy is a method worthy of consideration for elderly patients or those with cardiopulmonary problems [13]. However, in patients with

F.J. Gerges et al. limited cardiac, pulmonary, or renal function, abdominal wall lifting have no clinically relevant advantages compared with low-pressure (5-7 mm Hg) pneumoperitoneum; furthermore, abdominal wall lifting combined with low-pressure pneumoperitoneum might be a good alternative [14].

3. Pathophysiological changes during laparoscopy Laparoscopy induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a carbon dioxide pneumoperitoneum can help minimize complications and render laparoscopic surgery a safer technique.

3.1. Effects of carbon dioxide absorption Carbon dioxide diffuses to the body more during extraperitoneal than intraperitoneal insufflation, and its diffusion is not influenced by the duration of intraperitoneal insufflation [15]. Furthermore, extraperitoneal carbon dioxide insufflation leads to higher Paco2 (tension of carbon dioxide in arterial blood) values in the postoperative period [16]. Intraperitoneally, carbon dioxide was shown to be affected by raising the intraperitoneal pressure above the venous vessels pressure, which prevents carbon dioxide resorption leading to hypercapnia. Hypercapnia by itself increases minute ventilation by as much as 60% to normalize the end-tidal carbon dioxide (etco2) and activates the sympathetic nervous system leading to an increase in blood pressure, heart rate, myocardial contractility, and arrhythmias. It also sensitizes the myocardium to catecholamines, particularly when volatile anesthetic agents are used [10].

3.2. Creation of the pneumoperitoneum The creation of a pneumoperitoneum is ideally done with 2.5 to 5.0 L of insufflated carbon dioxide to permit adequate visualization and manipulation of the abdominal viscera. The pneumoperitoneum necessarily raises IAP, which can have significant cardiovascular, respiratory, and neurologic effects. 3.2.1. Cardiovascular effects Major hemodynamic changes include alterations in arterial blood pressure (ie, hypotension and hypertension), arrhythmias, and cardiac arrest. The extent of the cardiovascular changes associated with creation of pneumoperitoneum will depend on the IAP attained, volume of carbon dioxide absorbed, patient’s intravascular volume, ventilatory technique, surgical conditions, and anesthetic agents used. However, the critical determinants of cardiovascular function during laparoscopy are the IAP and patient position. At IAP levels below 15 mm Hg, venous return is augmented as blood is bsqueezedQ out of the splanchnic venous bed, producing an increase in cardiac output. Further increase in cardiac output at lower IAP may result from increased

Anesthesia for laparoscopy cardiac filling pressures due partly to mechanical factors and partly to sympathetically mediated peripheral vasoconstriction along with the effects of hypercapnia on cardiac efferent sympathetic activity, which can increase systemic vascular resistance and reduce cardiac index. At IAP levels greater than 15 mm Hg, venous return decreases as the inferior vena cava is compressed along with the surrounding collateral vessels leading to decreased cardiac output and hypotension [17]. Recent studies recommend a moderate to low IAP (b12 mm Hg) as it limits the alteration in splanchnic perfusion, and consecutive organ dysfunctions will be minimal, transient, and will not influence the outcome [10]. Zuckerman and Heneghan [18] demonstrated that these changes are short lived and lose their statistical significance at 10 minutes from the time a patient undergoes pneumoperitoneum. Bradyarrhythmias, including significant bradycardia, atrioventricular dissociation, nodal rhythm, and asystole have been reported. These are attributed to vagal stimulation caused by insertion of the Veress needle or the trocar, pneumoperitoneum-induced peritoneal stretch, stimulation of the fallopian tube during bipolar electrocauterization, or carbon dioxide embolization [19]. Tachyarrhythmias can occur because of increased concentrations of carbon dioxide and catecholamines. Paroxysmal tachycardia and hypertension, followed by ventricular fibrillation, have been reported during laparoscopic adrenalectomy [20]. The induction of pneumoperitoneum with the patient in the horizontal position rather than in head-up or head-down position can decrease the severity of these hemodynamic changes. Patients with normal cardiovascular function are able to well tolerate these variations in preload and afterload. Those with cardiovascular disease, anemia, or hypovolemia require meticulous attention to volume loading, positioning, and insufflation pressures. However, many cases of cardiovascular collapse during laparoscopy occurs in healthy patients, because of, namely, vasovagal reflex response to peritoneal stimulation from trocars or insufflation, myocardial sensitization by halothane, reduced venous return secondary to reverse Trendelenburg position, inferior vena cava compression, high insufflation pressures, hypovolemia, hypercapnia particularly in longer procedures, and venous gas embolism. 3.2.2. Respiratory effects Changes in pulmonary function during laparoscopy include reduction in lung volumes, increase in peak airway pressures, and decrease in pulmonary compliance secondary to increased IAP and patient positioning [21]. Creation of pneumoperitoneum at an IAP of 15 mm Hg reduces respiratory system and compliance and increases peak inspiratory and mean airway pressures, which quickly return to normal values after deflation. Elevated IAP reduces diaphragmatic excursion and shifts the diaphragm cephalad, resulting in early closure of smaller airways leading to intraoperative atelectasis with a decrease in functional residual capacity. On one hand, upward displacement of the diaphragm leads to preferential ventilation of nondependent

