Chapter 57
- Anesthesia for Laparoscopic Surgery
- Jean L. Joris
Surgical procedures have been improved to reduce trauma to the
patient, morbidity, mortality, and hospital stay, with consequent reductions in health
care costs. The provision of better equipment and facilities, along with increased
knowledge and understanding of anatomy and pathology, has allowed the development
of endoscopy for diagnostic and operative procedures. Starting in the early 1970s,
various pathologic gynecologic conditions were diagnosed and treated using laparoscopy.
This endoscopic approach was extended to cholecystectomy in the late 1980s. Since
the introduction of the first laparoscopic cholecystectomy procedures, laparoscopy
has expanded impressively in scope and volume. It quickly became apparent that laparoscopy
results in multiple benefits compared with open procedures,[1]
[2]
[3]
and it was
characterized by better maintenance of homeostasis. Overenthusiasm ensued, which
explains the effort to use the laparoscopic approach for gastrointestinal (e.g.,
colonic, gastric, splenic, hepatic surgery), gynecologic (e.g., hysterectomy), urologic
(e.g., nephrectomy, prostatectomy), and vascular (e.g., aortic) procedures.
The pneumoperitoneum and the patient positions required for laparoscopy
induce pathophysiologic changes that complicate anesthetic management. The duration
of some operative laparoscopies, the risk of unsuspected visceral injury, and the
difficulty in evaluating the amount of blood loss are other factors that make anesthesia
for laparoscopy a potentially high-risk procedure.
An understanding of the pathophysiologic consequences of increased
intra-abdominal pressure (IAP) is important for the anesthesiologist who must ideally
prevent or, when prevention is not possible, adequately respond to these changes
and who must evaluate and prepare the patient preoperatively in light of these disturbances.
The pathophysiologic changes and the complications of laparoscopy are reviewed first.
The postoperative period is considered
next, with examination of the benefits of laparoscopy and certain specific postoperative
problems (e.g., pain, nausea). Practical consequences for the anesthetic management
of laparoscopy are presented. Many animal and human studies of the consequences
of laparoscopy have been published since the early 1970s. Because much higher IAPs
(>20 mm Hg) were previously used and because of potential species differences,
we have focused on the human literature published after 1990 using low IAP (<15
mm Hg) and modern anesthesia techniques.
