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310
Evaluation for Surgery
Determination of Cardiovascular
and Physiologic Risk Stratifi cation
The World Health Organization has broadly defi ned “elderly”
as any patient who is eligible for pension benefi ts. However,
given the varied standards across the world, anyone over the
age of 50 may be loosely defi ned as “elderly.” In the USA,
this defi nition is likely inappropriate, as the retirement age is
most commonly 65, and health risks do not substantially
increase in the sixth decade of life. Nevertheless, most
screening standards do change in the age group over 50.
After 50 it is recommended that all patients receive a preoperative chest X-ray and preoperative lab work. There is no
mandatory age indicating preoperative cardiovascular testing, rather this decision is the responsibility of the operating
surgeon.
Preoperative Risk Assessment
Appropriate preoperative risk assessment is the surgeon’s
responsibility when planning for surgery of any kind. This is
more important in the elderly patient due to the increased
incidence of signifi cant comorbidities associated with age.
The most recent American Heart Association guidelines [ 1 ]
delineate the recommended approach to risk stratifi cation.
Not surprisingly, an appropriate history and physical examination provides most of the information that will be needed
to identify risk factors.
The initial decision process should be aimed at identifying
any cardiac condition that would increase the risk of an adverse
cardiac event in the perioperative period. In general, any patient
with active cardiac disease such as unstable coronary syndrome, decompensated or worsening CHF, signifi cant arrhythmia, or signifi cant valvular disease should receive cardiology
evaluation and baseline cardiac testing (Table 28.1 ).
In the absence of serious comorbidities, a rough assess-
ment of exercise tolerance may be all that is needed to determine if further testing is needed (Table 28.2 ). Age as a sole
criterion defi nes only the need for EKG and chest X-ray for
patients over 50 years. Advanced age alone is not an indica-
tion for further cardiac testing. In patients with good exercise
tolerance (>4 METS) [ 2 ], further testing for any elective pro-
cedure is usually unnecessary. Of note, elective abdominal
operations are considered intermediate-risk operations.
Other signifi cant clinical risk factors include a history of
ischemic heart disease, compensated or prior CHF, diabetes
mellitus, renal insuffi ciency, and cerebrovascular disease,
which all represent comorbidities that may require preoperative evaluation.
J.I.S. Bleier and B.R. Kann
Table 28.1 Active cardiac conditions for which the patient should
undergo evaluation and treatment before non-cardiac surgery
Condition Examples
Unstable coronary
syndromes
Decompensated heart failure
(NYHA functional class IV,
worsening or new-onset HF)
Signifi cant arrhythmias High-grade AV block
Severe valvular disease Severe aortic stenosis (mean pressure
CCS Canadian Cardiovascular Society, HF heart failure, HR heart rate,
MI myocardial infarction, NYHA New York Heart Association
a
May include stable angina in patients who are unusually sedentary
b
The American College of Cardiology National Database Library
defi nes recent MI as more than 7 days but less than or equal to 1 month
(within 30 days)
Adapted from Fleisher LA, Beckman JA, Brown KA, Calkins H,
Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on
Perioperative Cardiovascular Evaluation and Care for Noncardiac
Surgery: Executive Summary: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 2002 Guidelines on
Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Developed in Collaboration With the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart
Rhythm Society, Society of Cardiovascular Anesthesiologists, Society
for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, and Society for Vascular Surgery. J Am Coll
Cardiol 2007 Oct 23;50(17):1707–1732. [
Unstable or severe angina (CCS class
III or IV)
Recent MI
Mobitz II AV block
Third-degree AV block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including
atrial fi brillation) with uncontrolled
ventricular rate (HR > 100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular
tachycardia
gradient greater than 40 mmHg, aortic
valve area <1.0 cm
Symptomatic mitral stenosis
(progressive dyspnea on exertion,
exertional presyncope, or HF)
a
b
2
, or symptomatic)
1 ] With permission
Exercise tolerance is an excellent overall assessment
of fi tness, and in the setting of good exercise tolerance,
even with multiple clinical risk factors described above,
often intermediate-risk surgery can be undertaken with
acceptable risk. Perioperative heart rate control with betablockade should be considered mandatory in anyone with
any of the above risk factors since this has been shown to
reduce cardiac morbidity and mortality [ 3 ].
