PHYSIOLOGICAL CHANGES DURING LAPAROSCOPY

IMAD ZAFAR

HISTORY OF LAPAROSCOPY 1902 - GEORG KELLING, OF DRESDEN, SAXONY, PERFORMED

THE FIRST LAPAROSCOPIC PROCEDURE ON DOGS.

1910 - HANS CHRISTIAN JACOBAEUS OF SWEDEN, REPORTED THE FIRST LAPAROSCOPIC OPERATION ON HUMANS.

1980 - PATRICK STEPTOE FROM ENGLAND, STARTED TO PERFORM LAPAROSCOPIC PROCEDURES IN THE OPERATING ROOM UNDER STERILE CONDITIONS.

1982 - THE FIRST SOLID STATE CAMERA WAS INTRODUCED AND THIS WAS THE START OF 'VIDEO-LAPAROSCOPY’.

1987 - PHILLIPE MOURET PERFORMED THE FIRST VIDEO-LAPAROSCOPIC CHOLECYSTECTOMY IN LYONS, FRANCE.

1994 - A ROBOTIC ARM WAS DESIGNED TO HOLD THE LAPAROSCOPE CAMERA AND INSTRUMENTS.

1996 - THE FIRST EVER LIVE BROADCAST OF LAPAROSCOPIC SURGERY VIA THE INTERNET WAS PERFORMED.

WHY LAPAROSCOPY? THERE ARE A NUMBER OF ADVANTAGES TO OPERATING

ON THE PATIENT WITH LAPAROSCOPIC SURGERY VERSUS OPEN SURGERY. SOME OF THESE ARE:

Less post-operative scarring Reduced pain Shorter recovery time Less time spent in hospital to recover Reduced hemorrhaging Reduced risk of exposing internal organs to external

contaminants Quicker return to normal activities Quicker return to work Reduced wound complications

LAPAROSCOPIC SURGERY CHOLECYSTECTOMY, APPENDECTOMY &

COLECTOMYVAGOTOMYHIATAL,

INGUINAL & DIAPHRAGMATIC HERNIA REPAIR

UROLOGICAL- NEPHRECTOMY,

ADRENELECTOMY & PROSTATECTOMY.

OBG-TUBAL SURGERIES,CYSTECTOMIES,HYSTRECTOMIES & VARIOUS ABLATIONS (ENDOMETRIOSIS)

THORACOSCOPIES

NEUROSURGERIES

LUMBAR DISCECTOMIES

DIAGNOSTIC PROCEDURES

ADVANTAGES AND DISADVANTAGES

ADVANTAGES Minimal pain & illeus Improved cosmesis Shorter hospital stay , faster recovery & rapid return to work Non muscle splinting incision & less blood loss Post op respiratory muscle function returns to normal more quickly Wound complications i.e. infection & dehiscence are less Lap surgery can be done as day care surgery

 

DISADVANTAGES Longer duration of surgery Loss of 3D view, impaired touch sensation poor dexterity, fulcrum effect, risk of visceral / vsl. Injury (may go

unrecognised) Long learning curve for surgeons

LAPAROSCOPY Laparoscopic surgeries are commonly carried out through

transperitoneal or retroperitoneal approaches with insufflation of CO2 and fewer commonly with another inert gas such as helium or argon.

Typically, intra-abdominal pressures (intra abdominal pressure) of Ten to fifteen mm Hg are sufficient for visualization and dissection.

Physiologic effects seen with CO2 insufflation are transient and derive from the body's reaction to increases in intra abdominal pressure and CO2 absorption as it tries to achieve a new state of homeostasis.

People who are otherwise healthy will tolerate laparoscopy well, while individuals with underlying cardiopulmonary or renal diseases may not tolerate prolonged CO2 insufflation.

Additionally, patient positioning, for example steep Trendelenburg in prostatectomy, can exacerbate cardiovascular alterations in laparoscopy.

CARDIOVASCULAR RESPONSE

The cardiovascular response to increased intra abdominal pressure appears to be phasic:

early transient phase (venous return and cardiac filling pressures increase due to upward mechanical pressure)

Increased intrathoracic pressure (as well as intra-abdominal compression about the splanchnic venous bed and vena cava, which increases venous return.)

Mechanical pressures on the venous vasculature (result in increases in central venous pressure, pulmonary capillary wedge pressure, and right- and left-side cardiac filling pressures.)

CARDIOVASCULAR RESPONSE A steady state of decreased blood circulation (with the

inferior vena cava comes after due to the compressive effects of continued intra-abdominal pressure.)