69 parts of the lung, which results in ventilation-perfusion (V/Q) mismatch with a higher degree of intrapulmonary shunting, whereas on the other, it leads to endobronchial intubation. These pulmonary pathophysiological changes lead to hypercapnia and hypoxemia in case of noneffective ventilation leading to pulmonary vasoconstriction [10]. Higher IAP reduces more the thoracic compliance and can cause pneumothorax and pneumomediastinum owing to the increase in alveolar pressures, particularly in patients with extensive pulmonary disease undergoing laparoscopic upper abdominal surgeries [21]. In patients with significant pulmonary dysfunction, preoperative pulmonary function testing including arterial blood gas analysis should be performed, and intraoperative radial artery cannula should be placed. If refractory hypoxemia, hypercapnia, or high airway pressures occur during the laparoscopy, the pneumoperitoneum should be released followed by slow reinsufflation using lower IAPs. If complications recur, conversion to an open procedure is a must [21]. 3.2.3. Neurologic effects Increased intracranial pressure (ICP) along with a decrease in cerebral perfusion pressure is encountered whenever hypercapnia, increased systemic vascular resistance, head-down positioning, and elevated IAP are present. Because of this phenomenon, it is inadvisable to perform laparoscopic surgery on patients with reduced intracranial compliance unless absolutely necessary [22].

3.3. Patient positioning Adverse patient positions can further compromise cardiac and respiratory function, can increase the risk of regurgitation, and can result in nerve injuries. These complications were relatively rare when laparoscopy was mainly confined to brief gynecologic procedures in healthy patients but become more likely with longer and more complex surgery performed in older and sicker patients. 3.3.1. Cardiovascular changes and patient positioning Cardiovascular changes are complicated by the patient’s position during laparoscopic surgery. The head-up position reduces venous return and cardiac output, with a decrease in mean arterial pressure and cardiac index, as well as an increase in peripheral and pulmonary vascular resistance [10,17,23]. These effects may be mistaken as the side effects of anesthetic agents. Furthermore, a study done by Cunningham et al [24] using transesophageal echocardiography has showed an increase in left ventricular end-systolic wall stress, along with a decrease in left ventricular end-diastolic area, with left ventricular ejection fraction being the same. Conversely, head-down position increases venous return and normalizes blood pressure [17]. 3.3.2. Respiratory changes and patient positioning Blood gas changes and respiratory mechanics are affected by the duration of pneumoperitoneum and patient positioning. The deterioration in respiratory function is

70 reduced when the patient is in the reverse Trendelenburg position and worse when the patient is in the Trendelenburg position [25].

4. Patient monitoring Appropriate anesthetic techniques with proper monitoring to detect and reduce complications must be used to ensure optimal anesthesia care during laparoscopy. Hence, electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, pulse oximeter, etco2 concentration monitor, peripheral nerve stimulation and body temperature probe are routinely used. For hemodynamically unstable patients or those with compromised cardiopulmonary function, careful monitoring of cardiovascular and blood gases by an arterial cannulation is indicated along with urine output measurement. These measures also apply for obese patients [14]. End-tidal carbon dioxide is most commonly used as a noninvasive substitute for Paco2 in evaluating the adequacy of ventilation during laparoscopic surgery. However, a careful consideration should be taken for the gradient between Paco2 and PEco2 (tension of carbon dioxide in expired air) because the etco2 may differ considerably from Paco2 because of V/Q mismatching. In patients with compromised cardiopulmonary function, the gradient between Paco2 and PEco2 increases to become unpredictable so that direct estimation of Paco2 by arterial blood gas analysis may be necessary to detect hypercarbia. Therefore, a radial artery cannulation for continuous blood pressure recording and frequent arterial blood gas analysis should be considered in patients with preoperative cardiopulmonary disease and in situations where intraoperative hypoxemia, high airway pressures, or elevated etco2 are encountered [14]. An airway pressure monitor is routinely used during intermittent positive pressure ventilation. A high airway pressure alarm can aid detection of excessive elevation in IAP [14]. Nerve stimulation ensures adequate muscle paralysis, which reduces the IAP necessary for abdominal distension and prevents sudden patient movement that can lead to accidental injuries of intra-abdominal structures by laparoscopic instruments [14]. Inadequate anesthesia may occur in the presence of neuromuscular block, resulting in awareness. The use of a Bispectral Index, a possible monitor of depth of hypnosis, can help to reduce the occurrence of awareness. Some anesthesiologists have used this monitor to titrate intravenous and inhaled anesthetic drugs to fasten emergence and improve recovery [26-28].

5. Anesthetic techniques Because more laparoscopic procedures are done on an outpatient basis, general and regional anesthesia have been

F.J. Gerges et al. successfully and safely used with great emphasis on short duration drugs, cardiovascular stability, rapid recovery and fast-tracking, mobility, and freedom from postoperative nausea and vomiting and pain.

