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therapeutic side, BL in acute acalculous cholecystitis allows for simultaneous placement of a drainage catheter [5]. Likewise, BL can be used for placement, reassessment, and/or revision of gastrostomy tubes and peritoneal dialysis catheters [6].
BL is particularly useful in acute mesenteric ischemia (AMI). In this diagnostically challenging disease, the exam is unreliable, there are no denitive laboratory
values, and computed tomography (CT) scans can be inconclusive. Bergamini etal.
recently demonstrated that BL allowed them to avoid unnecessary laparotomies in
post-cardiac surgery ICU patients with AMI and nonocclusive mesenteric ischemia [7].
R. Bradshaw et al.
2 Benefits
BL can be used to conrm or rule out the presence of intra-abdominal pathologies
in patients who are too unstable for transport to radiology for diagnostic imaging.
Additionally, CT is unreliable for some conditions, namely, diaphragmatic injuries
[8, 9], hollow viscus injuries [10, 11], or intestinal ischemia in the absence of perfo-
ration; in these cases, laparoscopy may be necessary to make a diagnosis. As noted
by Rehm, “the abdomen is a notorious black hole” for these problems [5].
BL not only reduces the incidence of nontherapeutic laparotomies [12] but also
reduces morbidity [13, 14]. The morbidity from a negative laparotomy varies
between 5 and 43% [15]. Possible short-term complications include wound infection [16], skin/fascial dehiscence, evisceration, or prolonged ileus. Long-term complications including incisional hernia or adhesive small bowel obstruction are
common [17, 18].
BL can help avoid a positive, but futile, laparotomy in patients with an intraabdominal catastrophe. For example, Peris etal. reported diffuse intestinal hypoperfusion in 2 of 32 patients in whom diagnostic BL was performed [3]. The BLs
avoided what is colloquially known as a “peek and shriek” type of operation—a
laparotomy in which most bowel is noted to be nonviable and the patient is closed
without further intervention. Gagne et al. similarly found extensive intestinal
necrosis in 3 of 19 patients. This allowed them to have informed discussions with
the family and avoid further futile interventions [19].
BL is often more expeditious than a trip to the OR, as it can be completed and a
diagnosis obtained very quickly. Often, all that is necessary is a single 5 or 10mm
trocar for the camera (Table1). Additional trocars can be added as needed.
Gagne etal. demonstrated the feasibility of a mini-BL using a 3mm camera and
instruments [19]. These mini-laparoscopies took an average of 21 min [19].
Traditional BL procedure times have been reported between 20 and 40min [3, 20,
21]. Compared to diagnostic peritoneal lavage in the ICU, BL took only 5min lon-
ger: 14min vs. 19min [22].
BL can be performed with local anesthesia (e.g., lidocaine or bupivacaine), conscious sedation (e.g., intravenous midazolam, fentanyl, or propofol), or both, avoiding the need for and risks of general anesthesia. Successful cases performed in ICU
patients without the use of endotracheal intubation have also been reported [19, 20].
Role ofBedside Laparoscopy
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Table 1 Suggested surgical equipment
Minimum required equipment
Laparoscopic tower (insufation, light source, camera, monitor)
5 or 10mm laparoscope
Two trocars (Hasson or Veress needle)
Blunt laparoscopic grasper
Basic laparoscopic surgical tray (scalpel, sponges, forceps)
Fascial suture and needle driver
Closing equipment (skin glue and/or subcuticular suture)
Sterile drapes, prep
Suggested additional equipment
Additional laparoscopic instruments (ultrasonic dissector, multiple graspers)
Laparoscopic suction/irrigation
Additional trocars
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The series reported by Gagne etal. did not require anesthesia providers and were
completed with a surgeon and one assistant. Laparoscopy can be done with carbon
dioxide or nitrous oxide insufation to avoid hypercapnia or acidosis [19]. In most
cases, insufation to pressures of 8–10mm Hg are sufcient, avoiding potential
cardiovascular effects.
Early reports of diagnostic laparoscopy were performed only in patients without
previous surgery [1]. Subsequent reports found prior abdominal surgery to not be a
contraindication for BL and a recent laparotomy is not an absolute contraindication.
Pecoraro etal. reported a series in which 7 of 11 patients had a recent laparotomy [20].
