The laparoscopic and laparoscopic-assisted approaches have vastly expanded from routine gynecological procedures (e.g., tubal ligation) and cholecystectomies to complex gastrointestinal (e.g., colonic, gastric, splenic, hepatic), urologic (e.g., nephrectomy, prostatectomy), and vascular (aortic) surgeries. The major benefits of laparoscopy are a direct result from the avoidance of large abdominal incisions. Therefore, hospitalizations are shorter, recoveries faster, pain less severe, and pulmonary function better preserved.
In the case of the commonly performed laparoscopic cholecystectomy, benefits of the laparoscopic approach compared to open cholecystectomy are listed in the following table. These benefits may extend to other surgeries using this minimally invasive technique in the hands of a skilled and timely surgeon (Table 175-1).
TABLE 175-1Potential Benefits of Laparoscopic Surgery |Favorite Table|Download (.pdf) TABLE 175-1 Potential Benefits of Laparoscopic Surgery
Limited abdominal incisions
Diaphragmatic function preserved
Pulmonary function preserved
Less postoperative pain
Less postoperative ileus
Earlier ambulation and return to normal activities
Shorter hospital stay
Given the plethora of potential benefits, laparoscopy has found use in the pediatric and pregnant populations. Robotic surgery is an advanced form of laparoscopic surgery with its own unique anesthetic implications. Furthermore, techniques associated with laparoscopy are used outside the abdomen.
General anesthesia with cuffed endotracheal tube using a balanced technique is the preferred anesthetic technique. This is due to the discomfort of a pneumoperitoneum, positioning, length of surgical time, and hypercarbia. The stomach should be decompressed with a nasogastric tube postinduction. Also, the bladder should be decompressed to avoid injury during trocar insertion. Pneumatic compression boots will reduce venous stasis from high intra-abdominal pressure (IAP) in the lower extremities.
Nitrous oxide as part of the anesthetic technique is controversial. However, there is no conclusive evidence that N2O contributes to bowel distention that is clinically significant.
Other important considerations include the duration of procedure, the risk of visceral or vascular injury, difficulty in evaluating blood loss and the possibility of conversion to laparotomy under emergent conditions.
The pneumoperitoneum is created when carbon dioxide is insufflated into the peritoneal cavity. This can be accomplished via a “closed” or blind technique in which a Veress needle is punctured through the abdominal layers into the peritoneal cavity. Direct entry with a trocar, another “closed” or blind technique, may also be used. The “open” method involves inserting a trocar into the peritoneal cavity under direct vision through an abdominal incision (mini laparotomy). Trendelenburg positioning provides gravitational displacement of the abdominal viscera away from the entry site of the Veress needle or trocar. After the initial entry is made, carbon dioxide is insufflated and additional ports are placed into the cavity under visualization through a mini laparoscopic camera. Each method of entry has its advantages and ...