5.1. General anesthesia for laparoscopy General anesthesia using balanced anesthesia technique including inhalational agents such as nitrous oxide, sevoflurane, isoflurane, and desflurane; intravenous induction agents such as thiopentone, propofol, and etomidate; and a variety of muscle relaxants including succinylcholine, mivacurium, atracurium, and vecuronium have been reported. Shorter-acting drugs such as sevoflurane, desflurane, and continuous infusions of propofol represent the maintenance agents of choice. In fact, comparative studies have demonstrated an early recovery, which is similar with any of these drugs. Propofol, however, does have the advantage of producing less postoperative nausea and vomiting (PONV) [29,30]. The use of more rapid and shorter-acting volatile anesthetics such as desflurane and sevoflurane and bultrashort-actingQ opioid analgesics such as remifentanil has allowed anesthesiologist to more consistently achieve a recovery profile that facilitates fast tracking after the administration of general anesthesia. Fast tracking in the ambulatory setting implies taking a patient from the operating room directly to the less extensively monitored phase II step-down unit bypassing the postanesthesia care unit. It is applied in multiple laparoscopic procedures including cholecystectomy, gastric fundoplication, splenectomy, adrenalectomy, and donor nephrectomy [31]. Nowadays, fast-track anesthesia is gaining more and more practice in laparoscopic surgery to include the pediatric age group where laparoscopic appendectomy is demonstrated to be safely performed as fast-track or same-day surgery with a postoperative stay of 24 hours or less [32]. Furthermore, endoscopic thoracic sympathectomy is currently performed safely on an outpatient basis [33]. Compared with standard monitoring practices, the use of an auditory evoked potential or Bispectral Index monitor to titrate the volatile anesthetic leads to a significant reduction in the anesthetic requirement, resulting in a shorter postanesthesia care unit stay and an improved quality of recovery from the patient’s perspective [34]. Song et al [35] demonstrated that the electroencephalographic Bispectral Index values at the end of anesthesia is useful in predicting fast-track eligibility after laparoscopic tubal ligation with either a desflurane or propofol-based anesthetic technique. Total intravenous anesthesia using the following agents: propofol, midazolam and ketamine, and alfentanil and vecuronium have been reported for outpatient laparoscopy. Propofol-based anesthesia provided inferior perioperative conditions compared with isoflurane caused by more frequent movement in spontaneously breathing patients. Furthermore, sevoflurane and desflurane were still superior to propofol, even when PONV was considered, and resulted in a higher percentage of patients being judged fast-track eligible [36].

Anesthesia for laparoscopy Patients are more liable to develop perioperative awareness and PONV whenever opioid-based techniques are used for laparoscopy. Therefore, opioid supplementation of intravenous or inhalation-based anesthesia is more appropriate. The ultrashort-acting opioid remifentanil, which is rapidly hydrolyzed by circulating and tissue nonspecific esterases, has been shown to provide better control of perioperative hemodynamic responses, compared with alfentanil [37]. A major advantage of remifentanil is that doses sufficient to attenuate cardiovascular responses can be used without the risk of postoperative respiratory depression and delayed recovery. However, postoperative analgesia should be considered. Song and White [38] demonstrated that the adjunctive use of a remifentanil infusion during desflurane–nitrous oxide anesthesia facilitates early recovery without increasing PONV, pain, or the need for rescue medication after laparoscopic surgery. Yang et al [39] did not find any difference in PONV, pain, or anesthetic/ recovery times or costs between sevoflurane-remifentanil induction and propofol-fentanyl-rocuronium induction in the first 24 hours after laparoscopic surgery. Preemptive analgesic techniques using nonopioids such as acetaminophen, non steroidal anti-inflammatory drugs, a 2-agonists, and N-methyl D-aspartate antagonists proved to be of benefit in multimodal analgesia and ambulatory surgery where rapid recovery is the aim. Non-opioids are increasingly used during laparoscopy to decrease opioid requirements and avoid delayed recovery [40]. Nitrous oxide is commonly used to provide perioperative analgesia and to reduce the requirements for inhaled or intravenous anesthetics. The contribution of nitrous oxide to nausea and vomiting is still controversial. There is apparently no clinical advantage to omitting nitrous oxide, and any benefit from its elimination must be balanced against a greater risk of awareness [41]. Earlier anesthetic techniques described for laparoscopic cholecystectomy avoided nitrous oxide. Further studies have confirmed similar surgical conditions and view regardless of whether nitrous oxide was used, questioning its contraindication during laparoscopic cholecystectomy. However, omission of nitrous oxide improves surgical conditions for intestinal and colonic surgery by avoiding the possible nitrous oxide diffusion into the bowel lumen. Diemunsch et al [42] have demonstrated that nitrous oxide diffuses into a carbon dioxide pneumoperitoneum up to a level that can support combustion in a 2-hour interval. Whether nitrous oxide diffusion represents a real clinical risk of fire and explosion during prolonged laparoscopy remains unclear, however. In practice, some gas usually leaks from the abdomen and is replaced by fresh carbon dioxide, which would somewhat compensate for the ingress of nitrous oxide. Succinylcholine was once commonly used as the muscle relaxant of choice for short laparoscopic procedures, but it was associated with a high incidence of postoperative muscle pains. Currently, there is a considerable choice in nondepolarizing neuromuscular blocking drugs rendering

