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48
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.24 Intracorporeal suturing and knot tying—ending a running suture line.—Standard knot tying technique (see Fig. 2.3.17 ).
a Once the suture line is complete, the next to last stitch is left as a loose
loop that will be used as a free end to accomplish an intracorporeal
knot as previously described.
b The knot is pulled tight making sure to hold the suture and not the
needle.
a
b
Fig. 2.3.25 Intracorporeal suturing and knot tying—ending a running su-
ture line with a “Fisherman’s” knot.
a After the last suture is placed, pull only enough suture through so the
last loop (blue) is loose. Position this loop toward the surgeon and over
the tail with the needle (red) using the left-handed instrument. Next,
use the right-handed instrument to reach over this loop and grasp the
tail with the needle near its exit point from the tissue.
b Pull the tail with the needle taut and release the loop. This will create a
new loop (red) while tightening the original loop (blue). Pull the tail
taut using both instruments in a “hand over hand” fashion. Make sure
the end of the tail (with the needle here) is not pulled through the loop
until the final throw.
Fig. 2.3.c−h 컄
Staplers and Fibrin Glue
49
Fig. 2.3.25 c Use the left-handed instrument to position the new loop
toward the surgeon and over the tail, which is grasped near the wound
with the right-handed instrument in exactly the same fashion as in a.
d Pull the tail taut in a “hand over hand” fashion. Finishing with the left-
handed instrument to create a half-hitch knot and a new loop.
Fig. 2.3.25 e When pulled taut, the loop will tighten to create a half
hitch knot, while forming the next loop in the sequence. If the knot
doesn’t slide down, use the right-handed instrument to push it while
maintaining upward tension with the left-handed instrument.
f Position the newest loop towards the surgeon, grasp the tail near the
knot, and pull it taut. The number of times this step is repeated depends on the suture type and clinical situation.
Fig. 2.3.g−h 컄
50
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.25 g The knot is completed and “locked” by pulling the end of
the tail through the newest loop, releasing the loop, and pulling the tail
taut.
Staplers and Fibrin Glue
Staplers
The use of stapling devices for transecting tissues, and closing
and anastomosing hollow viscera has been well established.
The development of new designs continues to accomodate the
minimally invasive approach to an ever expanding list of procecures. Also, the advent of stapling devices to create vascular
anastomoses will certainlay make the list even longer. Details of
specific techniques are beyond the scope of this chapter, and we
will focus on a more general discussion.
Linear staplers with and without cutting ability are available for
minimally invasive approaches. Often times it is useful to use
their “open” ancestors and/or the circular end-to-end anastomosing staplers in a laparoscopically assisted fashion. During
thoracoscopy, it is possible to use standard and endoscopic stapling instruments as there is no need to maintain an airtight
seal in the rigid thoracic cavity.
Endoscopic linear staplers with a cutting knife (GIA™) place a
triple row of staggered, B-shaped, titanium staples on each side
of the blade, which will divide the tissue between the staple
lines. Linear staplers without a knife (TA™) place a triple row of
staggered, B-shaped, titanium staples that close an opening
without dividing any tissues. The staple height appropriate for
the thickness of a given tissue can be varied by using the exchangeable cartridges available. Staple heights vary slightly by
manufacturer, but are usually about 2.5 mm, 3.5 mm, and
4.5 mm for thin, medium, and thick tissue respectively. The
color of the cartridges are also fairly standard, and are white
(2.5 mm), blue (3.5 mm), and green (4.5 mm). A strip of ePTFE
has been developed as a long pledget for the linear staple lines,
and is available for both open and endoscopic linear staplers.
The endoscopically designed instruments have shafts that rotate 360 °, and can roticulate along the longitudinal axis as well.
Circular staplers (EEA™) can be used in an end-to-end or end-
h Cut the tail near the knot when complete.
to-side fashion. They create two concentric, staggered rows of
B-shaped, titanium staples, and contain a knife to excise the
tissue along the inside of these circular rows of staples. For rectal and lower sigmoid anastomoses, the anvil can be placed in
the proximal bowel through a small abdominal wall incision
(accomplished by slightly enlarging a trocar site), and the shaft
of the instrument with the cartridge passed through the anus.
