Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 3, 2003, pp. 232-240

Indian Journal of Surgery, Vol. 65, No. 3, May-June, 2003, pp. 232-240

Review Article

Anaesthesia for laparoscopic surgery

Jayashree Sood, V. P. Kumra

Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi 110060, India.
Address for correspondence Dr. Jayashree Sood, Sr. Consultant, Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi 110060, India.

Paper Received: October 2002. Paper Accepted: January 2003. Source of Support: Nil

Code Number: is03045

How to cite this article: Sood J, Kumra VP. Anaesthesia for laparoscopic surgery. Indian J Surg 2003;65:232-40.

The use of laparoscopic techniques has become common in clinical practice. Operations that once required long hospitalization are now being performed on a short-stay basis. Initially, laparoscopy was confined to short, diagnostic gynaecological procedures carried out on young, healthy females. However, it has now extended to various intra-abdominal surgeries and is now also being performed on older patients who may have coexisting cardiac or pulmonary diseases.

The progress in laparoscopic procedures has largely been due to the technological advances in endoscopic optics, video cameras and endoscopic instrumentation. The advantages of small incisions, reduced postoperative pain and discomfort, shorter hospital stay, early ambulation and return to work have increased the popularity of laparoscopic procedures.

Although they are visually `minimally invasive' to the patient, the intraoperative requirements of laparoscopic surgery produce significant physiological changes, some of which are unique to these procedures. Therefore, it is very essential that the surgeons and the anaesthesiologists thoroughly understand the pathophysiology and management of the potential problems and complications associated with laparoscopic surgery.

While each procedure may be associated with its own specific problems, the standard surgical technique commences with the intra- or extra-peritoneal insufflation of carbon dioxide (CO₂) through a Veress needle.

An electronic, variable flow insufflator terminates flow when a preset pressure is attained, usually 12-15 mm Hg. The desired number of trocars are inserted and a videolaparoscope introduced.

The physiological changes observed during laparoscopic surgery are a result of

1. Patient position
2. Introduction of exogenous insufflating gas, CO₂
3. Pneumoperitoneum and increased intra-abdominal pressure

PATIENT POSITION

During laparoscopic surgery, the patient's position is altered several times to produce gravitational displacement of the viscera away from the surgical site.

The Trendelenburg position (15-20°) is used temporarily in upper abdominal surgery for trocar insertion, but is retained for longer periods in lower abdominal surgery. This position increases the venous return (VR), the right atrial pressure (RAP), the central blood volume and the cardiac output.¹ The CVP increases by an average of 8 mm Hg at an intra-abdominal pressure (IAP) of 15 mm Hg in the supine position. It increases by an additional 6 mm Hg at similar IAP in the Trendelenburg position.² However, it reduces the vital capacity (VC), functional residual capacity (FRC), and lung compliance, thus predisposing to atelectasis.³ There is a potential for an inadvertent right main stem bronchial intubation and hypoxaemia due to cephalad displacement of the diaphragm and carina.⁴ Nerve compression is possible in the head-down position. Brachial plexus injury has been reported during prolonged laparoscopic procedures in the Trendelenburg position.⁵ The Trendelenburg position may also affect cerebral circulation resulting in an elevation of the intracranial and intraocular pressure.⁴

The reverse Trendelenburg position (20°-30°)

This position improves diaphragmatic function and is considered more favourable to respiration.⁶ However, it results in decreased venous return (VR), right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP), resulting in a fall in the mean arterial blood pressure (MAP) and cardiac output (CO) reflected by changes in the left ventricular end diastolic area.⁷ These changes get exacerbated by compression of the inferior vena cava (IVC) during pneumoperitoneum, and may be disastrous in patients with coronary insufficiency.⁸ A steep head-up position causes venous stasis in the legs predisposing these patients to deep vein thrombosis, particularly in procedures of long duration.⁹

INSUFFLATION OF EXOGENOUS GAS, CO₂

The insufflation of an exogenous gas produces a physiological trespass which along with its pharmacological properties may result in untoward side effects.