When a patient has any of these other signifi cant comorbidities, a specifi c workup may be indicated as per the AHA
guidelines [ 2 ]:
Pulmonary Disease . The presence of restrictive or obstruc-
tive pulmonary disease signifi cantly increases the risk of
28 Laparoscopy in the Elderly Patient
311
Table 28.2 Estimated energy requirements for various activities
Metabolic
equivalent (MET) Activity
1 MET Eat, dress, use the toilet
Walk indoors around the house
Walk a block or 2 on level ground at 2–3 mph?
4 MET Do light housework (dusting, washing
dishes)
Climb a fl ight of stairs or walk up a hill?
Walk on level ground at 4 mph?
Run a short distance
Do heavy housework (scrubbing fl oors, lifting/
moving furniture)
Participate in moderate recreational activities
(golf, bowling, dancing, double tennis,
baseball or football catch)
>10 METS Participate in strenuous sports (swimming,
single tennis, football, basketball, skiing)
Adapted from Fleisher LA, Beckman JA, Brown KA, Calkins H,
Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on
Perioperative Cardiovascular Evaluation and Care for Noncardiac
Surgery: Executive Summary: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 2002 Guidelines on
Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Developed in Collaboration With the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart
Rhythm Society, Society of Cardiovascular Anesthesiologists, Society
for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, and Society for Vascular Surgery. J Am Coll
Cardiol 2007 Oct 23;50(17):1707–1732. [
1 ] With permission
and major vascular surgery, a hematocrit <28 % was associated
with an increased risk of perioperative ischemia and postoperative complications.
Laparoscopy in the Elderly: What Are the Outcomes?
As improvements in health care and advances in medicine
have led to an aging population, colorectal surgeons are now
required to evaluate and operate on increasingly older
patients. The use of a laparoscopic approach would seem to
be an attractive alternative to traditional open approaches in
this patient population in whom minimizing postoperative
complications and enhancing postoperative recovery are
likely to have signifi cant benefi t. A population-based study
of laparoscopic colorectal cancer surgery in the United
Kingdom from 2006 to 2008 showed that the use of laparoscopy for colorectal procedures increased from 10.0 % in
2006 to 28.4 % in 2008. Of 58,135 resections, 54.6 % were
inpatients greater than 70 years of age. Age did not have an
effect on whether laparoscopy was attempted; 18.5 % of
resections in patients older than 70 years were performed
laparoscopically, which was similar to the overall rate of
18.8 % in all patients [ 4 ].
Early Studies
perioperative pulmonary complications. In these cases,
preoperative pulmonary testing to determine volume and diffusion capacity, response to bronchodilators, and a baseline
blood gas will help guide postoperative therapy.
Diabetes Mellitus . This is the most common metabolic dis-
ease associated with advanced age and is often associated
with coronary disease. The presence of insulin-dependent
DM increases the risk of perioperative myocardial ischemia
and heart failure. Careful attention to glucose management
with insulin infusions and tight glycemic control has been
found to signifi cantly reduce postoperative wound infection
in CABG pts, and this paradigm can be applied to major
abdominal surgery.
Renal Failure . Renal failure is associated with an increased
risk of perioperative cardiac morbidity. In addition, preoperative levels of creatinine >2 mg/dl are associated with an
increased risk of postoperative renal failure, cardiac complications, and increased mortality.
Hematologic Disorders . Preoperative anemia can impose
cardiac stress, worsen ischemia, and exacerbate preexisting
CHF. In one study looking at patients undergoing prostate
Early in the experience with laparoscopic colorectal
surgery, initial reports sought to establish safety, in terms of
equivalency or improved morbidity and mortality, compared
with open procedures. In 1995, Peters and Fleshman
published the results of a prospective study describing the
outcomes of minimally invasive colectomy attempted in 103
patients greater than 65 years old, 78.6 % of which were able
to be completed laparoscopically. Complication rates were
no different in patients who underwent successful laparoscopic resection compared with those who required conversion to laparotomy. The length of stay was signifi cantly
lower in patients who underwent successful minimally invasive colectomy (5.3 vs. 8.1 days, p < 0.001) [ 5 ].
In 1996, Reissman and Wexner published the results of a
study looking at outcome in “older” patients, which they defi ned
as age greater than 60 years. Thirty-six “older” patients (mean
age 73) undergoing laparoscopic or laparoscopic- assisted
colorectal procedures were compared with 36 younger patients
(mean age 44). No differences were seen in rates of complications (11 % vs. 14 %), conversion (8 % vs. 11 %), length of ileus
(2.8 vs. 4.2 days), or hospital stay (5.2 vs. 6.5 days) [ 6 ].