More proximal bowel and esophageal anastomoses are accomplished in a laparoscopically assisted fashion, or by placing the
handle of the EEA™ through an enlarged port site.
Fibrin Glue
Fibrin glue is composed of a mixture of fibrinogen and thrombin. The fibrinogen is available in the form of fresh frozen
plasma, cryoprecipitate, or using the patient’s own serum. The
thrombin is a liquid that is commercially available in vials.
Within a few seconds of mixing the two substances, they form a
thick clot that can be used for hemostasis, plugging defects, and
reinforcing anastomoses. Its elastic nature makes it well suited
for minimally invasive surgery. The components of fibrin glue
are applied with two syringes through either a single or double
lumen catheter. If a single lumen catheter is used, the components should be injected more rapidly to prevent coagulation
within the catheter.
Fibrin glue has been use d to seal perforated ulcers (Fig. 2.3.26),
biliary leaks, and lymphatic leaks. Filling nonparasitic hepatic
cysts has been described as well. It has also been used for hemostasis over oozing raw surfaces such as the liver or retroperitoneum, for uterine defects after myomectomy, and after proximal gastric seromyotomy; it may also prevent nerve regeneration in the latter situation. Additionally, it has been used to prevent adhesions from serosal abrasions of bowel and the raw surfaces of fallopian tubes and ovaries. Finally, fibrin glue can be
used to reinforce anastomoses. It should be noted that fibrin
Goals and Methods
51
Fig. 2.3.26 Fibrin glue—sealing a perforated peptic ulcer.
a Fibrin glue is placed with a needle at varying depths surrounding the
perforation.
glue should not be used as a substitute for improperly placed
sutures or staples. Broad-based clinical application of fibrin
glue in minimally invasive surgery will depend on the repro-
ducibility of favorable results in the laboratory and clinically.
Bibliography
Adams JB. New Laparoscopic Suturing Device: Initial Experience. Urology
1995; 46(2):242−245.
Laws HL. Suturing Techniques in Principles of Laparoscopic Surgery. In
Arruegui ME, Fitzgibbons RJ, Karkhouda N, McKernen JB, Reich H, eds.,
pp. 35−45 Springer-Verlag 1995.
2.4 Gasless Laparoscopy
b The top of the perforation is then covered to completely seal the de-
fect.
Pennings JL, Kenyon T, Swanstrom L. The Knit Stitch. Surgical Endoscopy
1995; 9:537−540.
Soper NJ, Hunter JG. Suturing and Knot Tying in Laparoscopy. In Surgical
Clinics of North America Oct. 1992; 72(5):1139−1152.
Steichen FM et al. Current Concepts in Operative Surgery Using Videoendos-
copically Assisted Mechanical-Suture Techniques. In Arruegui ME, Fitzgibbons RJ, Katkhouda N, McKernan JB, Reich H, eds. Principles of Laparoscopic Surgery, pp. 46−65. Springer-Verlag 1995.
Szabo Z, Hunter J, Berci G, Sackier J, Cuschieri B. Analysis of surgical move-
ments during suturing in laparoscopy. Endoscopic surgery and allied technologies. 1994; 2(1):55−61.
V. Paolucci, A. Encke
Goals and Methods
The CO2pneumoperitoneum, standard in laparoscopic opera-
tions, causes problems by improving selected indications, influences anesthetic choices, and limits operative technique.
Rare but typical complications involve injury to intestinal loops
and vascular structures with the Veress needle, gas embolism
resulting from direct intravascular injection or diffusion of CO
and deep venous thrombosis due to the decrease in venous re-
turn blood flow. During laparoscopic procedures, hypercapnia is
a condition that, in combination with the increase in in-
traabdominal pressure, can lead to increased cardiopulmonary
risk in preexisting cardiac or pulmonary insufficiency. The result is that laparoscopic procedures are regarded as contraindicated in these patients.