Although room air and nitrous oxide (N₂O) have been used for diagnostic gynaecological procedures, they are unsuitable (flammable) when electrocautery is required or in the presence of methane (gut). CO₂ has remained the insufflation gas of choice because of its ready availability, low cost, a high Ostwald's blood/gas partition coefficient (0.48) and because it is odourless, relatively inert, and non-combustible. It is rapidly buffered in the blood by bicarbonates and excreted via the lungs.^10,11 Due to its high solubility, the incidence of gas embolism is rare (0.0016-0.013 per cent),¹² however it is a peritoneal irritant.

Absorption of CO₂ from the peritoneal cavity is the potential mechanism for hypercarbia and a rise in the end-tidal carbon dioxide (EtCO2).¹³ The CO₂ absorption is more following extraperitoneal rather than intraperitoneal insufflation.¹⁴ It stimulates the sympathetic nervous system and results in a fivefold increase in arginine vasopressin (AVP).¹⁵ Increasing the minute ventilation by 15-20 per cent is necessary to maintain normocarbia under well-functioning physiological mechanisms.¹⁶ Prolonged surgical time, along with underlying pulmonary disease, results in diminished respiratory capacity for CO₂ elimination leading to detectable hypercapnia and serum acidosis.¹⁷ The PaCO₂ usually correlates well with the EtCO₂, except in patients with cardiopulmonary compromise and associated ventilation perfusion mismatch. A direct estimation of PaCO₂ may become necessary in such patients.¹⁸ Acidosis lowers the threshold for arrhythmias thus increasing their incidence.¹⁹ Haemodynamic alterations occur only when the PaCO₂ is increased by 30 per cent above the normal levels. Mild hypercapnia causes sympathetic stimulation which results in tachycardia, increased systemic vascular resistance, systemic arterial pressure, central venous pressure and cardiac output.²⁰ This shortens the pre-ejection period and the left ventricular ejection time and shortens the diastolic filling phase of the coronary arteries, resulting in coronary ischaemia. Patients with ischaemic heart disease thus lie on the threshold of catastrophe if not properly managed.²¹

Severe hypercarbia exerts a negative inotropic effect on the heart and reduces left ventricular function.²²

All these effects persist into the postoperative period because of slow mobilization of CO₂ from body stores into the serum for excretion.²³ Residual CO₂ and the formation of carbonic acid (H₂CO₃) intrapleurally are some of the factors implicated for postoperative shoulder pain. These effects are not seen in patients in whom pneumoperitoneum is produced by nitrogen or helium gas.¹¹

PNEUMOPERITONEUM AND INCREASED INTRA-ABDOMINAL PRESSURE

Pneumoperitoneum is initiated by insufflation of gases through Veress needle at the rate of 1-2 L/min. Once pneumoperitoneum is achieved, overall pressure over the diaphragm at this point is almost 50 kg in the Trendelenburg position at an IAP of 15mm Hg.²⁴

The pneumoperitoneum produces increased IAP, CO₂ absorption, temperature variations (hypothermia) and neurohormonal stress response.

The introduction of several litres of gas into the abdominal cavity results in an increased intra-abdominal pressure. The extent of cardiovascular changes associated with pneumoperitoneum depends on the interaction of factors including position of the patient, rate and amount of insufflation of CO₂ and the intra-abdominal pressure obtained.