71 their use more frequent, although none of them are quite as short acting as succinylcholine. When they are used in place of succinylcholine, the amount of muscle pain especially in the neck is reduced [43,44]. Shoulder pain is still common, however, being largely a consequence of the pneumoperitoneum. The lack of a very-brief-duration nondepolarizing neuromuscular blocking drug is no longer a significant problem because laparoscopic surgery has become more complex and takes more time. However, it is desirable to use repeated doses of short-acting agents rather than occasional doses of longer-acting drugs. Using short-acting drugs makes it feasible to reverse residual neuromuscular block even if the last increment of a short-duration drug were given within the previous 5 to 10 minutes. Some anesthesiologists avoid the use of reversal drugs because it has been suggested that they increase the incidence of PONV [43]. However, others have not found an increase in PONV associated with the use of neostigmine and glycopyrrolate to reverse residual neuromuscular block [45]. More importantly, even minor degrees of residual neuromuscular block can produce distressing symptoms, such as visual disturbances, facial and generalized weakness, and the inability to sit without assistance [46]. These symptoms can be present despite signs of clinical recovery from neuromuscular block and can prolong the recovery process. These findings should present an incentive to minimize the use of neuromuscular blocking drugs in ambulatory anesthesia. When they are used, however, reversal drugs should be administered in appropriate doses without hesitation. General anesthesia without intubation can be performed safely and effectively with a ProSeal laryngeal mask airway (LMA) in nonobese patients [47]. Moreover, a correctly placed classic LMA or a ProSeal (ProSeal LMA, San Diego, CA, USA) LMA is as effective as an endotracheal tube for positive pressure ventilation without clinically important gastric distension in nonobese and obese patients [48]. However, it should be restricted to short procedures performed using low IAP and small degrees of tilt. It results in less sore throat and might be proposed as a safe alternative to endotracheal intubation [49]. Furthermore, it allows controlled ventilation and accurate monitoring of etco2. However, decreased thoracopulmonary compliance during pneumoperitoneum frequently results in airway pressures exceeding 20 cm H2O. Because the LMA cannot guarantee an airway seal above this pressure, its use for controlled ventilation should be limited to healthy, thin patients. If tracheal intubation is still required, it can be performed under deep intravenous [50] or inhalation anesthesia [51], eliminating the potential problem of excessively prolonged paralysis. Lu et al compared the ProSeal LMA with the classic LMA for positive pressure ventilation during laparoscopic cholecystectomy and found the ProSeal LMA to be a more effective ventilatory device than the classic LMA. Hence, he did not recommend the use of classic LMA for laparoscopic cholecystectomy [52]. Because general anesthesia with endotracheal intubation and controlled ventilation is certainly the safest technique, it

72 is recommended for inpatients and for long laparoscopic procedures. During pneumoperitoneum, controlled ventilation must be adjusted to maintain etco2 at approximately 35 mm Hg, requiring no more than a 15% to 25% increase in minute ventilation. In patients with chronic obstructive pulmonary disease (COPD) and in patients with a history of spontaneous pneumothorax or bullous emphysema, an increase in respiratory rate rather than tidal volume is preferable to avoid increased alveolar inflation and reduce the risk of pneumothorax [53,54]. Anesthetic agents that directly depress the heart should be avoided in patients with compromised cardiac function in favor of anesthetics with vasodilating properties such as isoflurane. Infusion of vasodilating agents, such as nicardipine, reduces the hemodynamic repercussions of pneumoperitoneum and might facilitate management of cardiac patients. Because of the potential for reflex increases of vagal tone during laparoscopy, atropine should be administered before the induction of anesthesia or should be available for injection if necessary.

5.2. Regional anesthesia for laparoscopy Regional anesthesia offers several advantages: quicker recovery, decreased PONV, less postoperative pain, shorter postoperative stay, cost effectiveness, improved patient satisfaction, and overall safety, early diagnosis of complications, and fewer hemodynamic changes [55,56]. Sequelae of general anesthesia such as sore throat, muscle pain, and airway trauma can be avoided. However, this anesthetic approach requires a relaxed and cooperative patient, low IAP to reduce pain and ventilatory disturbances, reduced tilt, a precise and gentle surgical technique, and a supportive operating room staff. Any compromise may result in increased patient anxiety, pain, and discomfort, necessitating supplementation with intravenous sedation. The combined effect of pneumoperitoneum and sedation can lead to hypoventilation and arterial oxygen desaturation [57]. Laparoscopic tubal ligation might be a good indication for regional anesthesia. However, any other laparoscopic procedure that requires multiple puncture sites, considerable organ manipulation, steep tilt, and voluminous pneumoperitoneum makes spontaneous breathing difficult for the patient and, consequently, must not be managed with regional anesthesia. Regional anesthetic techniques are subdivided into 3 main categories: peripheral nerve blocks, neuraxial blocks, and local anesthetic infiltration. 5.2.1. Peripheral nerve blocks Five techniques have been described for laparoscopy: rectus sheath block, rectus sheath block combined with mesoplanix block, inguinal block, pouch of Douglas block, and paravertebral block. They represent either the principal method of anesthesia or an adjunct to general anesthesia. 5.2.1.1. Rectus sheath block. The rectus sheath block, with successful blockade of the relevant intercostal nerves

