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  • Advantages
    • Small incisions
    • Minimal disruption of abdominal musculature
    • Faster postoperative recovery
    • Faster return of ventilatory function
    • Less postoperative pain
  • Common procedures
    • Appendectomy
    • Cholecystecomy
    • Nephrectomy
    • Prostatectomy
    • Many gynecologic and gastrointestinal procedures
  • Can be safely performed on children and pregnant women. Care should be taken to avoid hypercarbia and acidosis

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  • Keep in mind possible conversion to open procedure
  • Neuraxial analgesia usually not necessary
  • Adequate preoperative hydration: hypovolemia during insufflation of carbon dioxide may result in hypotension
  • Patients at risk for cardiac events (CHF, CAD) or poor respiratory tolerance (restrictive or obstructive syndrome) should be optimized, as laparoscopy causes hemodynamic changes, including reduced cardiac output and increased SBP
  • Thromboprophylaxis similar to open procedure
  • Contra-indications to laparoscopy
    • Emphysema with large bullae
    • Recurring pneumothorax
    • Patient with ASD or VSD
    • VP shunt, peritoneo-jugular shunt
    • Increased ICP, acute glaucoma
    • Diaphragmatic hernia

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  • General anesthesia with careful monitoring of ventilation and EtCO2
    • As CO2 from insufflation is systemically absorbed, EtCO2 will rise and minute ventilation needs to increase accordingly (usually by increasing RR)
    • EtCO2 should plateau after about 30 minutes. Significant increases after this time suggest subcutaneous emphysema
    • Increased intra-abdominal pressures and Trendelenburg position may cause a reduction in Vt delivered, particularly if pressure-controlled ventilation is used. Frequent adjustments in ventilator settings may be necessary to maintain adequate ventilation
    • Especially if pulmonary disease or CHF, the gradient between PaCO2 and PEtCO2 will increase
  • Invasive blood pressure monitoring, and even PAC/TEE, may be required for patients at risk for cardiac events or those who may not tolerate the reduced cardiac output and increased systolic blood pressure caused by laparoscopy

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  • Endotracheal intubation and muscle relaxation necessary
  • Careful attention to positioning
    • Steep Trendelenburg position may result in pressure on shoulders and neck
    • Arms tucked at sides or adequately secured to padded arm boards
  • Insert OGT to decompress stomach prior to trocar insertion
  • High risk of PONV. Unless contraindicated, give 10 mg dexamethasone IV after induction, then an HT5-inhibitor (e.g., ondansetron 4 mg IV) 30 minutes before extubation

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  • Careful attention to HR early in case, as insufflation can elicit a vagal response
    • Ask the surgeon to release abdominal pressure
    • If bradycardia does not resolve, administer 0.5–0.7 mg atropine IV
    • Typically, reinflation will not cause bradycardia, or the response will be attenuated
  • Maintain adequate level of general anesthesia and muscle relaxation
  • Over the length of the case, heart rate and blood pressure rise secondary to neurohumoral factors. These will decrease upon cessation of laparoscopy. Overaggressive treatment of hypertension and tachycardia may lead to hypotension following the removal of the trocars
  • BIS/Entropy monitors help in ensuring adequate levels of anesthesia
  • Changes in Vt, PAP, and EtCO2 should be closely monitored. Ventilation may need to be altered based on the intra-abdominal pressure, Trendelenburg position, and systemic absorption of end tidal carbon dioxide. Aim for PEtCO2 ≤ 38 mm Hg (unless chronic hypercarbia) and PAP ≤ 25 cmH2O. Use PEEP 5 cmH...

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