3 Potential Disadvantages
There are some drawbacks to BL.For example, transportation of the laparoscopic
equipment to the bedside may be inconvenient, may be cumbersome, and may result
in excessive wear/tear. Unfamiliarity, poor lighting, and lack of standard procedural
instruments may decrease the efcacy of BL. Should additional equipment be
required, it may not be readily available at the bedside. The ICU or ER bed is also
wider than an OR bed. Moving the ICU or ER bed into different positions may not
be possible, making some surgical movements more difcult or less precise than
they would be in the OR.Lastly, identication or denitive management of an intraabdominal pathology may still require a trip to the OR.
BL has further disadvantages when compared to traditional laparotomy. For
instance, laparoscopy is inherently limited in its evaluation of retroperitoneal structures. There are also patients who have a hostile abdomen not well suited to laparoscopy. Prior abdominal surgery, while not a contraindication to laparoscopy, may
cause adhesive disease that makes laparoscopy more difcult. Pregnancy may limit
intra-abdominal volume and therefore working space. Abdominal wall compliance
may be limited by carcinomatosis, tuberculous peritonitis [23], or “cocoon abdomen” secondary to sclerosing peritonitis. Together, these factors must be fully considered prior to utilization of BL.
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R. Bradshaw et al.
There are risks inherent to laparoscopy as a modality, whether at the bedside or
in the OR.Chief among these are the physiologic changes secondary to abdominal
insufation and its effect on multiple systems, including cardiovascular (e.g.,
decreased preload, increased central venous pressure, increased myocardial oxygen
consumption, possible hyper-/hypotension, arrhythmia, and myocardial infarction),
pulmonary (e.g., decreased lung volume, decreased compliance, potential for hypercarbia) [24], renal (e.g., decreased perfusion and urine output) [25], and neurologic
(e.g., increased intracranial pressure) [26]. Additionally, intraoperative decreased
venous return from the lower extremities may lead to deep vein thrombosis and
pulmonary embolism [27]. Entering the abdomen is not without risk and may lead
to inadvertent hollow viscus injury, vascular injury to epigastric vessels and major
intra-abdominal vessels (e.g., the aorta or inferior vena cava), or solid organ
injury [5].
4 Conclusions andFuture Directions
Current data has been unable to establish if BL may reduce overall cost of care. It
seems likely the reduction of required equipment, personnel, and time would signicantly reduce the estimated $36–37 USD per minute costs associated with more
traditional exploratory laparotomy [28]. More research is needed to quantify the
nancial benet of BL.
BL is a useful tool in the surgeon’s armamentarium for the diagnosis of intraabdominal pathology. It can be used in a wide range of patients and is especially
useful for the unstable patient who would otherwise require a potentially morbid
negative laparotomy. BL is efcient, requires minimal equipment and ancillary
staff, and may reduce the cost of care.
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7. Bergamini C, Alemanno G, Giordano A, Pantalone D, Fontani G, Di Bella AM, etal. The role
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J. 2020;71(2):231–7. https://doi.org/10.1177/0846537119888375.
9. İlhan M, Bulakçı M, Bademler S, Gök AF, Azamat İF, Ertekin C.The diagnostic efcacy of
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2015;21(6):484–90. https://doi.org/10.5505/tjtes.2015.94389.
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abdominal trauma with computed tomography. World J Surg. 2013;37(1):123–6. https://doi.
org/10.1007/s00268- 012- 1798- 3.
11. Mothes H, Mueller-Mau V, Lehmkuhl L, Lehmann T, Settmacher U, Teichgräber U,
et al. The role of computed tomography in the diagnostic pathway of acute mesenteric
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org/10.1177/0284185120905086.
12. Cocco AM, Bhagvan S, Boufer C, Hsu J.Diagnostic laparoscopy in penetrating abdominal
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13. Xie M, Qi Q, Xu Y, Wang H, Ge S, Luo P. [Comparison of laparoscopic exploration and
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15. Schnüriger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D.Negative laparotomy in trauma: are we getting better? Am Surg. 2012;78(11):1219–23.
16. Durbin S, DeAngelis R, Peschman J, Milia D, Carver T, Dodgion C.Supercial surgical infections in operative abdominal trauma patients: a trauma quality improvement database analysis.
J Surg Res. 2019;243:496–502. https://doi.org/10.1016/j.jss.2019.06.101.
17. Hathaway E, Glaser J, Cardarelli C, Dunne J, Elster E, Safford S, etal. Exploratory laparotomy
for proximal vascular control in combat-related injuries. Mil Med. 2016;181(5 Suppl):247–52.
https://doi.org/10.7205/milmed- d- 15- 00155.