F.J. Gerges et al. within the rectus sheath, provides anesthesia of the anterior abdominal wall. When administered in conjunction with general anesthesia, rectus sheath block resulted in improved postoperative analgesia and a faster discharge [56]. 5.2.1.2. Rectus sheath block and mesosalpinx block. When administered with general anesthesia, rectus sheath and mesosalpinx blocks resulted in less postoperative pain and analgesic requirement and earlier hospital discharge, as compared with general anesthesia with rectus sheath block alone [58]. 5.2.1.3. Inguinal block. Inguinal block is a useful adjunct to general anesthesia for laparoscopic hernia repair [56]. 5.2.1.4. Pouch of Douglas block. A catheter can be placed in the pouch of Douglas under direct vision using an epidural needle inserted through the abdominal wall. Local anesthetic placed into the pouch of Douglas provides effective pain relief after tubal ligation, whereas the use of a catheter technique permits repetition of the dose to prolong analgesia [59]. 5.2.1.5. Paravertebral block. Bilateral paravertebral blockade at T5-6 level combined with general anesthesia for patients undergoing laparoscopic cholecystectomy improved postoperative pain relief and resulted in less PONV, as compared with general anesthesia alone [60]. 5.2.2. Neuraxial blocks Regional anesthesia, including epidural and spinal techniques, combined with the head-down position, can be used for gynecologic laparoscopy without major impairment of ventilation. In fact, the respiratory changes are less evident when laparoscopy is performed in awake patients under regional anesthesia, and arterial blood gases are maintained within normal limits [61]. Globally, epidural and local anesthesia share the same benefits and disadvantages; however, neuraxial anesthesia alone has the advantages of reducing the need for sedatives and narcotics, produces better muscle relaxation, and can be proposed for laparoscopic procedures other than sterilization. 5.2.2.1. Epidural anesthesia. Epidural anesthesia was considered as a safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression because the respiratory control mechanism remains intact, allowing the patients to adjust their minute ventilation and, therefore, maintaining an unchanged etco2 [61]. Moreover, despite the increase in respiratory work and V/Q mismatch, alveolar ventilation was not compromised even in the Trendelenburg position, and the time to discharge was significantly reduced using epidural compared with general anesthesia. Shoulder pain, which is secondary to diaphragmatic irritation that results from abdominal distension, is incompletely alleviated using epidural anesthesia alone. Extensive sensory block (T4 through L5) is necessary for surgical laparoscopy and may also lead to discomfort. The epidural administration of opiates and/or clonidine might help to provide adequate analgesia [56]. In case of gasless laparoscopy for gynecologic surgery, epidural anesthesia can provide comfort and more adequate

Anesthesia for laparoscopy pain relief while avoiding most of the side effects of carbon dioxide pneumoperitoneum. Furthermore, no significant difference in cardiorespiratory function is present in gasless gynecologic laparoscopy whenever general or epidural anesthesia is performed [62]. In patients with COPD, epidural anesthesia could be safely and effectively used for laparoscopic cholecystectomy, therefore avoiding general anesthesia in patients with chronic respiratory disease [63,64]. Laparoscopic extraperitoneal herniorrhaphy can be performed effectively under epidural anesthesia, obviating the need for general anesthesia [65]. 5.2.2.2. Spinal anesthesia. Spinal anesthesia is the simplest and most reliable of the regional anesthesia techniques. It has become more common in ambulatory practice with the introduction of fine-gauge pencil-point needles. Spinal anesthesia, as the primary technique for laparoscopy, offers many benefits over general anesthesia; however, conventional dose hyperbaric spinal anesthesia might not be ideal for laparoscopy. In fact, the Trendelenburg position predisposes to cephalad spread of the spinal block, a greater sympathetic block, bradycardia, and hypotension [66]. Administration of reduced doses of the local anesthetics or hypobaric solutions minimizes side effects such as hypotension, bladder distension, and prolonged sensory and motor block traditionally associated with conventional doses [67]. For short-duration laparoscopy, a spinal hypobaric solution of 10 mg lidocaine with 10 lg of sufentanil provides adequate analgesia [68]. In ambulatory gynecologic laparoscopy, small-dose spinal anesthesia is an effective alternative to a desflurane general anesthetic. It results in less postoperative pain, cost, and faster recovery [69]. As compared with propofol-based anesthesia, small-dose selective spinal anesthesia has significantly shorter recovery period [70]. Laparoscopic extraperitoneal inguinal hernia repair under spinal anesthesia and extraperitoneal nitrous oxide insufflation has been performed safely and effectively [71]. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum has been performed successfully [72]. In patients with severe COPD undergoing laparoscopic intraperitoneal inguinal hernia repair, spinal anesthesia using hyperbaric bupivacaine is an effective alternative to general anesthesia [73]. With the advent of gasless laparoscopy and microlaparoscopy, the role of spinal anesthesia will probably increase in the future. 5.2.2.3. Combined spinal-epidural anesthesia. One disadvantage of epidural anesthesia is the relatively slow onset of anesthesia. Recently, there has been increasing interest in combining spinal and epidural anesthesia. Potential advantages of combined spinal-epidural (CSE) anesthesia include rapid onset of anesthesia and the ability to administer minimally effective doses of intrathecal agents initially.