Alternatives to the pneumoperitoneum in laparoscopic operations have occasionally been suggested. Sixteen systems that
permit laparoscopic surgery at low intraabdominal gas pressure
or completely dispense with the pneumoperitoneum have been
,
presented. The necessary exposure of the upper abdominal or-
2
gans is achieved by precise mechanical expansion of the
abdominal wall. In the following sections, we will describe the
four most popular systems in greater detail.
52
2.4 Gasless Laparoscopy
Laparolift
Laparoscopic instrumentation for gasless mechanical elevation
of the abdominal wall is commercially available throughout the
world (Laparolift, Origin, Menlo Park, CA, USA).
The essence of this instrumentation is an electrically operated
lifting arm (Laparolift), which is fixed to the operating table at
the required height and covered with sterile drapes. It can be
operated at the touch of a button, rotates, and can be extended
along its longitudinal axis.
The second part of the system consists of a spreadable retractor.
Its arms have a maximum length of 15 cm. The retractor must
be introduced into the abdominal cavity (Figs. 2.4.1−2.4.3). The
positioning of the retractor depends on the specific anatomy.
For laparoscopic cholecystectomy, it should be inserted in the
right upper quadrant.
Fig. 2.4.1 The fan-shaped abdominal wall retractor with closed blades is
inserted into the abdomen via a 1−2 cm incision.
Fig. 2.4.2 The blades are spread once the retractor is correctly oriented.
The positioning of the retractor device depends on the anatomic situation
and varies with the area of exposure.
Mouret’s Suspendeur Trois-X
After creating a low-pressure pneumoperitoneum (6−8 mmHg),
the two halves of a hexagonal metal frame (Figs. 2.4.4) are intro-
duced into the abdomen through a mini-laparotomy and
brought together. Traction is applied to the abdominal wall by
means of a metal arm attached to the operating table
(Fig. 2.4.5). The system is used in laparoscopic gallbladder
surgery, gynecologic procedures, and colon surgery.
Step-by-Step Procedure
1. Make a periumbilical incision of at least 1.5 cm.
2. Retract the subcutaneous fatty tissue down to the fascia.
3. Insert two S-shaped or Army-Navy retractors to expose the
aponeurosis.
4. Place two retaining sutures in the fascia.
5. Longitudinally incise the fascia.
6. Expose and open the peritoneum.
7. Insert a finger through the parietal peritoneum and palpate
for possible adhesions.
8. Under direct visual and digital control, introduce the abdomi-
nal wall retractor into the abdominal cavity. Position and fix
the arms of the retractor.
9. Fasten the retractor to a device above the abdominal wall and
raise it. This produces sufficient free space within the abdomen to perform the procedure.
10. Insert the laparoscope/camera into the same port. The laparoscopic operation can continue in the usual manner.
11. After completing the laparoscopic procedure, let down the
arm to relax the abdominal wall. Close and remove the retractor.
12. Close the elevated fascia with interrupted sutures.
13. Close the skin incision.
Fig. 2.4.3 A pliable rubber sleeve without a valve can be inserted as a
port to permit the use of conventional surgical instruments.
Hashimoto’s “Subcutaneous Wiring”
To lift the abdominal wall, two metal wires are placed through
the subcutaneous tissue of the anterior abdominal wall
(Fig. 2.4.6). Two strong sutures (Fig. 2.4.7) retain the subcutaneous metal wires. Traction is placed on the sutures by means
of a Kent retractor fixed to the operating table. This permits
elevation of the anterior abdominal wall over a wide area.
Operative Technique
53
Fig. 2.4.4 Mouret’s Suspendeur Troix-X.
Semm’s WISAP-ACE
The Abdominal Cavity Expander permits precise manual elevation of the abdominal wall enhanced by a limited pneumoperitoneum. The system consists of a metal rod with a double grip
that is introduced through a normal trocar sleeve. The intraabdominal end of the rod is unfolded and pulled against the
abdominal wall. An external seal fixes the unit in place and seals
the abdominal cavity. The purpose of Abdominal Cavity Ex-
pander is to maintain sufficient elevation of the abdominal wall,
even in situations involving sudden loss of intraabdominal gas
pressure.