More recently, a review of data from the Nationwide
Inpatient Sample (NIS) database for 2009 showed that
35.4 % of colorectal resections were performed laparoscopi-
7 ]. Controlling for a number of factors, including age,
cally [
312
J.I.S. Bleier and B.R. Kann
Table 28.3 Comparison of
outcomes for laparoscopic
colectomy in younger vs. older
patients
Author Year Age N
Reissman [ 6 ] 1996 <60 36 8 5.2 11 0
Delgado [
Senagore
22 ]
[
Sklow [
Chautard [
Akiyoshi
11 ]
[
Fiscon [
Roscio [
* p < 0.05
multivariate analysis showed improved short-term outcomes
in the laparoscopy group, as well as decreased length of stay
and lower cost.
Comparisons of Laparoscopic Outcomes in the Young vs. Elderly
A number of reports have shown equivalent short-term
outcomes in older patients when compared with
younger patients undergoing laparoscopic colorectal surgery.
Unfortunately, most of these are small case series or
case- control studies (Table 28.3 ).
Sklow et al. published a retrospective review of patients
greater than and less than 75 years of age undergoing laparoscopic colectomy who were case-matched with controls
undergoing open colectomy. Complication rates were similar
between the laparoscopy and open groups, and laparoscopy
was associated with a faster return of bowel function and less
narcotic usage postoperatively. Interestingly, faster postoperative recovery was seen with laparoscopic left colectomies
in the older group compared to the open group, while faster
recovery was seen with laparoscopic right colectomies in the
younger group compared with the open group [
Chautard et al. described a matched case-control study comparing 75 patients greater than 70 years old with 103 patients
less than 70 years old undergoing laparoscopic colorectal
surgery. While the older group had more frequent cardiopulmonary preoperative comorbidities (80 % vs. 33 %,
p < 0.001), the groups had similar operative time (244 ± 89
vs. 242 ± 80 min), complication rates (32 % vs. 26 %), and
hospital stay (11 ± 8 vs. 10 ± 9 days) [ 9 ].
8 ]. In 2008,
Conversion
rate (%)
>60 36 11 6.5 14 0
39 ] 2000 <70 70 11.4 5 ± 2 15.6 0
>70 59 16.9 6 ± 2 21.4 1.6
2003 <60 181 3.9 ± 5.9 10.5 0
>70 50 4.2 ± 3.0 16 0
8 ] 2003 <75 38 16 6.1 ± 0.4 29 0
>75 39 8 6.1 ± 0.3 31 2.6
9 ] 2008 <70 103 16 10 ± 9 27 0
>70 75 21 11 ± 8 32 0
2009 <75 228 0.4 % 15 13.6 0
>75 44 0 19 11.8 0
20 ] 2010 <75 50 4 9 8 0
>75 50 6 10 24* 0
10 ] 2011 <70 101 2 8.1 ± 2.8 3.8 0
>70 58 1.7 10.8 ± 6.6* 3.4 1.7
Hospital
stay (days)
Morbidity
(%)
Mortality
(%)
Roscio et al. reported a series of 159 consecutive patients
undergoing laparoscopic resection for colorectal cancer
grouped by age less than or greater than 70 years and found
no differences in terms of time to return of bowel function or
postoperative complications. Older patients in this study had
more comorbid conditions and had a signifi cantly longer
length of stay [
10 ].
Looking specifi cally at rectal cancer, Akiyoshi et al. compared 44 elderly patients greater than 75 years of age undergoing laparoscopic rectal resection (group A) with 228
patients less than 75 years old undergoing laparoscopic proctectomy (group B) and 43 patients greater than 75 years old
undergoing open rectal resection (Group C). While group A
had a higher ASA classifi cation than group B, the rate of
postoperative complications did not differ between the two
(13.6 % vs. 11.8 %). Complications were seen less frequently
in group A than in C (13.6 % vs. 25.6 %), though this did not
reach statistical signifi cance. Group A also demonstrated
faster return to fl atus (1.3 vs. 3.7 days, p < 0.001), shorter time
to liquid diet (2.2 vs. 7.0 days, p < 0.001), and a shorter
hospital stay (19 vs. 22 days, p = 0.002) [
11 ].