73 In a prospective randomized study, Hirschberg et al [74] studied the clinical impact of CSE anesthesia in patients undergoing total extraperitoneal laparoscopic hernia repair vs balanced general anesthesia with controlled ventilation. The respiratory compensation of extraperitoneal gas insufflation was not decreased by CSE anesthesia; however, most of the patients with CSE anesthesia showed severe agitation often accompanied by chest pain. Hence, the author did not recommend this technique. 5.2.2.4. Caudal epidural block. Caudal epidural blocks are an effective modality for providing postoperative analgesia after laparoscopic hernia surgery in children. Children receiving caudal anesthesia as an adjunct to general anesthesia have lower pain scores and do not require supplemental analgesia in the postoperative period [75]. When combined with general anesthesia, caudal epidural block is more effective than ilioinguinal/iliohypogastric block in controlling pain after laparoscopic herniorrhaphy in children, thereby resulting in earlier hospital discharge [76]. 5.2.3. Local anesthetic infiltration The advances in optical fiber technology have now produced laparoscopes with external diameters of as little as 1.2 to 2.2 mm. These instruments allow ‘‘microlaparoscopyQ to be performed with local anesthesia alone or supplemented by sedation. Therefore, local anesthesia could be used as a reliable and affordable alternative to general anesthesia. It is safe, effective, and less costly and has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation [77,78]. Office microlaparoscopy for female sterilization under local anesthesia is cost-effective and safe [79], with less postoperative analgesic requirement as compared with conventional laparoscopic sterilization [80]. In the therapy for polycystic ovarian syndrome, ovarian drilling in minilaparoscopy under local anesthesia has similar therapeutic results to those achieved by traditional laparoscopy. It offers a lessinvasive technique with an early hospital discharge that can be carried out in an outpatient service without the need for general anesthesia and postoperative additional analgesia [81]. Obese patients are unsuitable for microlaparoscopy; the short instrument is likely to end up in the extraperitoneal space, and the low insufflation pressures can be insufficient to lift the weight of the abdomen and provide a good view. Patients with multiple adhesions from previous surgery are also less suitable. Further developments in optics and small instruments could increase the indications for microlaparoscopy. In laparoscopic cholecystectomy under general anesthesia, preinsertion of local anesthesia at the trocar site significantly reduces postoperative pain and decreases medication usage costs [82]. Moreover, intraperitoneal spray of local anesthetic significantly decreases postoperative pain [83]. The extraperitoneal laparoscopic repair of inguinal hernia is feasible under local anesthesia alone. This technique adds a new treatment option in the management

74 of bilateral inguinal hernias, particularly in the population where general anesthesia is contraindicated [84].

6. Recovery after laparoscopy During the early postoperative period, respiratory rate and etco2 of patients breathing spontaneously are higher after laparoscopy as compared with open surgery. The additional carbon dioxide load can lead to hypercapnia even in the postoperative period. This causes an increased ventilatory requirement, when the ability to increase ventilation is impaired by residual anesthetic drugs and diaphragmatic dysfunction. Patients with respiratory disease can have problems excreting excessive carbon dioxide load, which results in more hypercapnia and eventually respiratory failure. Patients with cardiac disease are more prone to hemodynamic changes and instability caused by the hyperdynamic state developing after laparoscopy. As compared with other outpatient procedures, laparoscopic surgery still produces substantial morbidity. Telephone follow-up revealed incisional pain in about 50% of laparoscopic patients, double the overall incidence of pain in outpatients. Drowsiness (36%) and dizziness (24%) were also more common after laparoscopic surgery than after any other ambulatory procedure [85]. A high incidence of minor morbidities is noticed: abdominal pain (71%), shoulder pain (45%), sore throat (26%), headache (12%), and nausea (3%), and only 8% of the patients would have preferred an overnight stay [86]. Although morbidity is considerable, most symptoms resolve within a week [87]. The anesthesiologist must deal with these postoperative problems and address them adequately.

6.1. Postoperative pain Although laparoscopic surgery results in substantially less severe and prolonged discomfort compared with the corresponding open procedure, postoperative pain still can be considerable. Prevention and treatment of pain relies on local anesthesia, nonsteroidal anti-inflammatory drugs, and opioid analgesics, often used in combination. 6.1.1. Local anesthesia All the regional anesthesia techniques previously described reduce postoperative pain and delay the requirement for rescue analgesics. 6.1.2. Nonsteroidal anti-inflammatory drugs Because nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic properties comparable with opioid compounds without opioid-related side effects, these drugs are often administered as adjuvant during and after surgery. There is no significant difference between the various NSAIDs in their efficacy, provided that an adequate dose is used and sufficient time is allowed for the onset of effect. There could be minor differences between drugs in the pattern of side effects, but most patients tolerate short-term administration of NSAIDs remarkably well [88].