Indications
Regardless of the system chosen, mechanical elevation and expansion of the abdominal cavitiy without the aid of a
pneumoperitoneum is possible in most laparoscopic opera-
tions. This technique is recommended for slender patients with
cardiopulmonary risk factors and for patients who have undergone previous operations with suspected adhesions.
Fig. 2.4.5 Mouret’s Suspendeur. Precise elevation of the lower abdomen
during a left hemicolectomy. An incision is made in the left midabdomen
to retrieve the specimen.
tage is particularly apparent in overweight patients and in
young patients with prominent abdominal musculature.
Anesthesia
In addition to general anesthesia, epidural or spinal anesthesia
is also possible.
Patient Positioning
At the beginning of the abdominal wall elevation maneuver, the
patient should lie supine on the operating table. After the retractors have been inserted and sufficient cavity enhancement
has been obtained, the patient is placed in the desired position.
Technique
As for open laparoscopy.
Contraindications
There are no contraindications to the use of gasless laparoscopy.
However, intraabdominal visualization is significantly more difficult to obtain than with a pneumoperitoneum. This disadvan-
Operative Technique
With any gasless system, the absence of a pneumoperitoneum
eliminates the need to use airtight trocars. A simple plastic
sleeve without a valve will be sufficient as a port for changing
instruments (Fig. 2.4.3).
54
2.5 Anesthesia in Videolaparoscopic and Thoracoscopic Surgery
Fig. 2.4.6 (18.1 Hashimoto) Hashimoto’s system of “subcutaneous wiring” for gasless laparoscopic cholecystectomy. After making a 4-mm inci-
sion at the level of the right anterior axillary line midway between the
costal arch and the iliac spine, a tunnel is opened through the subcutaneous tissue with a curved clamp. Then two metal wires are introduced
to surround a broad oval area of the abdominal wall.
The additional working trocars are placed in the usual manner.
The main port for the retractor and the laparoscope/camera can
usually be used for an additional instrument. The technique of
gasless laparoscopic cholecystectomy varies from the familiar
technique in that conventional surgical instruments (suction
cannula, gallbladder forceps, Overholt clamps, and Küttner dis-
sectors) can be used in addition to laparoscopic instruments.
The exposure of intraabdominal organs is generally sufficient,
although it is not comparable to the broad exposure provided by
the pneumoperitoneum. The transverse colon and the gastric
antrum occasionally represent an obstacle because they gradually increase in volume by intraluminal distension, particularly
in longer procedures. The disadvantages of the limited exposure
are compensated for by the possibility of using conventional
surgical instruments. Being able to grasp the gallbladder with
conventional forceps and bluntly dissect with a Küttner dissector speeds up the procedure.
Fig. 2.4.7 (19.1 Hashimoto) Using strong suture material (No. 5), sutures are placed along the subcutaneous wires and the abdominal wall is
elevated. Traction is maintained on the subcutaneous wires by suspending the suture tails on the Kent retractor.
Bibliography
Araki K, Namikawa K, Yamamoto H, Mizutani J, Doiguchi M, Arai M, Yamagu-
chi T, Uno K, Ido Y, Hayashi N, Ogawa M. Abdominal wall retraction during
laparoscopic cholecystectomy. World J. Surg. 1993; 17:105−108.
Hashimoto D. Advanced techniques in gasless laparoscopic surgery. Singa-
pore − New Jersey − London − Hong Kong: World Scientific Publishing;
1995.
Kitano S, Iso Y, Tomikawa M, Moriyama M, Sugimachi K. A prospective ran-
domized trial comparing pneumoperitoneum and U-shaped retractor
elevation for laparoscopic cholecystectomy. Surg. Endosc. 1993; 7:311−
314.
Smith RS, Organ CH. Gasless laparoscopy with conventional instruments.
The next phase in minimally invasive surgery.San Francisco: Norman Publishing; 1993.
