Anaesthetic considerations for laparoscopic cholecystectomy

Best Practice & Research Clinical Anaesthesiology Vol. 16, No. 1, pp. 1±20, 2002

doi:10.1053/bean.2002.0204, available online at http://www.idealibrary.com on

1 Anaesthetic considerations for laparoscopic cholecystectomy Irene E. Leonard

MB, FFARCSI

Lecturer in Anaesthesia

Anthony J. Cunningham*

MD, FRCPC

Professor of Anaesthesia Department of Anaesthesia, Beaumont Hospital/Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland

Minimally invasive surgical procedures aim to minimize the trauma of the interventional process but still achieve a satisfactory therapeutic result. Tissue trauma is signi®cantly less than that with conventional open procedures, o€ering the advantages of reduced post-operative pain, shorter hospital stay, more rapid return to normal activities and signi®cant cost savings. Laparoscopic cholecystectomy is now a routinely performed procedure and has replaced conventional open cholecystectomy as the procedure of choice for symptomatic cholelithiasis. Public expectation and developments in instrumentation have fuelled this change. The physiological e€ects of intraperitoneal carbon dioxide insu‚ation combined with variations in patient positioning can have a major impact on cardiorespiratory function, particularly in elderly patients with co-morbidities. Intra-operative complications may include traumatic injuries associated with blind trocar insertion, gas embolism, pneumothorax and surgical emphysema associated with extraperitoneal insu‚ation. Appropriate monitoring and a high index of suspicion can result in early diagnosis of, and treatment of, complications. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease. Key words: laparoscopy; cholecystectomy; pneumoperitoneum; intra-operative complications; embolism; pneumothorax; analgesia; ambulatory.

Over the past decade there has been an enormous expansion in the use of minimally invasive surgical procedures which aim to `minimize the trauma of the interventional process but still achieve a satisfactory therapeutic result'.1 Minimal-access surgical procedures produce signi®cantly less trauma than conventional open procedures, with the potential advantages of reduced post-operative pain, shorter hospital stays, more rapid return to normal activities and signi®cant cost savings.2 Laparoscopic cholecystectomy was ®rst described in 1987 by Phillipe Mouret; the ®rst series was reported by Perissat et al3 and the technique was introduced into the United States in 1988 by Reddick and Olsen.4 Laparoscopic cholecystectomy rapidly *To whom correspondence should be addressed. 1521-6896/02/010001‡20 $35.00/00

c 2002 Elsevier Science Ltd. *

2 I. E. Leonard and A. J. Cunningham

emerged as an alternative to traditional open cholecystectomy. It is now a routinely performed procedure and has replaced conventional open cholecystectomy as the procedure of choice for symptomatic cholelithiasis.5,6 The evolution of laparoscopic cholecystectomy has represented a departure from traditional surgical development. Few prospective randomized controlled trials comparing laparoscopic and open procedures have been performed. Public expectation and perception of the superiority of minimally invasive techniques led to poorly controlled and audited introduction of laparoscopic surgical procedures. However, a signi®cant body of experience and literature has emerged in the 1990s, con®rming the safety and ecacy of laparoscopic cholecystectomy. Increasing surgical experience and improvements in instrumentation has resulted in an expansion of both the range of surgical procedures performed by the laparoscopic approach,7±10 and the patient population to whom such procedures are o€ered. Increasingly, laparoscopic cholecystectomy is being performed in older patients with co-existing cardiopulmonary disease, in pregnancy, morbid obesity and in paediatric patients. Laparoscopy produces signi®cant physiological changes associated with peritoneal insu‚ation and alteration in patient position which can have a major impact on cardiopulmonary function, particularly in American Society of Anesthesiologists (ASA) class III or IV patients. Speci®c intra-operative complications due to traumatic injuries and gas embolism may also occur and present signi®cant challenges in anaesthetic management. SURGICAL TECHNIQUE The operative technique involves intraperitoneal insu‚ation of carbon dioxide (CO2) through a Veress needle inserted into a small infra-umbilical incision, with the patient in a 15±208 Trendelenburg position11 (Figure 1). Modern laparoscopic insu‚ators automatically terminate gas ¯ow when a preset intra-abdominal pressure (IAP) of 10± 15 mmHg is reached. An access port is then inserted in place of the needle to maintain insu‚ation during surgery. A video laparoscope, inserted through the port, allows visualization of the operative ®eld. Additional access ports are inserted through three small skin incisions which allow the introduction of surgical dissection instruments.

Figure 1. Laparoscopic cholecystectomy: patient positioning and equipment.