Comparisons of Laparoscopic vs. Open Outcomes in the Elderly
Similar to comparisons of laparoscopy in the young vs. the
elderly, most of the published data comparing laparoscopic to
open procedures in the elderly is limited to case-control series
(Table 28.4 ). In 2000, Stocchi et al. described a series of 42
patients greater than 75 years old undergoing laparoscopicassisted colectomies that were matched to 42 similar patients
28 Laparoscopy in the Elderly Patient
313
Table 28.4 Comparison of
outcomes for laparoscopic vs.
open colectomy in the elderly
(* p < 0.05)
Conversion
Author Year Open vs. lap N
Stewart [
Delgado [
Stocchi [
Law [
Senagore [
Sklow [
Vignali [
Feng [
Frasson [
Akiyoshi [
Lian [
13 ] 1999 Lap 42 11.9 9 16.6 7.1
Open 35 17 42.8* 11.4
39 ] 2000 Lap 59 16.9 6 ± 2 10.2 1.6
Open 67 7 ± 3* 31.3 %* 0
12 ] 2000 Lap 42 14.3 6.5 ± 4.0 14.3 0
Open 42 10.2 ± 4.4* 33.3* 0
14 ] 2002 Lap 65 12.3 7 27.7 1.5
Open 89 9* 37 5.6
22 ] 2003 Lap 50 4.2 ± 3.0 16 0
Open 123 9.3 ± 7.6* 37.4* 1.6
8 ] 2003 Lap 39 8 6.1 ± 0.3 31 2.6
Open 39 7.8 ± 0.6* 31 0
15 ] 2005 Lap 61 6.1 9.8 21.5 1.6
Open 61 12.9* 31.1 2.2
16 ] 2006 Lap 51 3.9 17.6 0
Open 102 37.3* 1.9
17 ] 2007 Lap 89 4.5 9.5 18 4.5
Open 112 13* 42* 0.9
11 ] 2009 Lap 44 0 19 13.6 0
Open 43 22* 25.6 2.3
18 ] 2010 Lap 97 14.4 6 37.1 5.2
Open 97 7* 43.3 5.2
rate (%)
Hospital
stay (days)
Morbidity
(%)
Mortality
(%)
undergoing open colectomy. Despite longer operative times
(190 vs. 142 min, p < 0.001), the laparoscopic- assisted group
had fewer complications (14.3 % vs. 33.3 %, p = 0.04), less
narcotic usage (2.7 vs. 4.8 days, p < 0.001), faster return to
bowel movements (3.9 vs. 5.9 days, p < 0.001), and shorter
hospital stay (6.5 vs. 10.2 days, p < 0.001). Additionally, inde-
pendent-living status was more frequently maintained
postoperatively in the laparoscopic-assisted group compared
with the open group (35/37 vs. 29/38, p = 0.025)—a key fac-
tor in looking at outcome with elderly patients that many
studies do not address [ 12 ].
Stewart et al., in 1999, compared patients aged 80 years
or greater undergoing elective laparoscopic ( n = 42) and
open ( n = 35) colorectal procedures. The open group dem-
onstrated a higher incidence of cardiopulmonary complications, wound infections, postoperative ileus, and ICU
admission; patients in the laparoscopy group had a shorter
length of stay and were more likely to be discharged to
home instead of to a rehabilitation facility or nursing home.
At 6-month follow- up, 82 % of surviving patients in the
laparoscopy group who were independent preoperatively
were living independently postoperatively, compared with
only 64 % of surviving patients in the open group, indicating that a fair number of elderly patients undergoing major
open abdominal surgery never return to an independent
lifestyle [
13 ].
Law et al. compared laparoscopic and open colectomy in
patients greater than 70 years old and found that laparoscopy
was associated with less operative blood loss, earlier return
of bowel function, earlier resumption of solid diet, shorter
hospital stay, and less cardiopulmonary morbidity [
14 ].
In 2005, Vignali et al. published the results of a case-matched
control study comparing 61 octogenarians undergoing laparoscopic colectomy for cancer with 61 patients undergoing
open colectomy, matched for gender, age, year of surgery,
site of cancer, and comorbidities. Despite longer operative
times in the laparoscopic group (220 vs. 171 min, p = 0.01),
postoperative morbidity rates were similar (25.5 % vs.
31.1 %, p = 0.30), and the laparoscopy group demonstrated
faster return of bowel function (4.8 vs. 5.9 days, p = 0.005)
and shorter length of stay (9.8 vs. 12.9 days, p = 0.001).
Laparoscopy also allowed better preservation of postoperative independence status compared with open surgery (98 %
vs. 82 %, p = 0.02) [ 15 ].
