**Anesthetic Management for Laparoscopic Cholecystectomy**

Somchai Amornyotin

**11. Biofilms**

38 Endoscopy

**Author details**

Norman Miner

**References**

9.

is to culture the endoscope, at least periodically.

MicroChem Laboratory, Inc.Euless, Texas, USA

Hosp. Epidem. 2011, 33: pp 527 – 537.

The interior channels of endoscopes can be convoluted, and the air-water channel is too nar‐ row to brush. Therefore it is possible over time for the channels of an endoscope to develop a film of microbes, called a biofilm. Endoscope channels that contain a biofilm cannot be dis‐ infected [5]. Detection of a biofilm is one reason why endoscopes should be periodically cul‐ tured. Biofilms can be removed by soaking the endoscope and all of its channels in an enzyme detergent for a prolonged period of time such as one or two hours, followed by vig‐ orous brushing of the channels. After this prolonged soaking, brushing and rinsing proce‐ dure, the endoscope should again be cultured to determine that the biofilm has been removed. The hospital laboratory or a contract microbiologist can be the Endoscopists best friend, and the only way to know for certain that procedures lead to a disinfected endoscope

[1] Petersen, B T, Chennat, J, Cohen, J, Cotton, P B, Greenwald, D A, et.al. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes. Infect. Control and

[2] Miner N, Harris V, Ebron T, Cao T. Sporicidal activity of disinfectants as one possible cause for bacteria in patient-ready endoscopes. Gastroenterol Nurs.2009; 30: 285-90.

[3] Miner N, Harris V, Lukomski N, Ebron T. Rinsability of ortho-phthalaldehyde from

[4] Miner N, Harris V, Cao T D, Ebron T, and Lukomski N. Aldahol High Level Disin‐

[5] Pajkos A, Vickery K, Cossart Y. Is biofilm accumulation on endoscope tubing a con‐ tributor to the failure of cleaning and decontamination? J Hosp Infect. 2004; 58: 224 –

endoscopes. Diagnost and TherapEndosc. 2012; 2012: Article 853781.

fectant. Amer J Infect Control. 2010; 38: No.3, 205 – 211.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52742

### **1. Introduction**

Laparoscopic surgery aims to minimize trauma of the interventional process but still ach‐ ieve a satisfactory therapeutic result. It is commonly performed because of various advan‐ tages such as reduced postoperative pain, faster recovery and more rapid return to normal activities, shorter hospital stay, and reduced postoperative pulmonary complications. The operative technique requires inflating gas into the abdominal cavity to provide a surgical procedure. An intra-abdominal pressure (IAP) of 10-15 mmHg is used. Carbon dioxide (CO2) is commonly used because it does not support combustion, is cleared more rapidly than other gases, and is highly soluble in blood. However, the disadvantage of CO2 is that the absorption of CO2 can cause hypercapnia and respiratory acidosis [1].

Laparoscopic cholecystectomy (LC) procedure offers several advantages such as a reduction in stress response, postoperative pain, postoperative wound infection rate, intraoperative bleeding, impairment of respiratory function and pulmonary complications, short recovery time, and cosmetic appearance [1,2]. LC reduces hospital stay but has no overall effect on postoperative mortality [3]. The risk factors for perioperative complications in patients un‐ dergoing LC can be estimated based on patient characteristics, clinical findings and the sur‐ geon's experience [4]. The advantages should to be balanced with potential adverse effects caused by CO2 pneumoperitoneum.

The physiological effects of intra-abdominal CO2 insufflation combined with the variations in patient positioning can have a major impact on cardiorespiratory function. In addition, the sequential effects of anesthesia combine to produce a characteristic hemodynamic re‐ sponse. A thorough understanding of these physiological changes is fundamental for opti‐ mal anesthetic care. Several anesthetic techniques can be performed for LC. General anesthesia using balanced anesthetic technique including intravenous drugs, inhalation

© 2013 Amornyotin; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

agents and muscle relaxants is usually used. Short acting drugs such as propofol, atracur‐ irm, vecuronium, sevoflurane or desflurane represent the maintenance drugs of choice. Pre‐ procedure assessment and preparation, appropriate monitoring and a high index of suspicion can result in early diagnosis and treatment of complications.