Anaesthesia for laparoscopic cholecystectomy 3

The patient's position is changed to a steep reverse Trendelenburg (rT) with left lateral tilt to facilitate retraction of the gallbladder fundus and to minimize the diaphragmatic dysfunction associated with the induced pneumoperitoneum. The cystic duct and artery are identi®ed and ligated. The diseased gallbladder is dissected from the hepatic bed and removed through the periumbilical cannula. Despite concerns about technical diculties due to tissue oedema and in¯ammation, acute cholecystitis is no longer considered a contraindication to laparoscopic cholecystectomy.12 The reported rate of conversion to an open procedure is, however, high, particularly in patients with acute gangrenous cholecystitis (49%), and in patients with an operative delay of more than 96 hours from the onset of cholecystitis (47%).13 PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY The physiological consequences of laparoscopy relate to the combined e€ects of intraperitoneal insu‚ation of carbon dioxide to create a pneumoperitoneum, alteration of patient position, and the e€ects of systemic absorption of CO2 (Table 1). Cardiovascular e€ects The haemodynamic response to peritoneal insu‚ation has been well described, and depends on the interaction of factors that include patient positioning,14 neurohumoral response,15 and patient factors including cardiorespiratory status16 and intravascular volume17 (Table 2). The principal physiological responses are an increase in systemic vascular resistance (SVR), mean arterial blood pressure (MAP) and myocardial ®lling pressures, accompanied by an initial fall in cardiac index (CI), with little change in heart rate.18±20 A characteristic phasic haemodynamic response is described with initial reduction in cardiac index after CO2 insu‚ation and subsequent recovery.19 Using ¯ow-directed pulmonary artery catheters in healthy patients during laparoscopic cholecystectomy, Table 1. Physiological e€ects of laparoscopy. . ± ± ± ±

Mechanical ± CO2 insu‚ation " SVR, " MAP, # CI [phasic response] " CBF, " ICP # renal, portal, splanchnic blood ¯ow # pulmonary compliance

. Patient position ± Trendelenburg: # FRC, # pulmonary compliance ± rTrendelenburg: # LV preload, LVEF ! or # . Systemic ± CO2 absorption ± hypercapnia, acidosis ± # arrhythmia threshold SVR ˆ systemic vascular resistance; MAP ˆ mean arterial pressure; CI ˆ cardiac index; CBF ˆ cerebral blood ¯ow; ICP ˆ intracranial pressure; FRC ˆ functional residual capacity; LVEF ˆ left ventricular ejection fraction.

4 I. E. Leonard and A. J. Cunningham Table 2. Haemodynamic e€ects of laparoscopy. . Patient factors ± Cardiorespiratory status ± Intravascular volume . Patient position ± rTrendelenburg: # LV preload, LVEF . ± ± ±

! or #

Intra-abdominal pressure " SVR, " MAP, # CI [phasic response] " CBF, " ICP # renal, portal, splanchnic blood ¯ow

. Neurohumoral responses ± RAA system activation [ " renin, " vasopressin, " aldosterone] ± Sympathetic nervous system activation [ " catecholamines] LVEF ˆ left ventricular ejection fraction; SVR ˆ systemic vascular resistance; MAP ˆ mean arterial pressure; CI ˆ cardiac index; CBF ˆ cerebral blood ¯ow; ICP ˆ intracranial pressure; RAA ˆ renin-angiotensin-aldosterone.

Joris and colleagues19 observed a signi®cant (35±40%) reduction in CI with induction of anaesthesia and rT positioning, which was further decreased to 50% of baseline following peritoneal insu‚ation. Gradual restoration of CI and reduction of SVR occurred. A similar phasic haemodynamic response to pneumoperitoneum was observed by Branche and colleagues20 using echocardiographic assessment. The left ventricular fractional area of shortening decreased signi®cantly immediately after insu‚ation and returned to the pre-insu‚ation value after 30 minutes of pneumoperitoneum. Mechanical e€ects of pneumoperitoneum Increased IAP associated with pneumoperitoneum may compress venous capacitance vessels causing an initial increase, followed by a sustained decrease in pre-load.21 Compression of the arterial vasculature increased after-load and may result in a marked increase in calculated systemic vascular resistance (SVR).19 Cardiac index may be signi®cantly reduced, and the magnitude of this e€ect is proportional to the intraabdominal pressure achieved. In healthy subjects undergoing laparoscopic cholecystectomy, Dexter et al22 using transoesophageal Doppler found that cardiac output was depressed to a maximum of 28% at an insu‚ation pressure of 15 mmHg but was maintained at an insu‚ation pressure of 7 mmHg. In an animal model, Ishizaki et al23 report that the threshold IAP which had minimal e€ects on haemodynamic function was 412 mmHg and recommend this pressure limit to avoid cardiovascular compromise during CO2 insu‚ation. Neurohumoral response Potential mediators of the increased SVR observed during pneumoperitoneum include vasopressin and catecholamines. Hypercapnia and pneumoperitoneum are likely to cause stimulation of the sympathetic nervous system and catecholamine release.24,25 A number of investigators have reported activation of the renin-angiotensin system with vasopressin production.25±27 Joris and colleagues25 observed a marked increase in plasma