F.J. Gerges et al. 6.1.3. Opioids Opioid analgesics are obviously effective in treating pain after laparoscopic procedures; however, these drugs are associated with numerous side effects, including nausea, respiratory depression, and sedation, which are especially undesirable in outpatients. 6.1.4. Multimodal analgesia techniques The most effective pain relief can be obtained by combining opioids, local anesthetics, and NSAIDs into balanced analgesia. This approach at least allows the opioid dose to be reduced by the use of other modalities, thereby limiting side effects, reducing postoperative pain and analgesic requirements, and facilitating an earlier return to normal activities [89,90]. 6.1.5. Other analgesic techniques A variety of other therapeutic modalities have been used to try to reduce pain after laparoscopy, including anticholinergic drugs, tramadol, acetaminophen, and dexmedetomidine. 6.1.5.1. Anticholinergic drugs. Anticholinergic smooth muscle relaxants have been used to treat pain induced by spasm in the smooth muscle of the fallopian tube after laparoscopic sterilization. Glycopyrrolate reduced patient pain scores on patients’ awakening and reduced requirements for morphine [91], but buscopan failed to achieve the same results [92]. 6.1.5.2. Tramadol. Tramadol is a weak opioid that also has analgesic effects through inhibition of neurotransmitter uptake. It is effective in reducing pain scores and opioid analgesic requirements [93]. 6.1.5.3. Acetaminophen. Combinations of acetaminophen with either dextropropoxyphene or codeine are as effective as tramadol administration in treating postoperative pain [94]. 6.1.5.4. a 2 Agonist. Dexmedetomidine has sedative, hypnotic, and analgesic properties. It diminishes the need for other anesthetics and sympathicolytics, and it reduces catecholamine release. Furthermore, it lowers the need both for other sedatives and for analgesic morphine, although spontaneous breathing is not affected [95].

6.2. Postoperative nausea and vomiting Postoperative nausea and vomiting is extremely common after laparoscopic surgery and can delay discharge after outpatient surgery. Some aspects of the anesthetic technique as well as the use of antiemetic medications could decrease the incidence of PONV. 6.2.1. Anesthetic technique Because propofol has the lowest incidence of PONV, maintenance of anesthesia for laparoscopic surgery with propofol results in a lower incidence of PONV, compared with inhalation anesthetics [29,30]. Nitrous oxide is known to increase the incidence of PONV; however, its omission failed to reduce the occurrence of PONV after laparoscopies [41]. Because opioids are a potent cause of PONV, the concomitant

Anesthesia for laparoscopy use of NSAIDs and opioids helps to better control postoperative pain, while decreasing opioid-related side effects. The routine use of neostigmine to reverse residual neuromuscular block has been reported to increase the incidence of PONV compared with spontaneous recovery from mivacurium [43]; however, others have failed to confirm an adverse effect of neostigmine in a similar study [96]. 6.2.2. Antiemetic medications Although ondansetron (an antagonist of the 5-HT3 receptor), is as effective as older antiemetics such as droperidol [97] or cyclizine [98], it avoids most of their adverse effects. Ondansetron given at the end of surgery results in a significantly greater antiemetic effect, compared with preinduction dosing [99]. Dolasetron and granisetron, other 5-HT3 antagonists, are effective as well [100,101]. Dexamethasone reduced PONV in the first 24 hours after laparoscopic sterilization and reduced the requirement for rescue antiemetics with no adverse effects noted from this single dose of steroid [102].

7. Contraindications for laparoscopy Laparoscopy brings the highest benefits to the highest risk group of patients notably in intensive care unit patients, patients with cardiac and/or respiratory compromise, renal failure, obese, children, and the elderly. However, extreme care to anesthetic management and surgical performance must be considered. Absolute contraindications for laparoscopy include shock, markedly increased ICP, severe myopia and/or retinal detachment, inadequate surgical equipments, and inadequate monitoring devices. Relative contraindications include bullous emphysema, history of spontaneous pneumothorax, pregnancy, life-threatening emergencies, prolonged laparoscopy more than 6 hours associated with acidosis and hypothermia, and new laparoscopic procedures. Special care must be taken in patients with increased ICP resulting from brain tumors, hydrocephalus, or head trauma. Patients having ventricular peritoneal shunt must have the shunt clamped before peritoneal insufflation.

8. Complications of laparoscopy The incidence of complications associated with laparoscopic procedures varies significantly, depending on the type of procedure and the training and experience of the surgeon. The anesthesiologist has to be aware and deal with these potential problems to avoid any undesirable outcome.