Increased IAP influences

The cardiovascular system
The respiratory system
The gastrointestinal system
Mesenteric circulation
Hepatoportal circulation
Renal function
Intracranial pressure (ICP) and intraocular pressure (IOP)

Cardiovascular System

An increase in the IAP is the most important factor contributing to circulatory instability during laparoscopy.²⁵ Reflex increase in vagal tone due to excessive stretching of the peritoneum may produce bradycardia.²⁶ The threshold pressure that has minimal effects on haemodynamic function is < 12 mm Hg.²⁷

A biphasic change in the cardiac output (CO) is observed. Up to an IAP of 10 mm Hg the cardiac filling pressures are normal or increased, and CO improves. But if the inflation pressures are increased further (>15 mm Hg), the insufflated CO₂ compresses both the venous capacitance and the arterial resistance vessels. This produces a rise in the systemic vascular resistance (SVR), and the pulmonary vascular resistance (PVR) leading to an increased afterload. The mean arterial blood pressure rises and the CO falls (25-35 per cent).²⁸ An IAP > 20 mm Hg reduces the renal and mesenteric blood flow markedly. The fall in CO is directly proportional to the rise in the IAP. Thus increased IAP has two opposing effects on the cardiovascular system it forces blood out of the abdominal organs and the inferior vena cava into the central venous reservoir, and at the same time it increases peripheral blood pooling in the lower extremities and thus tends to decrease central venous blood volume.²⁹ High IAP augments venous return in patients with high right-sided pressures maintaining a patent inferior vena cava (IVC), whereas low right-sided pressures lead to a compressed IVC and a decrease in venous return.³⁰

The combined effect of anaesthesia, head-up tilt and peritoneal insufflation (increased IAP) can reduce cardiac index (CI) by 50 per cent.⁸

These haemodynamic changes are well tolerated by healthy individuals, but may have deleterious consequences in patients with cardiovascular disease.³¹

Respiratory System

The increased IAP exerts pressure on the diaphragm leading to its cephalad displacement. This results in reduced lung volumes, viz., tidal volume (TV), minute ventilation (MV) and functional respiratory capacity (FRC), pulmonary compliance, increased airway pressure, and risk of barotrauma during intermittent positive pressure ventilation (IPPV).³ Uneven distribution of ventilation to the non-dependent parts of the lungs produces ventilation-perfusion mismatch, hypoxia and hypercarbia.¹⁷

An IAP of 15 mm Hg raises the PaCO₂ by 10 mm Hg, the PaCO₂ by 4 mm Hg and decreases lung compliance by 25 %.²

The raised IAP along with a Trendelenburg position lifts the diaphragm and the carina and may result in an inadvertent right main stem bronchial intubation since the endotracheal tube remains fixed at its proximal end, thus predisposing to hypoxaemia.⁴

It can also open embryonic channels to the pleural cavity, mediastinum and pericardium, leading to pneumothorax, pneumomediastinum and pneumopericardium respectively.³²

Gastrointestinal System

Patients undergoing laparoscopy are usually considered at high risk of acid aspiration syndrome due to gastric regurgitation which might occur due to the rise in intragastric pressure consequent to the increased IAP. However, during pneumoperitoneum, the lower oesophageal sphincter tone far exceeds the intragastric pressure and the raised barrier pressure limits the incidence of regurgitation.^33,34

Mesenteric Circulation

The visceral vascular bed is the primary site of compression during raised IAP resulting in organ dysfunction because of the collapse of capillaries and small veins. Hypercapnia induced sympathotonia, mechanical compression of abdominal organs, reverse Trendelenburg position and release of vasopressin are some of the contributory factors of reduced mesenteric circulation.²⁶

Hepatoportal circulation

Increasing levels of IAP adversely affect the vascular alterations. A rise in the IAP (> 20 mm Hg) leads to an increased resistance to prograde flow in the abdominal vasculature. Hormonal release (catecholamine, angiotensin, and vasopressin) during pneumoperitoneum further increases the mesenteric vascular resistance causing a significant fall in hepatic and splanchnic blood volume.³⁵ An IAP of > 20 mm Hg produces a 60 per cent decrease in the portal venous blood flow resulting in liver dysfunction, which persists for a longer duration in the postoperative period. There is an overall reduction of blood supply to all the organs except the adrenal glands.³⁶