Anaesthesia for laparoscopic cholecystectomy 5

vasopressin immediately after peritoneal insu‚ation in healthy patients, and the pro®le of vasopressin release paralleled the time course of changes in SVR. A fourfold increase in plasma renin and aldosterone concentrations correlating with increases in MAP was reported by O'Leary and colleagues.27 The time course of vasopressin release paralleling observed changes in CI and SVR suggests a possible cause±e€ect relationship. CO2 absorption Signi®cant hypercapnia and acidosis may occur during laparoscopy due to CO2 absorption.28 Hypercapnia may cause a decrease in myocardial contractility and lower arrhythmia threshold. The anticipated direct vascular e€ect of hypercapnia, producing arteriolar dilation and decreased SVR, is modulated by mechanical and neurohumoral responses, including catecholamine release. E€ect of patient position Intraperitoneal insu‚ation of CO2 is performed with the patient in a 15±208 Trendelenburg position. The patient's position is then changed to a steep rT position with left lateral tilt to facilitate retraction of the gallbladder fundus and minimize diaphragmatic dysfunction.11 The patient's position may have signi®cant e€ects on the haemodynamic consequences of pneumoperitoneum. In a series of 13 patients undergoing laparoscopic cholecystectomy Cunningham and colleagues,14 using transoesophageal echocardiography (TOE) monitoring, reported a signi®cant reduction in left ventricular end-diastolic area on assumption of rT position, indicating reduced venous return. Left ventricular ejection fraction was maintained throughout in these otherwise healthy patients. However, such changes in left ventricular loading conditions might have adverse consequences in patients with cardiovascular disease. Regional circulatory changes Global haemodynamic responses to laparoscopic surgery have been the subject of much attention. However, changes in regional organ perfusion also occur, and these may have particular relevance in the critically ill patient. Cerebral blood ¯ow. Increases in intra-abdominal pressure, cardiovascular responses to peritoneal insu‚ation, changes in patient position, and alterations in PaCO2 can alter cerebral perfusion and intracranial pressure. Cerebral blood ¯ow (CBF) has been shown to increase signi®cantly during CO2 insu‚ation using transcranial Doppler ultrasonography monitoring.29,30 De Cosmo and colleagues30 observed such a rise in CBF in the absence of an increase in end-tidal carbon dioxide (ETCO2) concentration. Intracranial pressure (ICP) also rises with the acute increase in intra-abdominal pressure occurring during insu‚ation. Rosenthal and colleagues31 demonstrated a linear increase in ICP with increasing IAP in a large animal model. The combination of an IAP of 16 mmHg and Trendelenburg position increased ICP 150% over controls. In a similar animal model the authors observed that the elevated ICP did not respond to hyperventilation and hypocapnia.32 ICP showed a signi®cant further increase, however, with hypoventilation and hypercapnia. The mechanism of increased ICP during abdominal insu‚ation has been investigated by Halverson and colleagues.33,34 Increased inferior vena caval pressure, with impaired venous drainage of the lumbar venous plexus, was associated

6 I. E. Leonard and A. J. Cunningham

with a subsequent decline in absorption of CSF during abdominal CO2 insu‚ation. In summary, CBF and ICP are therefore signi®cantly increased during pneumoperitoneum regardless of PaCO2 but hypercapnia may aggravate these e€ects. Renal blood ¯ow. Creation of a CO2 pneumoperitoneum reduces renal cortical and medullary blood ¯ow with an associated transient reduction in glomerular ®ltration rate, urinary output35 and creatinine clearance.36 McDougall and colleagues36 evaluated the e€ects of various levels of IAP (0±20 mmHg) on renal function. Renal vein ¯ow (RVF), urine output (UO), and creatinine clearance showed a signi®cantly greater decrease when IAP exceeded 15 mmHg. Two hours after desu‚ation, RVF had not returned to baseline, although UO improved. Limitation of IAP using a retraction method37 or abdominal wall-lifting38 technique has resulted in stable renal haemodynamics during laparoscopic cholecystectomy. Neurohumoral factors may also in¯uence renal perfusion during pneumoperitoneum. Renal vascular compression may increase plasma renin activity with consequent renal vasoconstriction.39 Anti-diuretic hormone (ADH) levels rise during pneumoperitoneum and pre-treatment with an ADH antagonist improves urine output and urea excretion despite an unaltered GFR.40 Hepatic and splanchnic blood ¯ow. The adverse e€ects of sustained elevated intraperitoneal pressure (IPP) on the hepatic circulation have been well documented. Flow through the hepatoportal circulation varies in relation to IAP. Jakimowicz and colleagues41 investigated the e€ect of increasing IAP on the portal venous ¯ow, using duplex Doppler ultrasonography in patients undergoing laparoscopic cholecystectomy. Portal blood ¯ow was reduced by 37% at an IAP of 7.0 mmHg and 53% when the IAP reached 14 mmHg. In an experimental model, helium intraperitoneal insu‚ation resulted in a signi®cantly greater impairment of hepatic blood ¯ow than CO2 insu‚ation.42 The patient's position also in¯uences changes in hepatic blood ¯ow. The reverse Trendelenburg position is associated with a reduction in total hepatic, hepatic arterial, and portal venous blood ¯ow.43 Splanchnic circulatory changes documented during high-pressure CO2 pneumoperitoneum include a decrease in mesenteric arterial blood ¯ow, diminished gastric perfusion and a decrease in gastric intramucosal pH (pHi).44,45 The decrease in splanchnic perfusion is mediated partly by mechanical compression of the mesenteric vasculature46 and is dependent on the extent of carbon dioxide pneumoperitoneum. The e€ect of low IAP (7 mmHg) on splanchnic perfusion is minimal. However, higher IAPs (14 mmHg) decrease portal and super®cial hepatic blood ¯ow and intestinal mucosal pH.47 Humorally induced vasoconstriction can also occur. ADH secretion is stimulated by pneumoperitoneum and is known to induce superior mesenteric artery constriction. Agusti and colleagues48 investigated the e€ects of dopamine and dobutamine administration on the mesenteric circulatory disturbances induced by pneumoperitoneum in a porcine model. Peritoneal insu‚ation to an IAP of 15 mmHg signi®cantly decreased superior mesenteric arterial and intestinal mucosal blood ¯ows. Dobutamine infusion failed to restore superior mesenteric artery blood ¯ow; however, intestinal mucosal blood ¯ow returned to baseline levels. Dopamine had no bene®cial e€ect on splanchnic haemodynamic variables. Splanchnic ischaemia is a risk factor for bacterial translocation, systemic in¯ammatory response syndrome, and multiple organ failure. Bacterial translocation into the blood, associated with CO2 pneumoperitoneum, has been reported as long as 18 hours after de¯ation in an experimental model.44