18. Hanna K, Asmar S, Ditillo M, Chehab M, Khurrum M, Bible L, etal. Readmission with major
abdominal complications after penetrating abdominal trauma. J Surg Res. 2021;257:69–78.
https://doi.org/10.1016/j.jss.2020.07.060.
19. Gagné DJ, Malay MB, Hogle NJ, Fowler DL. Bedside diagnostic minilaparoscopy in the
intensive care patient. Surgery. 2002;131(5):491–6. https://doi.org/10.1067/msy.2002.122607.
20. Pecoraro AP, Cacchione RN, Sayad P, Williams ME, Ferzli GS.The routine use of diagnostic laparoscopy in the intensive care unit. Surg Endosc. 2001;15(7):638–41. https://doi.
org/10.1007/s004640000371.
21. Jaramillo EJ, Treviño JM, Berghoff KR, Franklin ME Jr. Bedside diagnostic laparoscopy in the
intensive care unit: a 13-year experience. JSLS. 2006;10(2):155–9.
22. Walsh RM, Popovich MJ, Hoadley J.Bedside diagnostic laparoscopy and peritoneal lavage
in the intensive care unit. Surg Endosc. 1998;12(12):1405–9. https://doi.org/10.1007/
s004649900869.
23. Geis WP, Kim HC.Use of laparoscopy in the diagnosis and treatment of patients with surgical
abdominal sepsis. Surg Endosc. 1995;9(2):178–82. https://doi.org/10.1007/bf00191962.
24. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascular and ventilatory consequences of laparoscopic surgery. Circulation. 2017;135(7):700–10. https://doi.
org/10.1161/circulationaha.116.023262.
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25. Dunn MD, McDougall EM.Renal physiology. Laparoscopic considerations. Urol Clin North
Am. 2000;27(4):609–14. https://doi.org/10.1016/s0094- 0143(05)70110- 5.
26. Kamine TH, Papavassiliou E, Schneider BE.Effect of abdominal insufation for laparoscopy on intracranial pressure. JAMA Surg. 2014;149(4):380–2. https://doi.org/10.1001/
jamasurg.2013.3024.
27. Stein PD, Matta F, Sabra MJ.Pulmonary embolism and deep venous thrombosis following
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28. Childers CP, Maggard-Gibbons M.Understanding costs of care in the operating room. JAMA
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Anesthesia Considerations forMIS
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inEmergency andTrauma Surgery
HillaryPrince andMichaelW.Cripps
1 Introduction
The benets of minimally invasive surgery (MIS) have been well documented in
elective surgery cases. Today, MIS approaches are rapidly replacing open surgical
techniques as the standard of care, including several urgent and emergent operations; however, the minimally invasive approach to thoracic or abdominal pathology
can have a signicant, and potentially deleterious, effect on the patient’s physiology.
Regardless of the surgical approach, trauma and emergency general surgery
patients pose a great challenge to anesthesiologists; little may be known about the
patient’s baseline physiology and comorbidities, and the need for emergent intervention typically obviates a thorough preoperative workup. The move toward a
minimally invasive approach in these patients adds additional layers of complexity
that must be considered, including intraoperative decompensation, and the anesthetic plan must afford preparation for such an event. Careful planning and communication between the anesthesia and surgical team are essential to the safety of
the patient and to providing the best chance at successful completion of a minimally
invasive approach.
H. Prince
Department of Surgery, University of Texas Southwestern Medical Center at Dallas,
Dallas, TX, USA
e-mail: hillary.prince@utsouthwestern.edu
M. W. Cripps (*)
Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA
e-mail: michael.cripps@cuanschutz.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_27
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H. Prince and M. W. Cripps
2 Decision-Making forUsing MIS intheEmergency
General Surgery andTrauma Setting
The general principles of resuscitation of any trauma or emergency surgery patient
must always be followed. Conrmation of a secure airway, reversal of hypoxia,
management of hemorrhagic shock or sepsis, correction of acidosis or coagulopathy, and maintenance of normothermia must be prioritized.
2.1 Emergency General Surgery
The range of pathologies with which an emergency general surgery patient may
present is important to appreciate, as is the spectrum of severity of illness. This large
spectrum of disease type and inammation combined with various surgical
approaches can have a signicant impact on anesthesia planning.
Acute appendicitis and cholecystitis account for an extremely large proportion of
emergency general surgery operations. For many patients with early disease, there
is a minimal inammatory response, and the operations are very straightforward,
with the patients being discharged to home from the recovery unit. However, there
is increasing data codifying the severity of illness in these two common operations
that show how the inammatory sepctrum can effect critically ill and septic patients.
