Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ AdvantagesSmall incisionsMinimal disruption of abdominal musculatureFaster postoperative recoveryFaster return of ventilatory functionLess postoperative painCommon proceduresAppendectomyCholecystecomyNephrectomyProstatectomyMany gynecologic and gastrointestinal proceduresCan be safely performed on children and pregnant women. Care should be taken to avoid hypercarbia and acidosis ++ Keep in mind possible conversion to open procedureNeuraxial analgesia usually not necessaryAdequate preoperative hydration: hypovolemia during insufflation of carbon dioxide may result in hypotensionPatients 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 SBPThromboprophylaxis similar to open procedureContra-indications to laparoscopyEmphysema with large bullaeRecurring pneumothoraxPatient with ASD or VSDVP shunt, peritoneo-jugular shuntIncreased ICP, acute glaucomaDiaphragmatic hernia ++ General anesthesia with careful monitoring of ventilation and EtCO2As 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 emphysemaIncreased 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 ventilationEspecially if pulmonary disease or CHF, the gradient between PaCO2 and PEtCO2 will increaseInvasive 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 ++ Endotracheal intubation and muscle relaxation necessaryCareful attention to positioningSteep Trendelenburg position may result in pressure on shoulders and neckArms tucked at sides or adequately secured to padded arm boardsInsert OGT to decompress stomach prior to trocar insertionHigh 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 ++ Careful attention to HR early in case, as insufflation can elicit a vagal responseAsk the surgeon to release abdominal pressureIf bradycardia does not resolve, administer 0.5–0.7 mg atropine IVTypically, reinflation will not cause bradycardia, or the response will be attenuatedMaintain adequate level of general anesthesia and muscle relaxationOver 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 trocarsBIS/Entropy monitors help in ensuring adequate levels of anesthesiaChanges 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... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.