Anaesthesia for laparoscopic cholecystectomy 7

Respiratory e€ects Mechanical Changes in pulmonary function during abdominal insu‚ation include reduction in lung volumes, decrease in pulmonary compliance and increase in peak airway pressure.49±51 Reduction in functional residual capacity (FRC) and lung compliance associated with supine positioning and induction of anaesthesia is further aggravated by CO2 insu‚ation and cephalad shift of the diaphragm during head-down tilt.49,52 Hypoxaemia due to reduction in FRC is uncommon in healthy patients during laparoscopy.53 However, reduction in FRC may result in signi®cant hypoxaemia due to ventilation± perfusion mismatch and intra-pulmonary shunting in obese patients or in patients with pre-existing pulmonary disease. Gas exchange e€ects ± CO2 absorption Surgical exposure and access is facilitated during laparoscopic surgery by peritoneal gas insu‚ation. CO2 is the insu‚ation gas of choice for laparoscopic surgery. Unlike nitrous oxide, it does not support combustion and therefore can be used safely with diathermy. Compared to helium, the high blood solubility of CO2 and its capability for pulmonary excretion reduces the risk of adverse outcome in the event of gas embolism.54 CO2 insu‚ation into the peritoneal cavity increases arterial carbon dioxide tension28 (PaCO2) which is managed by increasing minute ventilation. Carbon dioxide absorption is greater during extraperitoneal (pelvic) insu‚ation than during intraperitoneal insu‚ation. Mullet and colleagues55 examined end-tidal CO2 (ETCO2) and pulmonary CO2 elimination during CO2 insu‚ation for laparoscopic cholecystectomy and pelviscopy. Carbon dioxide absorption reached a plateau within 10 minutes after initiation of intraperitoneal insu‚ation, but continued to increase slowly throughout extraperitoneal insu‚ation. The resulting rise in PaCO2 is unpredictable, particularly in patients with severe pulmonary disease. Wittgen and colleagues56 observed signi®cant decreases in pH and increases in PaCO2 in ASA III patients during pneumoperitoneum, and these patients had signi®cantly higher minute ventilation requirements and peak airway pressures. Furthermore, ETCO2 levels may not correlate with arterial concentrations in this patient population. The PETCO2 gradient remained stable during laparoscopy in ASA III patients,57 while other investigators have found that the PETCO2 gradient is variable in patients with cardiopulmonary disease.56 Therefore, ETCO2 may not be a reliable index of PaCO2 during CO2 insu‚ation in this patient population. PaCO2 may remain elevated despite increasing minute ventilation in ASA III and IV patients, and refractory hypercapnia may occur.58 Pre-operative pulmonary function testing with FEV1 5 70% predicted and di€usion defects less than 80% predicted may identify patients at risk.59 ANAESTHETIC TECHNIQUE Anaesthetic technique for laparoscopic cholecystectomy has been limited mainly to general anaesthesia. Diagnostic laparoscopic procedures have been performed under spinal anaesthesia,60,61 and successful performance of laparoscopic cholecystectomy under continuous epidural anaesthesia has been reported in patients with chronic respiratory disease,62 including cystic ®brosis.63 However, the high level of sympathetic denervation required, the frequent need for change of patient position, and the

8 I. E. Leonard and A. J. Cunningham

mandatory pneumoperitoneum may be associated with adverse ventilatory and circulatory responses complicating peri-operative management.

Airway management Endotracheal intubation and controlled mechanical ventilation comprise the accepted anaesthetic technique to reduce the increase in PaCO2, and to avoid ventilatory compromise due to pneumoperitoneum and initial Trendelenburg position.64 The laryngeal mask airway (LMA) has been used widely during pelvic laparoscopy. Continuous oesophageal pH monitoring65,66 and clinical monitoring67,68 failed to detect gastro-oesophageal re¯ux in patients undergoing gynaecological laparoscopy using LMA. However, this evidence cannot be extrapolated to upper abdominal laparoscopy, and high intra-abdominal pressures during laparoscopic cholecystectomy may increase the risk of passive regurgitation of gastric contents. Cu€ed endotracheal tube placement will minimize the risk of acid aspiration should re¯ux occur. The choice of neuromuscular blocking drug will depend on the anticipated duration of surgery and the individual drug side-e€ect pro®le. Reversal of residual neuromuscular blockade with neostigmine has been reported to increase the incidence of postoperative nausea and vomiting (PONV) following laparoscopy compared with spontaneous recovery,69 and some practitioners avoid its use. However, other investigators have found no e€ect on the incidence of PONV associated with the use of neostigmine,70 and speci®cally in patients undergoing outpatient gynaecological laparoscopy the use of neostigmine and glycopyrrolate did not increase the incidence or severity of PONV.71 Even minor degrees of residual neuromuscular blockade can produce distressing symptoms and must be avoided. Therefore, any bene®t from omitting neostigmine must be balanced against the risk of inadequate reversal of neuromuscular blockade.