Although intuitive, there is now clear data that demonstrates that increased severity
of inammation has signicant effect on time in the OR, hospital length of stay,
conversion to open, and complications [1].
Madni etal. demonstrated that patients with high-grade cholecystitis (Parkland
Grading Scale 4 or 5) have signicantly increased OR time and risk of conversion
to open [1]. This grading of severity can be done early in the operation and can
assist in anesthesia planning.
Open operative approaches have been the main interventional modality for emergency general surgery. However, there is increasing use of laparoscopy in other
emergency general surgery cases, such as perforated peptic ulcer disease and diverticulitis. These disease processes also have signicant spectrum of severity; historically, only those patients with minimal to no physiologic derangements would
undergo laparoscopic repair. However, with increasing data suggesting improved
outcomes in these patients with less invasive approaches, and the increased comfort
level of surgeons utilizing minimally invasive techniques, a trend toward greater use
of laparoscopy in more severely ill patients is to be expected [2].
Similarly, patients with bowel obstruction can present quite variably, from
single- band adhesive disease to segments of necrotic bowel. Like the above descriptions, these patients will have diametrically opposite physiologic responses that
must be taken into consideration. Specic considerations in these patients include
increased abdominal pressure resulting from dilated bowel that can become signicantly increased during insufation; this increased abdominal pressure can have an
untoward effect on tidal volume and peak airway pressures. Additionally, if there is
a closed-loop obstruction that is reduced, there can be an increase in inammatory
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cytokines resulting in altered physiology. Careful observation of the progress of the
operation and communication with the operative team is critical.
For the septic patient in need of operative intervention, initial management
should focus on Surviving Sepsis guidelines, with a focus on the Hour-1 Bundle of
Care Elements—obtaining a lactate level and blood/urine cultures, administering
broad-spectrum antibiotics, crystalloid resuscitation of 30mL/kg for hypotension
(mean arterial pressure [MAP] <65) or lactate >4, and addition of vasopressors if
hypotension is refractory [3]. The importance of early recognition and initiation of
therapy cannot be understated; for each hour that antibiotic administration is
delayed, for example, the mortality increases by 3–6% [4]. Achieving source control with surgical intervention, while taking into account the hemodynamic instability of the patient, often cannot be delayed. It is important to note that this instability
does not necessarily preclude a minimally invasive approach.
With all abdominal emergency general surgery cases, there is a potential for conversion to an open operation. Fortunately, conversion to an open procedure in the
abdomen should have no effect on positioning of the patient, and any physiologic
effect of the pneumoperitoneum is immediately resolved on opening the abdomen.
2.2 Trauma Surgery
Trauma patients who present in hemorrhagic shock can pose a signicant problem
to all providers, as the body’s compensatory mechanisms can often mask signicant
volume loss. This pattern of physiologic compensation is used to dene the classes
of shock, listed in Table1.
Table 1 Classes of shock
Classes of shock
Class I <15% No drop in BP
Class II 15–30%
Class III 30–40%
Class IV >40%
Total blood volume lost (%)
Clinical presentation
No or slight ↓PP
No to slight ↑HR
Mental status: normal to slightly anxious
Normal to ↓BP
↓PP
↑HR
↑RR
Mental status: mildly anxious
↓BP
↓↓PP
↑↑HR
↑↑RR
Mental status: anxious, confused
↓↓BP
↓↓PP
↑↑↑HR
↑↑↑RR
Mental status: lethargic, confused
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H. Prince and M. W. Cripps
The response to transfusion can provide useful clinical information, as a patient
whose hemodynamics respond appropriately to the volume of blood given likely
have tamponaded the source of bleeding or are bleeding at a slower rate, whereas
transient responders or nonresponders have ongoing blood loss, potentially with an
element of coagulopathy.
The selection of patients for a minimally invasive approach will depend on the
patient’s physiologic parameters at the time that intervention is required as well as
the pattern of injury and the surgeon’s comfort level with such techniques. If a minimally invasive approach is selected, the anesthesia team must be prepared for any
number of clinical scenarios in which the patient may decompensate during the
operation or at any point during the perioperative period.
Appropriate vascular access must be in place prior to induction. For the injured
patient, two peripheral large-bore IVs (at least 18G) are usually placed in the trauma
bay; if unable to do so, or if vasopressor or inotrope use is anticipated, then intraosseous or central venous access should be established. The patient’s injury pattern
can play a role in site selection for central venous catheters (CVCs), and the subclavian vein may be preferrable for its accessibility without ultrasound guidance or in
the presence of a pelvic injury or cervical collar.