Bradyarrhythmias are attributed to vagal stimulation caused by insertion of the needle or the trocar, peritoneal stretch, stimulation of the fallopian tube during bipolar electrocauteri‐ zation, or carbon dioxide embolization [11]. These may induce cardiovascular collapse dur‐ ing laparoscopy even in the healthy patients. Increased concentrations of CO2 and catecholamines can create tachyarrhythmias. Paroxysmal tachycardia and hypertension, fol‐

Anesthetic Management for Laparoscopic Cholecystectomy

http://dx.doi.org/10.5772/52742

41

Increases in IAP, cardiovascular responses to peritoneal insufflations, changes in patient po‐ sition and alterations in CO2 concentration can alter intracranial pressure (ICP) and cerebral perfusion. ICP shows a significant further increase. Cerebral blood flow has been shown to

Pneumoperitoneum reduces renal cortical and medullary blood flow with an associated re‐ duction in glomerular filtration rate (GFR), urinary output and creatinine clearance [2]. The reduction of renal blood flow may be due to a direct pressure effect on renal cortical blood flow and renal vascular compression as well as an increase in antidiuretic hormone (ADH), aldosterone and renin. Pretreatment with an ADH antagonist improves urine output and

Increased in IAP reduces femoral venous blood flow. This is due to increased pressure on the inferior vena cava and iliac veins, which reduces venous blood flow in the lower ex‐ tremetries. It also has been shown to reduce the portal blood flow, which may lead to transi‐

The C-reactive protein and interleukin-6 levels are less elevated after laparoscopy compared to the open surgery, suggesting an attenuation of the surgical inflammatory response [13].

Patient positions can further compromise cardiac and respiratory functions, can increase the risk of regurgitation and can result in peripheral nerve injuries. Head-up position re‐ duces venous return, cardiac output, cardiac index and mean arterial blood pressure as well as an increase in peripheral and pulmonary vascular resistance [5,14]. Head-down position increases volume and cardiac output back towards normal. Respiratory function is impaired because of the cephalad shifting of diaphragm is exaggerated. Intracranial

The general health status of each patient must be evaluated. History and physical examina‐ tions are generally sufficient techniques. The patients with cardiorespiratory diseases re‐ quire additional investigation. To aid in assessment risk, the American Society of Anesthesiologists (ASA) has developed a classification system for patients, which categoriz‐

lowed by ventricular fibrillation, have been reported [12].

increase significantly during CO2 insufflation.

urea excretion despite an unaltered GFR.

ent elevation of liver enzymes.

pressure is increased.

**3. Anesthetic management**

**3.1. Preoperative assessment**

**2.4. Effects of other systems**

### **2. Pathophysiological effects during laparoscopic cholecystectomy**

### **2.1. Physiological effects of pneumoperitoneum**

Carbon dioxide was shown to be affected by raising the intra-abdominal pressure (IAP) above the venous pressure which prevents CO2 resorption leading to hypercapnia. Hyper‐ capnia activates the sympathetic nervous system leading to an increase in blood pressure, heart rate, arrhythmias and myocardial contractility as well as it also sensitizes myocardium to catecholamines [5]. Increased IAP may compress venous vessels causing an initial in‐ crease in preload, followed by a sustained decrease in preload.

### **2.2. Respiratory effects**

The changes in pulmonary function during LC include reduction in lung volumes, decrease in pulmonary compliance, and increase in peak airway pressure [6]. Increased IAP shifts the diaphragm cephalad and reduces diaphragmatic excursion, resulting in early closure of smaller airways leading to intraoperative atelectasis with a decrease in functional residual capacity. Additionally, the upward displacement of diaphragm leads to preferential ventila‐ tion of nondependent parts of lung, which results in ventilation-perfusion (V/Q) mismatch with a higher degree of intrapulmonary shunting. Oxygenation is minimally affected with no significant change in alveolar arterial oxygen gradient [7]. Higher IAP reduces the thora‐ cic compliance and may cause pneumothorax and pneumomediastinum due to the in‐ creased in alveolar pressures [6].

#### **2.3. Cardiovascular effects**

Hemodynamic changes include the alterations in arterial blood pressure, arrhythmias and cardiac arrest. These cardiovascular changes depend on the interaction of several factors in‐ cluding patient positioning, neurohumoral response and the patient factors such as cardior‐ espiratory status and intravascular volume. The principal responses are an increase in systemic vascular resistance, mean arterial blood pressure and myocardial filling pressures, with little change in heart rate [2]. CO2 pneumoperitoneum is associated with increased pre‐ load and afterload in patients undergoing LC. It also decreased heart performance (fraction‐ al shortening), but does not affect cardiac output [8]. The patients with normal cardiovascular function are able to well tolerate these hemodynamic changes. At IAP levels greater than 15 mmHg, venous return decreases leading to decreased cardiac output and hy‐ potension [9]. However, these changes are short lived and have no statistical significance at 10 minutes from the time that the patient undergoes pneumoperitoneum [10].