Monitoring Standard intra-operative monitoring is recommended for all patients undergoing laparoscopic cholecystectomy. Invasive haemodynamic monitoring may be appropriate in ASA III or IV patients to monitor the cardiovascular response to pneumoperitoneum and position changes and to institute therapy.64 ETCO2 is most commonly used as a noninvasive indicator of PaCO2 in assessing the adequacy of ventilation during laparoscopic procedures. Wahba and Mamazza72 found that increasing minute ventilation by 12±16% maintained PaCO2 close to pre-insu‚ation levels, and that ETCO2 provided a reasonable approximation of PaCO2 in healthy patients undergoing laparoscopic cholecystectomy. McKinstry et al73 similarly observed equal and proportional increases in ETCO2 and PaCO2 following CO2 insu‚ation in healthy patients. In contrast, in patients with preexisting cardiopulmonary disease, signi®cant increases in PaCO2 occurred during CO2 insu‚ation, which were not re¯ected by comparable increases in ETCO2.56 Pre-operative pulmonary function tests showing low forced expiratory and vital capacity volumes, and high ASA status, may predict those patients at risk for development of hypercapnia and acidosis during laparoscopic cholecystectomy.59 In such patients it would seem prudent to monitor PaCO2 at times during the procedure to avoid adverse outcome. Persistent refractory hypercapnia or acidosis may require de¯ation of the pneumoperitoneum, lowering of the insu‚ation pressure, or conversion to an open procedure.

Anaesthesia for laparoscopic cholecystectomy 9

Nitrous oxide The use of nitrous oxide (N2O) during laparoscopic cholecystectomy has been controversial due to concerns regarding its ability to di€use into bowel lumen causing distension, and to increase post-operative nausea. As N2O is more soluble than nitrogen (N2), a closed air-containing space may accumulate N2O more rapidly than it can eliminate N2. Eger and Saidman74 noted an increase of more than 200% in intestinal luminal size after 4 hours of N2O breathing. The safety and ecacy of N2O, speci®cally during laparoscopic cholecystectomy, were investigated by Taylor et al.75 Surgical conditions during procedures lasting 70 to 80 minutes were identical regardless of whether or not N2O was used. In particular, bowel distension did not increase over time with N2O use, and surgeons were unable to distinguish between patients who had received N2O compared to air. Analgesia Although laparoscopic surgery, compared with open procedures, is associated with diminished surgical trauma, post-operative pain occurs frequently. The fact that laparoscopic cholecystectomy is increasingly being performed as a day-case procedure emphasizes the importance of improving early post-operative pain relief. Opioids remain an important component of a balanced general anaesthetic technique for laparoscopic cholecystectomy. Concern has been raised regarding narcotic-induced spasm of the sphincter of Oddi76 leading to misinterpretation of intra-operative cholangiographic ®ndings. Many opioids, including fentanyl, have been implicated, and there are con¯icting reports regarding the relative e€ect of individual opioids.77,78 Opioid-induced spasm of the sphincter of Oddi may be antagonized by several drugs, including glucagon78 and naloxone.79 Peripheral use of local anaesthetics to improve early pain control and minimize the need for opioids is an attractive approach, particularly in the context of ambulatory procedures. The analgesic e€ect of intraperitoneal instillation of local anaesthesia after laparoscopic cholecystectomy is, however, controversial. Reported results range from considerable pain reduction80,81 to no e€ect.82,83 Pasqualucci and colleagues80 achieved greatest bene®t from sub-diaphragmatic instillation of 20 ml of bupivicaine 0.5% both before surgery and again at completion of surgery. A multi-regional local anaesthetic in®ltration technique, combining incisional and intraperitoneal administration, signi®cantly reduced incisional pain, early post-operative nausea and morphine requirements, but had no e€ect on visceral or shoulder pain following laparoscopic cholecystectomy.84 Similarly, Joris and colleagues83 found that visceral pain accounted for most of the discomfort after laparoscopic cholecystectomy and was not attenuated by intraperitoneal administration of 80 ml of 0.125% bupivacaine. In a systematic review, Moiniche and colleagues85 recently evaluated 41 randomized controlled trials (RCT) of peripheral local anaesthetics compared with placebo or no treatment in the control of post-operative pain after laparoscopic surgery. Thirteen RCTs evaluated intraperitonal LA after cholecystectomy. Data analysis revealed a statistically signi®cant, though clinically small, di€erence in favour of the treatment groups compared to controls. There was a lack of evidence for any important e€ect of portsite in®ltration in reducing pain after laparoscopy. A multimodal analgesic regimen combining opioids, non-steroidal anti-in¯ammatory drugs (NSAIDs) and local anaesthetic administration may be the most e€ective approach, allowing reduction of opioid dose and thereby minimizing side-e€ects.