Renal Function

Increased IAP affects renal haemodynamics by alterations in cardiac output and a direct effect on renal blood flow.³⁷ Mechanical obstruction of renal venous blood flow along with increased sympathetic activity, elevation of plasma ADH and raised plasma renin angiotensin activity increase the renal vascular resistance leading to a fall in the filtration pressure and urine output.^38,39

Intracranial pressure (ICP) and Intraocular pressure (IOP)

The raised IAP compresses the inferior vena cava (IVC) and increases the lumbar spinal pressure by reducing drainage from the lumbar plexus, thus increasing the ICP and the IOP.⁴⁰ Hypercapnia produces reflex vasodilatation in the central nervous system and also contributes to the increase in ICP.⁴¹

Thromboembolism

An IAP above 14 mm Hg, reverse Trendelenburg position, obesity, pelvic surgery and surgery of long duration reduce venous flow in the lower extremities increasing the chances of thromboembolism.⁴² At least two of the three factors in Virchow's triad (venous stasis and hypercoagulability) are affected during increased IAP.⁴³ Therefore patients who are undergoing prolonged laparoscopic procedures in the reverse Trendelenburg position are more prone to thromboembolism.

Temperature Variations

During laparoscopy the continuous flow of dry gases over the peritoneal surfaces under pressure can lead to a fall in the body temperature because of the Joule Thompson effect (sudden expansion of gases), higher flow rates, especially during prolonged surgery, and leakage through the ports because of various reasons (leakage, changing cannulae, aspiration of gases and during lavage).⁴⁴

There is a 0.3° C decrease in core temperature per 50L volume flow of CO₂ pneumoperitoneum.⁴⁵

Neurohormonal Stress Response

Laparoscopy involves a classic stress response elucidated by the hypothalamopituitary adrenocortical axis, simultaneously affecting the glucose metabolism regulatory functions.⁴⁶ Levels of ACTH, cortisol, insulin and glucagon rise during laparoscopy. Thus it is concluded that laparoscopy is as stressful as conventional surgery.⁴⁷

Complications of gas insufflation

Gas insufflation and pneumoperitoneum can be complicated by arrhythmias, subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium and venous gas embolism. These complications occur most commonly due to malpositioned Veress needle, and depend upon the magnitude of the extraperitoneal dissection, duration of surgery and level of IAP attained. Absorption of CO₂ remains proportional to the rise in IAP.

Subcutaneous emphysema

Subcutaneous emphysema may occur if the tip of the Veress needle does not penetrate the peritoneal cavity prior to insufflation of gas.

The gas may accumulate in the subcutaneous tissue or between the fascia and the peritoneum. Extraperitoneal insufflation, which is associated with higher levels of CO₂ absorption than intraperitoneal insufflation, is reflected by a sudden rise in the EtCO_2, excessive changes in airway pressure and respiratory acidosis.^48-50

Pneumothorax, Pneumomediastinum and Pneumopericardium

Insufflated gas may travel along aortic and oesophageal hiatuses of the diaphragm or through a congenital defect in the diaphragm (patent pleuroperitoneal canal) to produce pneumothorax, pneumomediastinum or pneumopericardium.^51,52

Sudden hypoxia, rise in peak airway pressure, hypercarbia, haemodynamic alterations and abnormal movement of the hemidiaphragm on laparoscopic view should raise a suspicion of pneumothorax.

Incidence of pneumothorax has increased due to an increase in laparoscopic procedures involving dissection at the gastrooesophageal junction.⁵³

Venous gas embolism

Although a rare complication, it can be potentially fatal.¹² Gas may enter the circulation if the Veress needle or trocar directly punctures a blood vessel, but in some cases no evidence of vascular injury is found. The prognosis depends on the nature and size of the bubbles and the rate of intravenous entry of the gas.