2.5 Anesthesia in Videolaparoscopic Surgery
D. Kettler
Videolaparoscopic surgery has been accepted practice
throughout the world in the last few years. Here as with other
new procedures, anesthesiologists must ask themselves
whether their previous anesthetic techniques are applicable to
the new situation or whether the altered surgical setting dictates adaptive changes. The advent of laparoscopic procedures
with a CO
completely off guard. Anesthesiologists have been familiar with
intraabdominal CO
scopic diagnostic and therapeutic procedures. Videolaparoscopic surgery has become increasingly frequent in the daily
surgical routine.
pneumoperitoneum did not catch our specialty
2
insufflation since the introduction of pelvi-
2
Anesthesia
55
In contrast to the generally young and healthy women undergoing gynecological laparoscopic surgery, the patient population
in laparoscopic general surgery covers every age group, including patients over 90 years old. In these patients, the risk posed
by the pathophysiology is compounded by impaired organ
function (especially cardiac and respiratory function) due to ad-
vanced age.
Thus, careful preoperative risk assessment and preparation is
indicated with these patients. The anesthetic risk as usual is cal-
culated according to the classification system of the American
Society of Anesthesiologists (Table 2.5.1).
Several international studies have demonstrated that a higher
ASAclassificationcorrelateswithhigherperioperativemorbidity
and mortality. A few anesthetic risks are specific to laparoscopic
surgery.The CO
pneumoperitoneum produces an increase in in-
2
traabdominal pressure which, combined with head-down table
positioning used in lower pelvic procedures, will necessarily in-
terfere with the mechanics of breathing. Since the increased par-
tial CO
pressurein the blood also requiresincreasingtherespira-
2
toryminutevolume,patientswith circulatory disorders, and par-
ticularlythosepatientswithlimitedventilatorycapacityareatan
increased risk in videolaparoscopic surgery (Table 2.5.2).
Note: As with all preoperative planning, informing the patient
and a thorough history takes precedence over any laboratory
testing and examinations with clinical equipment. An informed
patient has reduced stress and needs less anxiolytics.
Table 2.5.1 Preoperative risk assessment according to the classification
system of the American Society of Anesthesiologists (ASA).
ASA I Normal healthy patient
ASA II Patient with one slight systemic disease
ASA III Patient with severe systemic disease(s) and limited
activity
ASA IV Patient with severe incapacitating systemic diseases
and permanent danger of death
ASA V Moribund patient not expected to survive 24 hours
(with or without surgery)
Table 2.5.2 Preoperative laboratory examinations for videolaparoscopic
surgery.
1. Basic examinations in
patients with healthy medical history (ASA I)
2. Additional examinations in
patients with enhanced cardiac and respiratory risk
(ASA II and ASA III)
Blood group
Hb/Hct
Electrolytes
Blood glucose
Creatinine, urea
Transaminases
Coagulation status
Thrombocyte count
Chest radiography, spirometry,
detailed examination of pulmonary function if necessary.
Blood gas analysis
Pathophysiology and Clinical Management of the CO
Insufflation of gases into the abdominal cavity improves the
surgeon’s view and makes surgery easier to perform. Although
other gases such as helium or nitrous oxide are occasionally
used as alternatives, CO
the world. It should be remembered that nitrous oxide itself is
not flammable, but it can combine with intestinal methane to
form an explosive mixture.
Carbon dioxide is available everywhere, inexpensive, nonflammable, and readily soluble. This last characteristic is an
advantage in case of a gas embolism. Intraabdominal gas insufflation, in conjunction with patient positioning, can be expected
to influence hemodynamics and ventilation. This is due primarily to the increase in intraabdominal pressure and CO
sorption across the peritoneum. With a CO
toneum, arterial carbon dioxide concentration is the sum of me-
tabolic production and absorption from the abdominal cavity.
Possible hemodynamic changes may include a decrease in car-
diac output. Here the reports from the literature are contra-
dictory. The anesthesiologist may assume that with intraperi-
toneal pressures up to 18−20 mmHg the effect on cardiac output will be minimal. Yet at the same time, the systemic vascular
resistance increases so that the mean arterial pressure generally
remains unchanged or may even rise. Positioning the patient
with the head up will decrease cardiac output; head-down posi-
tioning is hemodynamically better tolerated.
The only clinically relevant influence on ventilation occurs in
patients with a history of previous pulmonary disorders. These
patients have lower pH and higher pCO
with healthy lungs. Their respiratory tract peak pressures and
tidal volumes are also higher.