10 I. E. Leonard and A. J. Cunningham

Michaloliakou and colleagues86 found that, following laparoscopic cholecystectomy, the combination of ketorolac 0.5 mg/kg, meperidine 0.6 mg/kg, and pre-incisional in®ltration with local anaesthesia resulted in 57% of patients being pain-free on arrival in the recovery room. This multimodal regimen was also associated with a sixfold reduction in post-operative pain, a reduction in PONV (from 29.5 to 4.7%) and promotion of a faster recovery and earlier discharge. Post-operative nausea and vomiting PONV is a common and distressing symptom following laparoscopy, with the reported incidence of post-discharge nausea following outpatient laparoscopy being as high as 48%.87 Reduction of opioid dose with multimodal analgesia regimes is likely to reduce the incidence of PONV. N2O has been implicated as an emetogenic agent in many studies, and its use as part of a balanced anaesthetic technique for laparoscopic cholecystectomy, particularly in the outpatient setting, remains controversial. Taylor and colleagues75 found no signi®cant di€erence in the incidence of PONV between treatment groups when anaesthesia was maintained with iso¯urane in either a 70% N2O/oxygen mixture or an air/oxygen mixture during laparoscopic cholecystectomy. In contrast, the results of the meta-analyses of Tramer et al88 and Divatia et al89 indicate a signi®cant reduction in post-operative emesis with omission of N2O. In an analysis of 24 randomized controlled trials, Divatia and colleagues found that omission of N2O reduced the relative risk of PONV by 28%, with the maximal e€ect being seen in female patients. The use of propofol-based anaesthesia for laparoscopic cholecystectomy is increasing, and has been associated with reduced PONV.90 In a meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents, Sneyd and colleagues91 found that patients who received propofol-based anaesthesia had a signi®cantly lower incidence of PONV. The reduced emesis with propofol anaesthesia was similar regardless of whether or not N2O was used. Arellano et al92 similarly found that omission of N2O from a propofolbased anaesthetic for ambulatory gynaecological surgery did not confer any additional bene®t in terms of post-operative nausea scores. The selective 5HT3 receptor antagonist, ondansetron, has been found to provide e€ective prophylaxis against post-operative emesis following laparoscopic cholecystectomy.93 In a comparison of the newer 5HT3 receptor antagonists, ramosetron was more e€ective than granisetron for prevention of PONV during the ®rst 48 hours after laparoscopic cholecystectomy.94 The timing of anti-emetic administration was found to be signi®cant in ambulatory patients, with administration of ondansetron at the end of surgery producing a signi®cantly greater anti-emetic e€ect compared to pre-induction dosing.95 SPECIFIC INTRA-OPERATIVE COMPLICATIONS Vascular injury Major vascular injuries may occur during surgical instrumentation, particularly during insertion of the Veress needle or trocar. The incidence of vascular injury during upper abdominal laparoscopy is reported to be approximately 0.03±0.06%96 and has decreased with increasing surgical experience. Haemorrhage may occur due to insertion of the Veress needle or trocar into major intra-abdominal vessels,97 or due to injury to abdominal wall vasculature.98 Disruption or avulsion of the cystic or hepatic artery may

Anaesthesia for laparoscopic cholecystectomy 11

cause major bleeding during laparoscopic cholecystectomy. Concealed bleeding, particularly into the retroperitoneal space, may result in delayed diagnosis of vascular injury which may be indicated initially by unexplained hypotension. The anaesthetist may therefore play a crucial role in early diagnosis of this potentially fatal complication of laparoscopic procedures.99 Uncontrollable haemorrhage requires immediate conversion to an open procedure to control bleeding and repair the vascular injury. Other reported intra-abdominal injuries associated with trocar insertion include gastrointestinal tract perforations, hepatic and splenic tears, and mesenteric lacerations.100 Unrecognized gastrointestinal (GI) injuries may be associated with signi®cant morbidity and mortality. Risk factors for GI injuries include gastric distension and adhesions due to previous abdominal surgery. Placement of the Veress needle using a minilaparotomy approach101 should be considered in patients at increased risk. Inadvertent extraperitoneal insu‚ation Access to the peritoneal cavity is achieved during laparoscopy by blind insertion of the Veress needle through a small subumbilical incision. Extraperitoneal insu‚ation of CO2 may occur if the needle tip lies in the subcutaneous, pre-peritoneal or retroperitoneal tissue during insu‚ation. The reported incidence of this complication varies from 0.4% to 2%.102 As there is a continuum of fascial planes, extensive subcutaneous emphysema can develop involving the abdomen, chest, neck and groin. Subcutaneous emphysema is indicated by the development of crepitus over the abdominal wall. Increased CO2 absorption may cause a sudden rise in ETCO2, and signi®cant hypercapnia and respiratory acidosis has been reported in association with subcutaneous emphysema due to extraperitoneal insu‚ation.103,104 In most cases no speci®c intervention is required and the subcutaneous emphysema resolves soon after the abdomen is de¯ated. Careful surgical technique during Veress needle insertion and veri®cation of intraperioneal location prior to insu‚ation105 will reduce the incidence of these complications. Pneumothorax and pneumomediastinum Pneumothorax has been reported during both intra-peritoneal and extra-peritoneal laparoscopic procedures54,106 and although rare, is a potentially life-threatening complication. During laparoscopic cholecystectomy, pneumothorax has occurred during Veress needle or trocar insertion, CO2 insu‚ation, or gallbladder dissection.107 The suggested mechanisms include tracking of insu‚ated CO2 around the aortic and oesophageal hiatuses of the diaphragm into the mediastinum with subsequent rupture into the pleural space. Passage of gas through anatomic defects in the diaphragm occurring at the outer crus, or through a congenital defect at the pleuroperitoneal hiatus (patent pleuroperitoneal canal), is also a probable mechanism.108 Tension pneumothorax has been described during laparoscopic cholecystectomy109,110 and has been attributed to such a congenital diaphragmatic defect. Alternatively, rupture of a lung bulla or bleb could produce a tension pneumothorax independent of the pneumoperitoneum. Clinical signs are variable. Pneumothorax may be undetected intra-operatively, or may present as unexplained increased airway pressure, hypoxaemia±hypercapnia, surgical emphysema, or, if tension pneumothorax occurs, severe cardiovascular compromise with profound hypotension. Maintaining a high index of suspicion will facilitate early diagnosis and treatment which can be life-saving. If pneumothorax is