Slow infusion of gas absorbed across the pulmonary capillary alveolar membrane is shown by rising pulse rate, systolic hypertension, increased oozing and rising EtCO₂ inspite of hyperventilation.⁵⁴ At high infusion rates, gas bubbles may lodge in the smaller pulmonary vessels or may lock the pulmonary outflow tract with catastrophic results. There will be a sudden fall in EtCO₂ and a cardiorespiratory collapse, requiring prompt management.⁵⁵

During laparoscopy the following additional causes must be considered in any event of acute hypotension, hypoxaemia and cardiovascular collapse:

1. Reflex increase in vagal tone due to excessive stretching of the peritoneum
2. Compression of vena cava leading to reduced cardiac output
3. Hypercarbia induced arrhythmias
4. Venous gas embolism
5. Pneumothorax
6. Subcutaneous emphysema

Anaesthetic Management

The anaesthetic management for patients undergoing laparoscopic surgery must accommodate the surgical requirements and should adapt for physiological changes during surgery. Recovery from anaesthesia should be rapid with minimal side effects.

Anaesthetic Goals

All the standards which are set for inpatient anaesthesia care should be followed:

• Haemodynamic stability
• Respiratory stability
• Muscle relaxation
• Control of diaphragmatic excursion
• Intra and postoperative analgesia
• Control of postoperative nausea and vomiting (PONV)
• Deep vein thrombosis (DVT) prophylaxis
• Protection against hypothermia
• Quick postanaesthesia recovery

Pre-anaesthetic assessment

Contraindications to laparoscopic surgery are relative. Conversion to laparotomy is always a possibility and must be considered during the pre-anaesthetic assessment. The cardiac and pulmonary status of all patients should be carefully assessed on priority and optimized preoperatively.

Premedication

A short-acting anxiolytic, such as a benzodiazepine allays anxiety and ensures a rapid recovery.
An antiemetic like domperidone, droperidol or ondansetron reduces PONV.
A gastroprokinetic, such as metoclopromide hastens gastric emptying.
An H₂ receptor antagonist reduces the volume and pH of gastric secretions.⁵⁶
Pre-emptive analgesia is achieved with NSAIDs, as opioids are associated with PONV.
An anti-sialagogue like glycopyrrolate reduces oral secretions.
A vagolytic such as atropine prevents the bradycardia associated with the stretching of the peritoneum during insufflation. However, it may be administered at induction since it produces dryness of mouth.
DVT prophylaxis is recommended for patients undergoing laparoscopic procedures of long duration in the reverse Trendelenburg position.⁹

Monitoring

Recommendations for routine patient monitoring include

• Pulse rate
• Continuous ECG
• Intermittent NIBP
• Pulse oximetry (SpO₂)
• Capnography (EtCO₂)
• Temperature
• Intraabdominal pressure
• Pulmonary airway pressure
• Peripheral nerve stimulation

Optional Monitoring includes

• Oesophageal stethoscope
• Precordial doppler
• Transoesophageal echocardiography
• ABG analysis

However, monitoring of pulse, NIBP and ECG poorly reflect the magnitude of the haemodynamic changes induced by pneumoperitoneum.⁸

Choice of Anaesthesia Technique

After a written informed consent, the procedure may be conducted under general, regional or local anaesthesia.

General Anaesthesia

General anaesthesia with endotracheal intubation and controlled ventilation is recommended for long laparoscopic procedures. This technique provides good muscle relaxation, ability to control hypercarbia, protection from aspiration of gastric contents, analgesia and optimal operative conditions.⁵⁷ General anaesthesia with spontaneous ventilation is best suited to lower abdominal laparoscopy of short duration.⁵⁸ A wide variety of anaesthetic drugs have been used for laparoscopies, but since many of these procedures are being conducted on an outpatient basis, the choice is shifting towards shorter-acting drugs. It is the tailoring of the anaesthetic technique that is required for optimal surgical conditions and quick recovery with minimal postoperative morbidity.