Based on studies in our department, we have reached the following conclusions with respect to quantification of carbon
dioxide resorption and necessary adaptation of ventilation.
Pneumoperitoneum
2
remains the gas of choice throughout
2
pneumoperi-
2
values than patients
2
ab-
2
쐌 Average CO2absorption was 37 ml/min (Fig. 2.5.1) and was
only minimally influenced by the level of intraabdominal
pressure.
쐌 Increasing the volume of CO
by 27% required an average in-
2
crease in ventilation of 24%. This also produced an increase
in absolute dead space, which together with the continuing
CO
pneumoperitoneum was responsible for the increasing
2
difference between end-tidal expired CO
쐌 The arterial CO
value increased slightly despite adjusted
2
and arterial CO2.
2
respiration. This means that the required ventilation is underestimated in spite of monitoring end-tidal CO
and that
2
slight hyperventilation is indicated.
Besides the changes in circulatory and respiratory function described above, complications observed in videolaparoscopic
surgery included pneumothorax and vasovagal episodes with
cardiac arrhythmias and occasionally accompanied by circulatory collapse.
Anesthesia
The general principles of anesthesia for abdominal surgery
apply here as well. On the evening before operation, the patient
is given appropriate sleeping medication orally, generally a benzodiazepine such as diazepam or midazolam. This medication is
administered again on the morning of surgery, so that the
patient arrives in the induction room sedated but responsive.
Anesthesia is started with oxygen per mask after blood pressure
and heart rate (ECG) have been checked. A hypnotic is administered intravenously in a dose tailored to the specific patient.
Today, barbiturates such as thiopental or methohexital are most
commonly used, or non-barbiturate hypnotics such as etomidate, and propofol. Which drug is used is left up to the discretion of the individual anesthesiologist who must decide on the
basis of the patient’s condition, the other drugs used in anesthesia, and additional anesthetic considerations such as the duration of the procedure, the stress it involves, and the presence of
56
resorbed (ml/min)
2
CO
Fig. 2.5.1 Average rate of CO2absorption during the first, second, third
and fourth hour of the CO
bar graph showing percentiles 0.5 and 95% of the data distribution, as
well as T-10 and 90%. The bar shows percentiles 25% and 75%, with median and average values.
2.5 Anesthesia in Videolaparoscopic and Thoracoscopic Surgery
60
40
n = 19 n = 4
n = 51 n = 40
20
0
12 34
Hours of CO2 pneumoperitoneum
pneumoperitoneum represented as a high-low
2
a recovery room, etc. The anesthesiologist inserts an endotracheal tube after the patient is asleep. Prior to intubation, an initial low dose of a non-polarizing muscle relaxant such as pancuronium or vecuronium is administered to prevent fasciculation of the muscles. This is then followed by a short-acting
depolarizing muscle relaxant such as succinylcholine.
Anesthesia is then generally continued as balanced anesthesia
consisting of hypnosis, analgesia, and muscle relaxation. Hypnosis and analgesia are provided by continuing ventilation with
a mixture of oxygen and nitrous oxide supplemented by low
concentrations of halogenated volatile anesthetics such as
halothane, enflurane, isoflurane, or sevoflurane. Problems are
associated with two aspects of using nitrous oxide in laparo-
scopic operations.
One problem is the distension of air-filled hollow spaces as
nitrous oxide diffuses into them. From our experience we know
that distended intestinal loops can seriously obstruct the field
of view in a laparoscopic fundoplication after about four hours.
A further consideration is the fact that nitrous oxide can also re-
tard the dissolving of carbon dioxide bubbles in the bloodstream. This increases both the possibility of a hemodynamically
significant gas embolism in the right heart and the risk of
smaller paradoxical embolisms with neurological or cardiologi-
cal sequelae. The risk of gas embolisms is increased when gas-
cooled lasers are used. Nitrous oxide should be avoided when it
is planned to use such instruments. Probably it is advisable to re-
frain from using nitrous oxide in laparoscopic procedures at all.