In patients with signicant traumatic injuries or sepsis, an arterial line is essential
not only for hemodynamic monitoring; it also allows for frequent blood sampling,
including serial ABGs.
Injured patients who are bleeding often invoke a response among care providers
to try and give as much uids as possible in order to achieve a more normal blood
pressure; however, this can result in an opposite and untoward effect of causing
increasing hemorrhage. Damage control resuscitation is a strategy whereby a patient
is given limited to no crystalloids, but rather blood component therapy, to provide
oxygen-carrying capacity and coagulation factors. Nested within this strategy is a
lower mean arterial pressure (MAP) goal. This restrictive strategy for resuscitation,
initially employed in the World War I era [5], is aimed toward preserving local vasoconstriction that decreases hydrostatic pressure on tenuous clots that, if disrupted,
would lead to increased hemorrhage. This subsequent hemorrhage would lead to
increased uid resuscitation and worsening coagulopathy, and the cycle would continue. There have been multiple retrospective analyses [6] using hypotensive resuscitation strategies, each showing either improved survival or decreased complications.
There have been ve prospective randomized controlled trials. One showed
improved survival for all, another showed improved survival in a post hoc analysis
of blunt trauma patients, and another showed decreased incidence of AKI and a
shorter length of stay. Potentially more importantly, none showed harm for hypotensive resuscitation. As a result, the 2013 European Guidelines recommend a target
systolic blood pressure (SBP) of 80–90mmHg until major bleeding has been controlled in the initial phase following trauma without brain injury [7].
Whether or not this strategy could be used in minimally invasive operations for
injured patients has not currently been studied. Potential caveats and concerns
would revolve around the effect of insufation on a purposefully low preload, and
this may require a higher SBP prior to initiation of pneumoperitoneum. It is
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important to note that the practice of limiting crystalloid and using whole blood or
blood component therapy should be followed, regardless of the surgical
approach used.
Communication between the anesthesia and surgery teams is a key component of
the success of any surgery, but it becomes even more important when managing an
unstable patient. Any bleeding or gross contamination should be conveyed by the
surgeon to the anesthesia provider; the anesthesia team must keep the surgeon
informed of any persistent hemodynamic instability, acidosis, or hypothermia
despite adequate resuscitation that may lead to the decision to convert to an open
procedure or even a damage control approach.
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3 Positioning
Patient positioning inuences the anesthesia plan for the operation and can greatly
impact the patient’s physiology. In elective thoracic or retroperitoneal operations,
the patient will be in lateral decubitus position. The airway and lines must be carefully attended to with any repositioning. Bony prominences must be padded to prevent pressure injuries, and care must be taken to avoid any excessive abduction or
extension to protect from possible nerve injury.
In emergency surgery, the need for rapid conversion to an open operation must
be taken into consideration. The same principles apply for protection against pressure injuries and excessive body positioning, but a plan for conversion must be in
place. The surgeon may utilize rolls or a beanbag to stabilize the patient in a modied lateral decubitus position and airplane the OR table to provide improved body
positioning that can be reverted to near decubitus position, should the operation
require conversion. Straps must be placed at multiple points along the length of the
patient to secure him/her to the operating table; this can both assist in initial positioning and improve safety during the case, as the surgeon will ask the anesthesia
team for several table adjustments. An axillary roll should be positioned beneath the
dependent axilla in order to decrease the pressure load on the inferior shoulder. The
superior arm is extended in order to displace the scapula from the operative eld,
while the inferior arm is either exed to no more than 90 degrees or extended out
onto a padded arm board.
In the event of a conversion from video-assisted thoracic surgery (VATS) to a
thoracotomy, the patient’s position should remain the same; however, the patient
may need to be repositioned supine, depending on clinical circumstances and surgeon preference. If an emergent repositioning is required, the airway and endotracheal tube must be protected; if there is any concern for tube malposition after
movement, a quick bronchoscopy can be performed to evaluate. For an intraabdominal approach, the patient should be supine with legs either at on the table
or in stirrups if a colorectal anastomosis or sigmoidoscopy/colonoscopy is planned.
Adjustable stirrups, such as yellowns, must be used to allow the surgeon access to
both the abdominal and perineal elds. Conversion from laparoscopy to an open
procedure should not require must adjustment, if any, to the patient’s position.
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