Feng et al., in 2006, compared 51 patients greater than 70
years old with colorectal cancer undergoing laparoscopic
resection with 102 matched controls undergoing open resection. Overall morbidity was signifi cantly reduced in the laparoscopic group (17.6 % vs. 37.3 %, p = 0.013), suggesting a
preferential benefi t to laparoscopy over open surgery in
elderly patients [ 16 ]. Frasson and colleagues described a
cohort of 535 patients with colorectal disease randomly
assigned to laparoscopic or open resection, 37.6 % of
whom were greater than 70 years old. In both the younger
and the older groups, complication rates and length of stay
were lower in the laparoscopic resection arm compared
with the open resection arm. However, in terms of reduced
morbidity and length of stay, the advantages were much
314
J.I.S. Bleier and B.R. Kann
more pronounced in the older group of patients, again
suggesting a benefi t to laparoscopy in this population [
Lian and associates compared 97 patients more than 80
years of age (mean age 82.8 years) undergoing elective laparoscopic colectomy with similar case-matched patients
undergoing open colectomy. The laparoscopy group demonstrated shorter hospital stay (6 vs. 7 days, p = 0.001) and
similar complication, readmission, and mortality rates.
Contrary to other reported studies, the rate of discharge to
home without assistance was not signifi cantly different
between the two groups (63.9 % vs. 62.9 %, p = 0.88) [ 18 ].
17 ].
Is Laparoscopy Not Benefi cial in the Elderly
Population?
In contrast to the majority of published literature, there are
some published series suggesting that elderly patients undergoing laparoscopic colorectal surgery may have poorer outcomes. Kirchhoff et al. found in a multivariate analysis of
risk factors associated with elective laparoscopic colorectal
procedures that age greater than 75 was a signifi cant risk factor for intraoperative (OR 1.69, 95 % CI 1.09–2.62, p = 0.019)
and postoperative (OR 1.57, 95 % CI 1.15–2.13, p = 0.004)
complications [
of 50 patients greater than 75 years old (median age 79.7
years) undergoing laparoscopic colorectal resection for cancer was matched by ASA score and operation with 50
patients less than 75 years old (median age 62 years), there
was a signifi cantly higher morbidity rate seen in the older
group—24 % vs. 8 % ( p = 0.05) [ 20 ].
19 ]. Fiscon et al. reported that when a group
open procedures in older patients (6.0 % vs. 6.5 %, p = NS)
but signifi cantly higher for laparoscopic procedures in the
younger cohort (9.4 % vs. 4.1 %, p < 0.05). Postoperative
complication rates were also signifi cantly reduced in the
laparoscopy group for older patients (16 % vs. 37.4 %,
p < 0.05) but not in the younger group (10.5 % vs. 13.1 %,
p = NS). The authors concluded that laparoscopic colectomy
managed with an enhanced recovery program offers particular advantages to older patients [ 22 ].
In one of the few randomized controlled trials in the literature evaluating laparoscopic colorectal surgery in the
elderly, Wang described the outcomes for 78 patients
greater than 65 years of age (mean age 71) undergoing laparoscopic colorectal resection who were randomized to a
“fast-track” protocol vs. a “conventional care” group. The
fast-track group had a faster return of bowel function as
measured by three separate indices, including a shorter
length of stay (5.5 vs. 7.0 days, p < 0.001), and fewer com-
plications (5.0 % vs. 21.1 %, p = 0.045) [ 23 ]. Pawa et al.
published outcomes for 688 colorectal resections managed
with an enhanced recovery protocol, 18.9 % of which were
inpatients greater than 80 years old; 93.1 % of resections in
the older cohort were performed laparoscopically, compared with 97.1 % in younger cohort ( p = 0.036). Both
groups demonstrated similar lengths of stay and readmission rates; however, there was a higher complication rate
(mainly cardiopulmonary and urinary) in the older group
(26.2 % vs. 9.3 %, p < 0.0001). The authors noted that there
was more diffi culty with adherence to the protocol in older
group, particularly with timely discontinuation of urinary
catheters and intravenous fl uids [ 24 ].
Laparoscopic Colorectal Surgery in the Elderly: Enhanced Recovery Protocols
A number of published studies have shown a clear benefi t to
the use of enhanced recovery, or “fast-track,” protocols following laparoscopic colorectal surgery. More recently, these
have been expanded to apply to elderly patients with similarly favorable outcomes. In fact, reports of discharge less
than 24 h postoperatively following laparoscopic right colectomy for cancer in octogenarians have been described [ 21 ].