A good alternative to balanced anesthesia is total intravenous
anesthesia. Total intravenous anesthesia offers several advan-
tages over other forms of general anesthesia. The hypnotic pro-
pofol is an extremely short-acting drug that gives the anesthesiologist excellent control of anesthesia. There are also findings indicating that propofol may have a postoperative antiemetic effect. This drug used in combination with alfentanil, fentanyl, remifentanil or, in applicable cases, ketamine can thus provide a
near ideal combination for total intravenous anesthesia.
According to studies at our department, the average wake-up
period after discontinuing the propofol infusion was ten
minutes. Within a short time the patients were coherent and
could be moved back to the ward from the recovery room.
In modern anesthesia, analgesia is achieved through the use of
potent opioids such as fentanyl, alfentanil, sufentanil, or remifentanil. These drugs provide complete analgesia and thus
prevent most surgery-related stress reactions. The very new
opioid remifentanil, because of its rapid metabolic breakdown,
has an extremely short analgesic action. When used together
with propofol a good controllable total intravenous anesthesia
can be achieved. However, termination of administration of remifentanil immediately results in complete loss of analgesia
and requires subsequent pain treatment with other opioids.
Note: Since severe respiratory depression is a side effect of all
opioids, postoperative respiratory monitoring for a period of
several hours in a post-anesthesia care unit is essential even
after laparoscopic surgery.
The third component of balanced anesthesia, muscle relaxation,
can be achieved with various non-depolarizing muscle relaxants such as pancuronium, vecuronium, or atracurium. Prostigmin may antagonize the muscle relaxant effect of these drugs
on the motor end plate postoperatively.
Regional anesthesia is rarely an option for videolaparoscopic
surgery, since the anesthetized region must extend to at least to
segment Th4. Thus, a simultaneous sympathetic block that may
produce brachycardia is often unavoidable. Regional anesthesia
can represent an alternative in short procedures, particularly in
the minor pelvis, when minimal pneumoperitoneum and minimal head-down positioning are allowed, and in the absence of
surgically significant comorbidities (such as adhesions).
However, general anesthesia is preferable in most cases.
Monitoring
Patient monitoring follows recognized principles and techniques for monitoring metabolism, respiration, and cardiovascular function during anesthesia. The depth of anesthesia
and degree of relaxation are primarily assessed subjectively;
the latter may be quantified by methods such as train-of-four
testing (Table 2.5.3). The patient’s blood pressure is monitored
with blood pressure cuff and a stethoscope or automatically by
oscillometry. Heart rate and rhythm are monitored by ECG. In
addition to this, a central venous catheter is placed to measure
the venous pressure. This permits estimating cardiac filling.
However, venous pressure is significantly influenced by respiration and positioning. Measuring pulmonary artery pressure is
rarely necessary and is indicated only in high-risk patients.
Monitoring respiration is important, since respiration often has
to be adapted to changing intraoperative situations (Table 2.5.4).
In doing so, the anesthesiologist may utilize three separate
monitoring techniques: determining respiration parameters,
oxygen supply, and carbon dioxide elimination.
Sufficient ventilation is ensured by continuously measuring respiration pressures and volumes. With the increasing use of rebreathing techniques, both the oxygen content of the anesthetic
Postoperative Effects of Videolaparoscopic Surgery
57
Table 2.5.3 Extent of monitoring according to severity of patient’s condition.
System Simple pro-
cedures,
“healthy patients”
Cardiovascular Blood pressure
ECG monitor
Gas exchange Pulse oximetry Pulse oximetry
Ventilation Capnometry
Minute volume
Relaxation Nerve stimulator
(train of four), tactile
Table 2.5.4 Monitoring ventilation (paCO
Patient status Basic monitoring Additional monitoring
Young, without pulmonary disease
Older Capnometry Occasional venous
Pulmonary disorder
(e. g. chronic
obstructive lung
disease)
Capnometry —
Capnometry Serial blood gas analy-
“Sick patients”
Blood pressure
ECG, central venous pressure (Swan-Ganz catheter
where indicated)
Minute volume
Capnometry, blood gas
analysis,
transcutaneous CO
measurement
Nerve stimulator
(train of four), tactile
).