Induction

Preloading with 5-10ml/kg crystalloid solution is recommended to prevent the haemodynamic changes during pneumoperitoneum. However, preloading must be done in moderation in patients with cardiac compromise. Atropine is administered at induction to prevent bradycardia which may occur due to peritoneal stretching at insufflation.⁵⁹

Thiopentone sodium is the usual induction agent, however induction with propofol is gaining popularity since it is associated with quick, clear-headed recovery and less postoperative nausea and vomiting (PONV).⁶⁰ TIVA (Total Intravenous Anaesthesia) with propofol and fentanyl is a popular technique for outpatient laparoscopic procedures.

Adequate abdominal and diaphragmatic muscle relaxation is essential for easy laparoscopic manoeuvres. It enables achieving adequate pneumoperitoneum at a lower intra-abdominal pressure. Rapid sequence induction with suxamethonium is recommended in patients undergoing anti-reflux surgery (Laparoscopic Fundoplication) for gastro-oesophageal reflux disease (GERD) and hiatus hernia. A considerable choice of non-depolarizing muscle relaxants is available depending on the duration of surgery anticipated. Due to raised IAP, an increase in the mechanical ventilation pressure is required to achieve adequate ventilation. Normocarbia (34-38 mm Hg) is maintained by adjusting the minute volume. This is achieved by increasing the respiratory rate rather than the tidal volume since lung compliance is reduced.

Following induction of anaesthesia, the patient is catheterized to empty the urinary bladder and a nasogastric tube inserted, to reduce the risk of bladder injury and visceral puncture respectively, during insertion of the trocar and creation of pneumoperitoneum.

Patient positioning should be done very gradually to avoid sudden haemodynamic changes, especially in cases with cardiopulmonary compromise.

The insufflation flow rate for achieving pneumoperitoneum should be slow initially (1-1.5 L/mt). Once adequate pneumoperitoneum has been achieved (1-2.5 L) the flow rate may be increased to 3-4 L/mt. Gas flow stops automatically once the preset pressure set on the insufflator is reached. The flow of gas is then regulated by the IAP at a preset flow rate.

Difference in the partial pressure of CO₂ between the capillary blood and the peritoneal cavity is the major driving force for diffusion of CO₂ from the peritoneal cavity into the blood stream during pneumo-peritoneum.⁶¹

Maximum absorption of CO₂ occurs at the beginning of insufflation and at exsufflation due to the difference in pressure gradient. Thus, both insufflation and exsufflation should be done slowly.⁶² The rate of CO₂ absorption is 20-30ml/hr at flow rates of 200 ml/min.⁶³

Maintenance of anaesthesia with nitrous oxide during laparoscopic surgery is controversial because of concerns about its ability to produce bowel distention during surgery and increased incidence of PONV.⁶⁴ Halothane in the presence of hypercarbia, as seen during spontaneous respiration, is likely to produce arrhythmias.⁶³

Maintenance of anaesthesia with inhalation agents like sevoflurane or isoflurane ensures rapid recovery with minimal PONV. They show least sensitivity to arrhythmias in the presence of increased catecholamines due to hypercapnia.⁶⁶

The position of the endotracheal tube should be checked after any change in posture and after insufflation because of the likelihood of endobronchial intubation during raised IAP.

The pressure points should be padded with great care to prevent nerve injuries. Intraoperative analgesia may be provided by short-acting opioids or NSAIDs.

Fentanyl, a potent narcotic analgesic with rapid onset of action, relative cardiovascular stability and negligible histamine release, is widely used in balanced anaesthesia technique. It prevents the haemodynamic responses to intubation. However, since opioids are associated with PONV, NSAIDs are suitable alternatives.

Intraoperative metoclopramide (5-10 mg), prophylactic droperidol (0.625 mg) and ondansetron (4 mg) intravenously before completion of surgery prevent PONV.⁶⁵ The neuromuscular block is reversed on completion of surgery even though some suggest that reversal drugs increase the incidence of PONV.

