ANESTHESIA FOR LAPAROSCOPY

Preoperative Evaluation of the Patient and Premedication

Without regard to surgical contraindications, absolute contraindications to laparoscopy and pneumoperitoneum are rare, and some still require characterization (see Chapter 25 ). Pneumoperitoneum is undesirable in patients with increased intracranial pressure (e.g., tumor, hydrocephalus, head trauma), hypovolemia, ventricular peritoneal shunt,^[142] and peritoneojugular shunt. Pneumoperitoneum, however, can be performed safely in patients with these shunts, provided the shunt has been clamped before peritoneal insufflation.^[293] In cases of glaucoma, the effects on intraocular pressure do not seem to be clinically significant but deserve further confirmation.^[144] Gasless laparoscopy may be a safe alternative to laparoscopy with pneumoperitoneum for all these cases.

In patients with heart disease, cardiac function should be evaluated in light of the hemodynamic changes

TABLE 57-2 -- Management of patients with cardiac disease for laparoscopy

Preoperative evaluation: echocardiography

If left ventricular ejection fraction < 30%

Intraoperative monitoring

Intra-arterial line

Pulmonary artery catheter?

Transesophageal echocardiography?

Continuous ST segment analysis?

Gasless laparoscopy?

Laparotomy?

Intraoperative management

Slow insufflation

Low intra-abdominal pressure

Hemodynamic optimization before pneumoperitoneum (preload augmentation)

Patient tilt after insufflation

Anesthesia: remifentanil, vasodilating anesthetic and drugs (nicardipine, nitroglycerin), cardiotonic agents

Experienced surgeon

Postoperative care

Slow recovery from anesthesia (benefit of clonidine)

induced by pneumoperitoneum and patient position, particularly in case of compromised ventricular function ( Table 57-2 ). Patients with severe congestive heart failure and terminal valvular insufficiency are more prone to develop cardiac complications than patients with ischemic cardiac disease during laparoscopy. Whether laparoscopy is more dangerous than laparotomy in these patients has not yet been explored directly, but it deserves careful consideration. For these patients, the postoperative benefits of laparoscopy must be balanced against the intraoperative risks when the choice of laparoscopy versus laparotomy is discussed ( Table 57-3 ). Gasless laparoscopy may represent an alternative for these patients.

Because of the side effects of increased IAP on renal function, patients with renal failure deserve special care to optimize hemodynamics during pneumoperitoneum, and the concomitant use of nephrotoxic drugs should be avoided.

In patients with respiratory disease, laparoscopy appears preferable to laparotomy because of reduced postoperative respiratory dysfunction. This positive effect counterbalances the risk of pneumothorax during pneumoperitoneum and the risk of inadequate gas exchange from V̇A/ mismatching.

Because of venous stasis in the legs during laparoscopy, prophylaxis of deep vein thrombosis should be initiated before surgery, as for laparotomy.

Premedication should be adapted to the duration of the laparoscopy and to the necessity for quick recovery in the outpatient setting. Preoperative administration of NSAIDs may be helpful in reducing postoperative pain and opiate requirements. Preoperative clonidine and dexmedetomidine decrease the intraoperative stress response and improve hemodynamic stability.^{[88] [110] [111] [112]}

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