2
blood gas analysis
sis, or, alternatively
transcutaneous CO
measurement
2
2
gas mixtures and the arterial oxygen saturation in the organism
itself measured by means of pulse oximetry have become decisive safety criteria. Not less important, and absolutely essential
in a CO
pneumoperitoneum, is determining the end-tidal CO
2
content by capnometry.
Here, carbon dioxide in expired air is determined by infrared
analysis. Capnometry is included as a respiratory monitoring
function, because every CO
molecule comes from the patient
2
and thus provides information on the patient’s metabolic condi-
tion. With the use of a CO
amount of CO
in CO
concentration (the normal value is about 5.2% by volume,
2
is absorbed in addition. An increase or decrease
2
corresponding to 40 mmHg of arterial pCO
pneumoperitoneum an unknown
2
) is also an indica-
2
tion of hyper- or hypoventilation. It is important to clearly separate the inspiration and expiration measurements (Fig. 2.5.2).
Additional monitoring of partial CO
pressure in the blood can
2
be achieved from time to time by blood gas analysis. Venous
blood analyses are sufficient for estimating pCO
, thus eliminat-
2
ing the need for arterial puncture. We give special emphasis to
measuring CO
since this is essential to safe anesthesia in video-
2
laparoscopic surgery for the reasons described in the section on
the CO
pneumoperitoneum.
2
Postoperative Effects of Videolaparoscopic Surgery Compared with Conven-
tional Cholecystectomy
The primary objective of videolaparoscopic surgery is to
shorten and to smooth the postoperative phase and minimize
complications. Particularly in upper abdominal procedures,
lung function (vital capacity and functional residual capacity) is
Expiration Inspiration
III
II
I
Fig. 2.5.2 Typical course of CO2concentration in the breathing circuit
during the respiratory cycle.
impaired. This is the cause of subsequent postoperative hypoxemia.
For example following laparoscopic cholecystectomy, a
decrease of 27% in vital capacity was described as compared
with 46% following a conventional open procedure, which continued for 24 hours. In our own study of 56 patients of various
age groups, we found a significant decrease in vital capacity
(19%), from a preoperative value of 3.61 to 2.91 on postoperative
day one. On postoperative day two, this limitation had largely
disappeared. There was no evidence of a significant decrease in
functional residual capacity.
The most serious pulmonary complication following laparotomy is pneumonia. Studies at our facility revealed a 50%
radiographic incidence of pulmonary infiltrates which prolonged the duration of intensive care from eight to fifteen days.
Aside from surgical complications such as wound dehiscence,
anastomosis insufficiency, and sepsis, pneumonia is the most
frequent cause of postoperative morbidity. No published studies
2
are yet available on the incidence of pneumonia or of radiologically confirmed pulmonary changes following laparoscopic
cholecystectomy. However, the findings of examinations of lung
function suggest that the incidence of these morbidities may be
less than after conventional upper abdominal procedures.
These findings demonstrate a decisive advantage of laparoscopic cholecystectomy over the conventional open procedure
with respect to pulmonary complications. They imply that this
surgical method can be advantageous for patients with a history
of pulmonary disease.
No distinct differences between surgical methods were found
with respect to stress as measured by endocrinological and immunological parameters such as adrenaline, cortisol, IL-6, etc. in
blood. However, findings regarding the postoperative analgesic
requirements following laparoscopic cholecystectomy as opposed to open lower abdominal laparotomy may be of interest
(Fig. 2.5.3).
With patient-controlled analgesia, all patients are able to determine their own analgesic requirements. The pain intensity was
recorded every hour using a visual analog scale. Both the pain
level and opioid consumption were significantly lower after laparoscopic surgery.
In summary, the experienced anesthesiologist should bear in
mind that videolaparoscopic surgery involves a few special considerations, particularly regarding the CO
pneumoperitoneum,
2
that require appropriate action on the part of the anesthesiologist. Such action includes the elimination of high-risk patients,
compensatory hyperventilation, adapted monitoring (carbon
dioxide) of respiration and cardiovascular function, close post-