12 I. E. Leonard and A. J. Cunningham

suspected a chest radiograph should be obtained to con®rm the diagnosis. In the event of haemodynamic instability or clinical evidence of tension pneumothorax, immediate abdominal de¯ation and chest tube decompression are indicated prior to chest radiograph. Further management depends on haemodynamic status. If the patient remains stable the abdomen may be insu‚ated and the procedure continued. Small pneumothoraces detected at the end of surgery and not associated with haemodynamic compromise may be treated conservatively. CO2 in the pleural cavity is rapidly resorbed following de¯ation of the abdomen, obviating the need for chest tube placement. Pneumomediastinum and pneumopericardium have also been reported during laparoscopic procedures. Hasel111 reports three cases of extravasation of CO2 during laparoscopic cholecystectomy resulting in subcutaneous emphysema, associated with pneumomediastinum, pneumothorax and ocular emphysema, all of which resolved spontaneously over 24 hours. High IAPs during insu‚ation may have contributed to these complications. Management depends on the degree of haemodynamic compromise that results. De¯ation of the pneumoperitoneum and close observation is adequate in many patients.107 Gas embolism Serious adverse intra-operative events attributed to gas embolism during laparoscopic procedures are widely reported.112,113 Venous CO2 embolism in these cases was associated with profound hypotension, cyanosis, and asystole after creation of the pneumoperitoneum. The proposed mechanisms of gas embolism include: inadvertent intravenous placement of the Veress needle, passage of CO2 into abdominal wall and peritoneal vessels during insu‚ation, or into open vessels on the liver surface during gallbladder dissection. Signs and severity of e€ects of CO2 embolism are variable and may include hypotension with cardiovascular collapse, hypoxaemia, detection of a `mill-wheel' murmur, and an associated decrease in ETCO2 due to reduction in pulmonary blood ¯ow. Paradoxical embolism through a probe-patent foramen ovale or an atrial septal defect114 may result in cerebral CO2 embolism. The reported incidence of gas embolism during laparoscopy varies with the sensitivity of the monitoring modality used. Using transoesophageal echocardiography Derouin and colleagues115 reported CO2 embolism occurring in 69% of patients during laparoscopic cholecystectomy but without signi®cant cardiopulmonary e€ects. In contrast, Wadhwa and colleagues, using precordial Doppler, did not observe any gas embolism in 100 patients undergoing gynaecological laparoscopic procedures.116 Appropriate monitoring and maintenance of a high index of suspicion can result in early detection and prevention of serious adverse sequelae from CO2 embolism. POST-OPERATIVE CONSIDERATIONS It has been suggested that laparoscopic surgery reduces post-operative pulmonary complications by avoiding the restrictive pattern of respiration that usually follows upper abdominal surgery. Although there have been few prospective randomized trials comparing laparoscopic and open cholecystectomy, many early studies100,117 report a lower incidence of pulmonary complications with the laparoscopic approach. Diaphragmatic dysfunction occurs following laparoscopic cholecystectomy and may last for up to 24 hours post-operatively.118,119 Visceral a€erents originating in the gallbladder

Anaesthesia for laparoscopic cholecystectomy 13

area or somatic a€erents arising from the abdominal wall, which exert an inhibitory action on phrenic discharge, may cause this diaphragmatic dysfunction.118 However, although spirometric measures of lung function are decreased following both procedures, compared with patients undergoing open cholecystectomy the laparoscopic approach was associated with 30±38% less impairment of post-operative pulmonary function, including FRC, forced expiratory volume in 1 second (FEV1), and vital capacity.120 In addition, global respiratory muscle strength is greater 24 and 48 hours after laparoscopic compared with open cholecystectomy as determined by mouth pressure measurements during maximal inspiratory and expiratory e€orts.121 Increased IAP during pneumoperitoneum has been reported to cause venous stasis which can increase the potential for deep vein thrombosis and pulmonary embolism (PE). The reported incidence of fatal PE following laparoscopic cholecystectomy (0.016%)122 is lower than that after open surgery (0.8%).123 Measures to reduce venous stasis, such as graduated elastic compression stockings, are indicated in the peri-operative period. Minimal tissue trauma with laparoscopic techniques, facilitating early post-operative ambulation, also reduces risk. Bile duct injuries are more common after laparoscopic compared with open cholecystectomy124 and tend to be more extensive and located higher in the duct system. Pain and jaundice associated with bile collections are typical presenting features in the postoperative period. MacFayden et al124 analysed a total of 114 005 laparoscopic cholecystectomies performed in the United States from 1989 to 1995. Major bile duct injuries occurred in 561 patients (0.5%). The common bile duct/common hepatic duct were most frequently injured (61.8%), and the majority of injuries required a surgical drainage procedure with either biliary-enteric anastomosis (41.8%) or T-tube placement (27.5%). Gasless laparoscopic cholecystectomy An abdominal wall-lift technique using a mechanical retractor has been introduced125 to avoid the adverse e€ects caused by CO2 insu‚ation and high IAP. With this method IAP can be maintained at 1±4 mmHg, and insu‚ation with only low volumes (2±6 litres) of CO2 is required. Koivusalo and colleagues,126,127 demonstrated minimal changes in haemodynamics, pulmonary and renal function and neuroendocrine responses during laparoscopic cholecystectomy with a combined abdominal wall lift and minimal CO2 insu‚ation method, compared with conventional insu‚ation. Recently a totally gasless laparoscopic technique, using a mechanical retractor to elevate the anterior abdominal wall by 10±15 cm, has been described.128 In a comparison of totally gasless laparoscopic cholecystectomy with conventional CO2 insu‚ation, the gasless method resulted in more stable cardiopulmonary function, higher urinary output, and better maintenance of renal oxygenation.39 Abdominal obesity and colonic distension limited the surgical view with the gasless technique and increased operation times. Currently gasless laparoscopic cholecystectomy is not widely practised as considerable experience is required to obtain an adequate view with the retractor method. The avoidance of high IAP and reduction of neuroendocrine stress responses with this technique may be particularly bene®cial in patients with borderline renal function and in ASA III and IV patients. Ambulatory laparoscopic cholecystectomy The minimally invasive nature of laparoscopic surgery facilitating earlier mobilization, and feeding, and reduced hospital stay, has extended the range of procedures that can be