In 2003, Senagore et al. evaluated the short-term outcomes in age-matched cohorts of patients undergoing laparoscopic vs. open segmental colectomy managed with an
enhanced recovery protocol. Length of stay was signifi cantly
shorter for the laparoscopy groups in each cohort. Unlike
prior studies, the authors also found a signifi cant reduction in
direct hospital costs associated with laparoscopy in the older
(greater than 70 years old) cohort ($3,920 vs. $6,448) but not
the younger (less than 60 years old) cohort ($3,616 vs.
$3,804). Readmission rates were similar for laparoscopic vs.
What Are the Long-Term Outcomes?
While short-term outcomes regarding outcomes for laparoscopic colorectal procedures in the elderly are well described,
data regarding long-term outcomes is generally lacking. The
COST trial, which proved similar oncologic outcomes in
patients undergoing laparoscopic and open colectomy, did not
stratify patients by age. However, keeping in mind that a number of studies defi ne “elderly” as greater than 70 years old and
that the median ages in the open and laparoscopic groups in
the COST trial were 69 and 70, respectively, one might surmise from this that oncologic outcomes in elderly patients
undergoing laparoscopic colectomy for cancer approximate
those of patients undergoing open colectomy, at least in the
setting of a strict, randomized controlled trial [ 25 ].
In the one study specifi cally looking at long-term outcomes, Cheung described a series of 101 octogenarians
(mean age of 83 years) undergoing laparoscopic colorectal
resection for cancer. At a median follow-up of 24 months,
there were 22 recurrences. The overall 5-year survival rate
28 Laparoscopy in the Elderly Patient
315
was 51 %, and 5-year disease-free survival rate was 49 % [ 26 ].
Determination of the true long-term benefi ts of laparoscopic
colorectal surgery would require a randomized control trial
incorporating quality of life measures to defi nitively answer
the question of whether laparoscopic colorectal surgery in
the elderly population offers a true advantage over open
surgery.
Operating Room Considerations
Physiology of Pneumoperitoneum
The common theme in terms of the elderly patient’s ability to
tolerate laparoscopy depends not on the chronologic age, but
more so on comorbid conditions and suffi cient physiologic
reserve. Laparoscopy in the elderly has previously been
approached with reservation because of concerns over the
possible adverse hemodynamic effects of pneumoperitoneum in this population that perhaps may have a more limited cardiopulmonary reserve. With laparoscopic surgery,
concerns have been raised regarding issues such as the duration of the procedure and extreme positioning which may
exacerbate this limited reserve (Fig. 28.1 ).
Insuffl ation of the peritoneal cavity to create pneumoperitoneum during laparoscopy induces a number of physiologic
changes (Table 28.5 ). In a healthy patient with normal physi-
ologic reserve, standard insuffl ation to an intra-abdominal
pressure of 15 mmHg produces relatively little in the way of
clinically relevant changes. However, in elderly patients in
whom this reserve may be limited due to underlying comorbid conditions, the physiologic changes induced by pneumoperitoneum can have profound effects [ 27 ].
Table 28.5 Physiologic effects of pneumoperitoneum
Parameter Change
Respiratory
Functional residual capacity Decrease
Alveolar dead space Increase
Peak airway pressures Increase
Pulmonary compliance Decrease
FEV-1 Decrease
Force vital capacity Decrease
Peak expiratory fl ow Decrease
Hemodynamic With
hypercarbia
Heart rate Increase Increase
Mean arterial pressure (MAP) Increase Increase or decrease
Central venous pressure Increase Increase or decrease
Stroke volume Increase Decrease
Cardiac output Increase Increase or decrease
Renal
Urine output Decrease
Glomerular fi ltration rate Decrease
Renal blood fl ow Decrease
Serum creatinine Increase or
no change
Vasopressin Increase
a
Increase or decrease depends on several factors. As preload falls, MAP
may compensate as well as cardiac output. However, if continues or
with large decrease in preload, cardiac output and MAP will decrease
With increased
abdominal pressure
a
a
a
Acid/Base Effects
The most commonly used gas for insuffl ations is carbon dioxide (CO 2 ), which is very effi ciently eliminated. CO 2 is
absorbed through the peritoneum and eliminated by respiratory exchange in lungs. Insuffl ation increases CO 2 delivery to
lungs by as much as 50 %, and an increase in minute ventilation of up to 16 % can be required to maintain normocarbia
during pneumoperitoneum [ 28 ]. Elderly patients with severe
chronic obstructive pulmonary disease, decreased cardiac
output, or high metabolic and cellular metabolic rates
(i.e., sepsis) may experience signifi cant hypercarbia if the
end-tidal CO 2 and arterial pH are not monitored [ 29 ].