The compressive effects on the arterial vasculature and capillaries ( afterload, systemic vascular resistance (SVR), and arterial pressure stroke volume and cardiac output decrease.)

MAP, mean arterial blood pressure; SVR, systemic vascular resistance; HR, heart rate; CVP, central venous pressure; PCWP, pulmonary capillary wedge pressure; PAC, pulmonary artery catheter; ED, esophageal Doppler probe; TEE, transesophageal echocardiography; TBC, transthoracic bioimpedence cardiography; ASA, American Society of Anesthesiologists.

PATIENT POSITIONING Attention to patient positioning and its impact on

cardiovascular response ought not to be neglected.

In cases where steep or reverse Trendelenburg positions are required, hemodynamic changes are magnified, with drops within the cardiac index (CI) of as much as 50% in certain reports.

In Trendelenburg position, venous return is improved with subsequent increases in cardiac filling pressures.

Reverse Trendelenburg position, venous pooling in the lower extremity occurs, generating decreased venous return, ejection fraction.

Fig. Trendelenburg Position

Fig. Reverse Trendelenburg Position

RESPIRATORY RESPONSE Ideal insufflating gas of choice

Colorless, non toxic, nonflammable, easily available, inexpensive, inert, readily soluble in blood and easily ventilated out of lungs

Why CO2 is the gas of choice for laparoscopy?

Nonflammable & does not support combustion Highly soluble in blood because of rapid buffering in

blood so risk of embolisation is small Rapidly diffusible through membranes so easily

removed by lungs CO2 levels in blood & expired air can be easily

measured & its elimination is augmented by increasing ventilation

CO2 is readily available & is inexpensive

RESPIRATORY RESPONSE Despite the proven effectiveness and protection of CO2

for insufflation in laparoscopy, the respiratory response to mechanical improves in intra abdominal pressure as well as hypercapnia from absorption should be considered.

With CO2 insufflation and increases in IAP the lung compliance decreases.

Functional residual capacity, vital capacity, and pulmonary compliance.

RESPIRATORY RESPONSE Laparoscopy is usually well tolerated in healthy

individuals, however those patients who have underlying COPD or interstitial pulmonary disease.

In otherwise, healthy individuals without having pulmonary disease, CO2 is eliminated efficiently through respiration by increases in minute ventilation (increases in respiratory rate and/or tidal volume).

Similar to the phasic cardiac response, CO2 excretion rises acutely, from the typical baseline degree of 125 mL/min to 200 mL/min, within approximately Quarter-hour of pneumoperitoneum then plateaus thereafter.

RESPIRATORY RESPONSE Poor CO2 diffusion and elimination can lead to significant

and catastrophic increases of PCO2 if blood gases are not supervised.

Periodic arterial blood gas measurements ought to be obtained as well as in the big event that CO2 cannot be quickly eliminated, pneumoperitoneum or pneumoretroperitoneum should be relieved immediately.

Once PCO2 has fallen to the acceptable range, CO2 insufflation could be resumed and also the laparoscopic procedure continuing.

RENAL RESPONSE Oliguria

Effects are transient and reversible upon desufflation.

Avoid over-resuscitation, fluid overload, pulmonary edema, and exacerbation of congestive heart failure.

IAP ERBF (compressive effects on renal vasculature, parenchyma, and IVC)

RENAL RESPONSE The renal effects are mild to negligible once the intra

abdominal pressure is under 10 mm Hg, but as intra abdominal pressure reaches and exceeds 15 mm Hg, there's a pressure-dependent decrease in

glomerular filtration rate (GFR), ERBF, creatinine clearance, sodium excretion, and urinary output.

(In a typical IAP of 15 mm Hg, urinary output decreases by as much as 63%, GFR by 21%, and ERBF by 26%. Despite this drop, however, there are no long-term renal sequelae, even in patients with pre-existing renal disease, and pneumoperitoneum-induced renal failure does not occur.)

RENAL RESPONSE renin, aldosterone, and antidiuretic hormone (ADH).

Resulting in systemic vasoconstriction and fluid retention.

Together with desufflation, these mediators return to baseline levels.

Twenty four hours after surgery with normalization of serum and urinary creatinine and electrolytes.

METABOLIC RESPONSE Metabolic acidosis from CO2 absorption is the primary

derangement.

In otherwise healthy patients, an increase in minute ventilation is enough, but for individuals with COPD, removal of CO2 is less capable, causing them to be afflicted by more major and extended derangements in acid-base balance.

REGIONAL CHANGES

THANK YOU