14 I. E. Leonard and A. J. Cunningham

performed on a day-case basis to include laparoscopic cholecystectomy. Some centres report successful same-day discharge following laparoscopic cholecystectomy in 68 to 94% of patients.129,130 Cost containment has been the major impetus for the trend towards increased ambulatory surgery, and outpatient laparoscopic cholecystectomy may signi®cantly reduce hospital costs.131 Caution is advised, however, against overenthusiastic ambulatory laparoscopic cholecystectomy based on the logical, if unproven, assumption that early discharge will lead to occasional delays in diagnosis and management of post-operative complications. In a series of 506 patients undergoing this procedure, 7.5% experienced post-operative complications, 61% of which had not become evident by 24 hours.132 Concerns have also been raised regarding patient satisfaction with outpatient laparoscopic cholecystectomy. An Australian study133 reports that 30% of patients still had nausea on the ®rst post-operative day following outpatient laparoscopic cholecystectomy, and 21% of patients would have preferred an overnight hospital stay. In a series of patients discharged to a simulated home environment, Fleisher et al131 found that, although 94% of patients did not require any additional therapy for post-operative pain other than routine oral medications, 12% of patients experienced PONV necessitating parental anti-emetic therapy and only 29% of patients felt that they were ready to be discharged to home on the day of surgery. Further research is needed to elucidate determinants of patient preferences and the potential role of pre-operative education on patient satisfaction. Appropriate patient selection (Table 3), will minimize complications following outpatient laparoscopic cholecystectomy. Table 3. Ambulatory laparoscopic cholecystectomy. . ASA I±II patients . Appropriate social conditions . Uncomplicated surgery . Minimal post-operative analgesia requirements . No PONV

SUMMARY Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease. The minimal-access nature of the surgical insult results in less pain and less post-operative ileus, facilitating faster recovery, shorter hospital stay, and more rapid return to normal activities. General anaesthesia and controlled ventilation comprise the accepted anaesthetic technique to control arterial carbon dioxide tension. There is no conclusive evidence demonstrating a signi®cant e€ect of N2O on surgical conditions during laparoscopic cholecystectomy or on the incidence of post-operative emesis. Opioids remain an important component of a balanced anaesthetic technique for laparoscopic cholecystectomy. A multimodal analgesic regimen combining opioids, non-steroidal antiin¯ammatory drugs (NSAIDs) and local anaesthetic in®ltration may be the most e€ective approach, allowing a reduction of opioid dose and thereby minimizing sidee€ects. Post-operative nausea and vomiting is common and requires appropriate prophylaxis and treatment.

Anaesthesia for laparoscopic cholecystectomy 15

Practice points . laparoscopic cholecystectomy is increasingly being performed in older patients with co-existing cardiopulmonary disease. Careful peri-operative monitoring of ASA III and IV patients is advised during peritoneal insu‚ation . intra-operative complications may arise due to the physiological changes associated with patient positioning and pneumoperitoneum creation. Traumatic injuries during blind trocar insertion, extraperitoneal insu‚ation, pneumothorax, and gas embolism are additional risks . a multimodal analgesic regimen combining opioids, non-steroidal antiin¯ammatory drugs, and local anaesthetic in®ltration is most e€ective, allowing reduction of opioid dose and minimizing side-e€ects . the minimal-access nature of the surgical insult results in less pain and less postoperative ileus, facilitating faster recovery, shorter hospital stay and more rapid return to normal activities. Careful patient selection for ambulatory laparoscopic cholecystectomy is necessary as early discharge may lead to occasional delays in diagnosis and management of post-operative complications

The physiological changes associated with patient positioning and pneumoperitoneum creation may cause signi®cant cardiorespiratory compromise, particularly in ASA III±IV patients, and careful monitoring during CO2 insu‚ation is recommended. Intraoperative complications may also arise due to traumatic injuries sustained during blind trocar insertion, CO2 embolism, extraperitoneal insu‚ation and surgical emphysema, pneumothorax and pneumomediastinum. Increasingly, laparoscopic cholecystectomy is being performed in pregnancy, morbid obesity, and in older patients with co-existing cardiopulmonary disease ± presenting signi®cant challenges in anaesthetic management. Appropriate monitoring and the maintenance of a high index of suspicion can result in early diagnosis of complications and prevent serious adverse sequelae.

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