Fig. 28.1 Steep reverse Trendelenburg may cause problems with physiology in the elderly
Pulmonary Effects
Abdominal insuffl ation during laparoscopy impedes diaphragmatic movement and results in decreased functional
residual capacity (FRC) and an increase in alveolar dead
space. Additionally, there is a rise in peak airway pressures
with a decrease in pulmonary compliance [ 27 ]. Collectively,
these factors can lead to signifi cant hypoxemia, which can
be minimized by controlled ventilation, which minimizes
alveolar atelectasis and the potential resulting ventilation/
perfusion mismatch [ 30 ]. Again, elderly patients with
316
J.I.S. Bleier and B.R. Kann
underlying pulmonary disease may be more prone to the
deleterious effects of pneumoperitoneum on pulmonary volumes and oxygenation.
Cardiovascular Effects
Pneumoperitoneum affects cardiovascular physiology, both
due to the effects of hypercarbia and the direct effect of the
increase in abdominal pressure on the thoracic cavity. At a
pCO 2 of 55–70 mmHg, hypercarbia and acidosis cause
hemodynamic changes due to myocardial depression and
vasodilation, effects that are countered by a centrally mediated sympathetic stimulation that causes tachycardia and
vasoconstriction, resulting in an increased heart rate, mean
arterial pressure, cardiac output, and stroke volume [ 27 ]. In
elderly patients with underlying pulmonary disease who
have diffi culty clearing the hypercarbia produced by CO 2
insuffl ation, these effects can be pronounced.
The hemodynamic effects attributed to the mechanical
effect of increased intra-abdominal pressure are much more
pronounced than the effects induced by hypercarbia. With
decreased right atrial pressures, pneumoperitoneum compresses the inferior vena cava, leading to decreased venous
return. With higher right atrial fi lling pressures, the vena
cava is able to resist compression, and increased intraabdominal pressure actually augments venous return [ 31 , 32 ].
Additionally, increased intra-abdominal pressure results in
compression of small capacitance vessels, further augmenting venous return. With hypervolemia, cardiac output is augmented by an elevated mean systemic pressure and increase
in venous return. With euvolemia or hypovolemia, increased
systemic pressure is outweighed by caval compression and
decreased venous return, causing a decrease in cardiac output, the level which is directly related to the degree of
increased abdominal pressure [ 33 ].
Certain considerations should be taken into account when
considering laparoscopy in elderly patients with underlying
cardiac disease. Increases in heart rate and afterload have the
potential to increase ventricular wall tension and subsequent
myocardial ischemia. Inadequate left ventricular reserve can
lead to transient cardiac decompensation during abdominal
insuffl ation, decreasing oxygen delivery and causing refl exive
increases in pulmonary arterial pressure. In patients with
underlying cardiac disease undergoing laparoscopy, additional
intraoperative monitoring, including direct measurements of
arterial and central venous pressure, may be considered.
Renal Effects
Increased intra-abdominal pressure created by pneumoperitoneum decreases renal blood fl ow and glomerular fi ltration
rate via a number of mechanisms. Decreased delivery of
blood to the kidneys as a result of decreased cardiac output
results in decreased renal blood fl ow. Animal studies have
clearly demonstrated that increased intra-abdominal pressure resulting from insuffl ation of the abdominal cavity also
results in decreased renal blood fl ow [
34 , 35 ], presumably
due to vascular and parenchymal compression, though the
exact mechanism by which this occurs has not been clearly
elucidated. There is also evidence that pneumoperitoneum
increases secretion of vasopressin, promoting water resorption and decreasing urine output. When performing laparoscopy on elderly patients with decreased baseline renal
function, one should be mindful of maintaining adequate
intravascular volume to promote renal blood fl ow.
Fortunately, long-term deleterious effects of pneumoperitoneum on renal function are rare; transient changes in serum
creatinine, glomerular fi ltration rate, and urine output tend to
return to baseline fairly quickly postoperatively.