Total intravenous anaesthesia and inhalation anaesthesia using the laryngeal mask airway have both been found to be equally effective and safe for laparoscopic day care surgery.⁶⁸

Adequate precautions should be taken to prevent hypothermia.

Recovery and Postoperative Monitoring

Recovery from anaesthesia should be rapid with minimal residual effects.

The vitals should be monitored since haemodynamic changes induced by the pneumoperitoneum outlast the release of pneumoperitoneum. All patients should be administered O₂ postoperatively since slow release of CO₂ from the tissues may result in hypoxia.⁶⁹

Regional Anaesthesia (Epidural/Spinal/Combined Spinal Epidural)

There are several advantages of performing laparoscopic procedures under regional anaesthesia. Since the patient is awake there is an early detection of complications. Induced vasodilatation and absence of positive pressure ventilation may reduce the cardiovascular changes seen during pneumo-peritoneum. Creation of pneumoperitoneum in patients breathing spontaneously under epidural anaesthesia results in an increase in minute ventilation with unchanged EtCO₂.⁷⁰ It provides excellent postoperative analgesia with a lower incidence of PONV.

However, abdominal laparoscopic procedures under regional anaesthesia can cause problems. Sympathetic block may exaggerate the development of vagal reflexes. Sedation given in conjunction with a regional block decreases sensitivity of CO₂ to hypoxia, and thus these patients are unable to deal effectively with hypercarbia. The combined effect of pneumoperitoneum and sedation can lead to hypoventilation and arterial oxygen desaturation.⁷¹

Since shoulder tip pain secondary to diaphragmatic irritation is mediated by the phrenic nerve, it is difficult to provide complete analgesia by a regional technique. In addition, an extensive sensory block (T4 - L5) is required to abolish the discomfort of manipulation of the upper gastrointestinal structures.

Procedures requiring only extraperitoneal insufflation of gas, like total extraperitoneal hernia repair (TEP), may be successfully conducted under regional anaesthesia.⁷²

Patient cooperation, a skilled laparoscopist, reduced level of IAP and low degrees of patient tilt are necessary for the success of laparoscopy under regional anaesthesia.

Local Anaesthesia

Laparoscopy under local anaesthesia is uncommon due to the peritoneal irritation that occurs with CO₂. N₂O may be a better option because of its decreased systemic absorption and minimal irritation of the peritoneal cavity. "Microlaparoscopy" office procedures may be conducted under local anaesthesia with or without sedation.⁷³

Postoperative Morbidity

Laparoscopic procedures are associated with quick recovery and minimal morbidity, however, postoperative pain and vomiting are common problems seen in the recovery room.

Postoperative Pain

Patients often complain of abdominal and shoulder tip pain after laparoscopic surgery. Complete removal of the insufflating gas is essential on completion of the procedure. Several modalities have been used, from local anaesthetics to NSAIDs and opioids, to control postoperative pain. Infiltration of the portal sites with a local anaesthetic reduces pain from the port sites while right-sided subdiaphragmatic instillation with a local anaesthetic reduces shoulder tip pain.⁷⁴ Short-acting opioids may be used for rescue analgesia.

Multimodal analgesia obtained by combining opioids, local anaesthetics and NSAIDs has been shown to provide superior pain relief with reduced PONV and earlier discharge.⁷⁵

PONV

PONV can be especially problematic after laparoscopic surgery.⁷⁶ Peritoneal insufflation, bowel manipulation and pelvic surgery are some of the causative factors. A meticulous anaesthetic technique along with antiemetics is helpful in reducing the incidence of PONV.⁷⁷

CONCLUSIONS

Laparoscopy has revolutionised surgery and in the process influenced the practice of anaesthesiology.

With patient expectation of no pain or nausea and early discharge, anaesthetic choices become vital for the ultimate success of the procedure.

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