8.1. Inadvertent extraperitoneal insufflation Misplacement of the Veress needle can lead to intravascular, subcutaneous tissue, preperitoneal space, viscus, omentum, mesentery, or retroperitoneum insufflation of carbon dioxide.

75 Direct intravascular gas insufflation, a tear in an abdominal wall or peritoneum vessel, can lead to gas embolism. It is a rare but potentially lethal complication of laparoscopic surgery where profound hypotension, cyanosis, dysrhythmias, and asystole may occur after intravascular embolization of carbon dioxide. Initially, there is a sudden increase in etco2 concentration, which then can decrease owing to cardiovascular collapse and reduction of pulmonary blood flow. A mill-wheel murmur can be auscultated. By using a precordial Doppler probe or transesophageal echocardiography, embolized carbon dioxide is detected earlier and confirmed. Rapid absorption of the carbon dioxide embolus facilitates dissolution of the resulting intracardiac or intravascular foam and leads to rapid reversal of hemodynamic impairment whenever the volume of carbon dioxide embolus is low [10]. If gas embolism is suspected, carbon dioxide insufflation should be discontinued and the abdomen deflated. The patient should be turned to the left lateral decubitus with a head-down position to allow the gas to rise into the apex of the right ventricle and prevent entry into the pulmonary artery. Hyperventilation with 100% O2 for rapid carbon dioxide elimination, central venous catheter placement for aspiration of gas, and aggressive cardiopulmonary resuscitation should be done [103]. Pulmonary air embolism after inadvertent vascular puncture by an air-cooled laser has been reported during laparoscopic cholecystectomy. Because carbon dioxide is more soluble in blood than air or nitrous oxide, a greater volume of carbon dioxide embolism can be tolerated when compared with air or nitrous oxide embolism [103]. Subcutaneous insufflation of carbon dioxide leads to subcutaneous emphysema. It is identified by the development of crepitus over the abdominal and chest wall, associated with an increase in airway pressures and etco2 concentrations, leading to significant hypercapnia and respiratory acidosis. In most cases, no specific intervention is necessary, and the subcutaneous emphysema resolves soon after the abdomen is deflated and nitrous oxide is discontinued to avoid expansion of carbon dioxide–filled space [103,104].

8.2. Pneumothorax Pneumothorax can occur with the gas traversing into the thorax either through a tear in the visceral peritoneum, breach of the parietal pleura during dissection around the esophagus, a congenital defect in the diaphragm (patent pleuroperitoneal canal), and spontaneous rupture of preexisting emphysematous bulla. Subcutaneous emphysema in the neck and face can result in gas tracking to the thorax and mediastinum, thereby resulting in pneumothorax or pneumomediastinum. Pneumothorax can be asymptomatic or can increase peak airway pressures, decrease oxygen saturation and, in severe cases, can lead to significant hypotension and cardiac arrest. The treatment is according to the severity of cardiopulmonary compromise from conservative treatment with close observation to chest tube placement [103].

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8.3. Pneumomediastinum and pneumopericardium Extension of subcutaneous emphysema from the cervical region into thorax and mediastinum can lead to pneumomediastinum. Although, pneumopericardium can occur when the carbon dioxide is forced through the inferior vena cava into the mediastinum and pericardium or when carbon dioxide tracks through the defect in the membranous portion of the diaphragm, which can have embryonic communication between the pericardial and peritoneal cavities. The management of pneumomediastinum and pneumopericardium depends on the severity of associated cardiopulmonary dysfunction. Release of the pneumoperitoneum is adequate in many patients [103].

8.4. Vascular injuries Accidental insertion of the Veress needle or trocar into major vessels such as the aorta, common iliac vessels, inferior vena cava, or cystic or hepatic artery can lead to serious and even fatal complications requiring conversion to laparotomy for control of bleed. Other minor vascular injuries involve the abdominal wall vessels and can be managed during laparoscopy [103].

8.5. Gastrointestinal injuries Gastrointestinal injuries frequently involve the small intestine, colon, duodenum, and stomach. Lacerations of the liver, spleen, and colonic mesentery also have been reported. Gastric decompression before placement of the Veress needle should minimize stomach injuries. In patients undergoing laparoscopic Nissen fundoplication, the anesthesiologist should carefully insert the esophageal bougies to avoid esophageal or gastric perforation especially in patients with Barrett’s esophagus, ulcers, or strictures [103].

8.6. Urinary tract injuries Although injuries to the bladder and ureters are rare, decompression of the bladder by placement of a urinary catheter before laparoscopy is advisable [103].

9. Summary Laparoscopy is most commonly performed with the patient under general anesthesia. For prolonged and upper abdominal procedures, this remains the only realistic option at present, but regional techniques involving peripheral and neuraxial blocks and local anesthetic infiltrations could be used with precautions for pelvic laparoscopy. Rectus sheath, mesosalpinx, inguinal, pouch of Douglas, paravertebral and caudal blocks are useful adjuncts to general anesthesia and facilitate postoperative analgesia. Other techniques such as spinal and epidural anesthesia and combination of the two are suitable as a sole anesthetic technique for pelvic laparoscopy.

F.J. Gerges et al.

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