Immune System Effects
Serum levels of several acute-phase reactants, proteins produced in response to tissue injury, have been shown to be
elevated after laparoscopy. Probably the most widely studied
of these is C-reactive protein (CRP), which rises 4–12 h after
surgery, peaks at 24–72 h postoperatively, and remains elevated for about 2 weeks [ 36 ]; after laparoscopy, CRP levels
do not reach the same degree of elevation as those seen after
laparotomy. Interleukin-6 (IL-6) is the major cytokine
responsible for the acute-phase protein response and is an
early marker for tissue damage. As with CRP, elevations in
IL-6 after laparoscopy are less pronounced than those seen
after laparotomy [ 37 ]. Insuffl ation of the abdomen with CO 2
as opposed to room air has also been shown to be associated
with a reduction in the IL-6 response. Similar associations
have been seen with decreased release of TNF-α and IL-1
from cells incubated in CO 2 compared with room air or nitro-
38 ], suggesting that there is a modulation of the proin-
gen [
fl ammatory response with CO
insuffl ation.
2
Laparoscopic Surgery in the Elderly: Changes and Technical Points
The basic tenets of laparoscopy in general hold true when
performing laparoscopic colorectal procedures on elderly
patients—safe access to the peritoneal cavity, adequate visualization and exposure of target tissues, triangulation of trocars, and delicate tissue handling with appropriate traction/
counter-traction are all paramount to successful laparoscopic
surgery.
Many older patients have undergone prior open abdominal
surgery, raising challenges with access and intra- abdominal
adhesions. Gaining access via a Veress needle or optical
28 Laparoscopy in the Elderly Patient
317
laparoscopic visualization technique may risk inadvertent
enterotomy if there are adhesions of bowel to the undersurface of the abdominal wall; in these circumstances a direct
cutdown or Hasson technique may be preferred. In patients
who have undergone previous abdominal surgery, extensive
laparoscopic lysis of adhesions may be required in order to
adequately visualize the target tissues. This can be very timeconsuming and tedious, with risk of inadvertent enterotomy,
which can be technically challenging to repair laparoscopically. In elderly patients with signifi cant comorbidities, the
benefi ts of laparoscopy must be weighed against the drawbacks of a prolonged operative time if extensive adhesiolysis
is required.
The cardiopulmonary effects of pneumoperitoneum, as
previously described, can be more pronounced in elderly
patients due to underlying disease. Additionally, extreme
positional changes are often utilized during advanced laparoscopic procedures to facilitate exposure, which can further
compound the hemodynamic effects produced by pneumoperitoneum. Elderly patients may not be able to tolerate the
physiologic changes induced by pneumoperitoneum and
may require lower levels of insuffl ation to decrease intraabdominal pressures. Patients with pulmonary hypertension
or right-sided heart failure may not be able tolerate steep
Trendelenburg position due to increased venous return to the
heart. If abdominal insuffl ation or extreme positional changes
create unsafe hemodynamics, one should consider converting to an open procedure.
Positioning is another very important factor. Baseline
coagulopathies, medications, or platelet dysfunction, along
with “frail” skin, may lead to increased bruising. Additional
padding on the bony prominences, sacrum, (Fig.
28.2 ), and
legs (Figs. 28.3 and 28.4 ) while in the modifi ed lithotomy
position is crucial.
Changes in the postoperative management in elderly
patients undergoing laparoscopic procedures may also be
Fig. 28.3 Added padding in the stirrups
Fig. 28.2 Additional padding on the sacrum
Fig. 28.4 Additional padding at the calf. Mechanical compression
devices are in place
needed. The concept of early postoperative ambulation may
be diffi cult to employ in this patient population, whose
mobility may have been poor even preoperatively [ 24 ]. Early
discontinuation of Foley catheters is often met with nursing
resistance due to urinary incontinence or the need for reinsertion in elderly men with enlarged prostates or women
with pelvic fl oor prolapse; Foley catheter reinsertion may
increase the risk for postoperative urinary tract infections.
Early enteral feeding post-laparoscopy should be employed
judiciously in elderly patients, as this population may be
more likely to have an aspiration event associated with episodes of nausea and vomiting, increasing the risk of pneumonia and need for mechanical ventilation.
318
Conclusions
Management of the elderly patient with colorectal problems
can be complex and may affect every aspect of the patients
care. Every plan for operative intervention should begin with
appropriate assessment of comorbidities and assessment for
fi tness for surgery. The use of laparoscopy, while previously
a contraindication in the elderly, has emerged to provide signifi cant advantages for the elderly patients similar to those in
younger patients. The use of laparoscopy introduces unique
and important physiologic changes perioperatively, of which
the responsible colorectal surgeon must be aware, and must
be taken into account in the context of common morbidities
in the elderly. Nevertheless, with appropriate preoperative
planning, laparoscopy seems to have proven advantages over
open surgery in the elderly and may soon be considered standard of care.
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