Bradyarrhythmias are attributed to vagal stimulation caused by insertion of the needle or the trocar, peritoneal stretch, stimulation of the fallopian tube during bipolar electrocauteri‐ zation, or carbon dioxide embolization [11]. These may induce cardiovascular collapse dur‐ ing laparoscopy even in the healthy patients. Increased concentrations of CO2 and catecholamines can create tachyarrhythmias. Paroxysmal tachycardia and hypertension, fol‐ lowed by ventricular fibrillation, have been reported [12].

### **2.4. Effects of other systems**

agents and muscle relaxants is usually used. Short acting drugs such as propofol, atracur‐ irm, vecuronium, sevoflurane or desflurane represent the maintenance drugs of choice. Pre‐ procedure assessment and preparation, appropriate monitoring and a high index of

Carbon dioxide was shown to be affected by raising the intra-abdominal pressure (IAP) above the venous pressure which prevents CO2 resorption leading to hypercapnia. Hyper‐ capnia activates the sympathetic nervous system leading to an increase in blood pressure, heart rate, arrhythmias and myocardial contractility as well as it also sensitizes myocardium to catecholamines [5]. Increased IAP may compress venous vessels causing an initial in‐

The changes in pulmonary function during LC include reduction in lung volumes, decrease in pulmonary compliance, and increase in peak airway pressure [6]. Increased IAP shifts the diaphragm cephalad and reduces diaphragmatic excursion, resulting in early closure of smaller airways leading to intraoperative atelectasis with a decrease in functional residual capacity. Additionally, the upward displacement of diaphragm leads to preferential ventila‐ tion of nondependent parts of lung, which results in ventilation-perfusion (V/Q) mismatch with a higher degree of intrapulmonary shunting. Oxygenation is minimally affected with no significant change in alveolar arterial oxygen gradient [7]. Higher IAP reduces the thora‐ cic compliance and may cause pneumothorax and pneumomediastinum due to the in‐

Hemodynamic changes include the alterations in arterial blood pressure, arrhythmias and cardiac arrest. These cardiovascular changes depend on the interaction of several factors in‐ cluding patient positioning, neurohumoral response and the patient factors such as cardior‐ espiratory status and intravascular volume. The principal responses are an increase in systemic vascular resistance, mean arterial blood pressure and myocardial filling pressures, with little change in heart rate [2]. CO2 pneumoperitoneum is associated with increased pre‐ load and afterload in patients undergoing LC. It also decreased heart performance (fraction‐ al shortening), but does not affect cardiac output [8]. The patients with normal cardiovascular function are able to well tolerate these hemodynamic changes. At IAP levels greater than 15 mmHg, venous return decreases leading to decreased cardiac output and hy‐ potension [9]. However, these changes are short lived and have no statistical significance at

10 minutes from the time that the patient undergoes pneumoperitoneum [10].

suspicion can result in early diagnosis and treatment of complications.

**2.1. Physiological effects of pneumoperitoneum**

**2.2. Respiratory effects**

40 Endoscopy

creased in alveolar pressures [6].

**2.3. Cardiovascular effects**

crease in preload, followed by a sustained decrease in preload.

**2. Pathophysiological effects during laparoscopic cholecystectomy**

Increases in IAP, cardiovascular responses to peritoneal insufflations, changes in patient po‐ sition and alterations in CO2 concentration can alter intracranial pressure (ICP) and cerebral perfusion. ICP shows a significant further increase. Cerebral blood flow has been shown to increase significantly during CO2 insufflation.

Pneumoperitoneum reduces renal cortical and medullary blood flow with an associated re‐ duction in glomerular filtration rate (GFR), urinary output and creatinine clearance [2]. The reduction of renal blood flow may be due to a direct pressure effect on renal cortical blood flow and renal vascular compression as well as an increase in antidiuretic hormone (ADH), aldosterone and renin. Pretreatment with an ADH antagonist improves urine output and urea excretion despite an unaltered GFR.

Increased in IAP reduces femoral venous blood flow. This is due to increased pressure on the inferior vena cava and iliac veins, which reduces venous blood flow in the lower ex‐ tremetries. It also has been shown to reduce the portal blood flow, which may lead to transi‐ ent elevation of liver enzymes.

The C-reactive protein and interleukin-6 levels are less elevated after laparoscopy compared to the open surgery, suggesting an attenuation of the surgical inflammatory response [13].

Patient positions can further compromise cardiac and respiratory functions, can increase the risk of regurgitation and can result in peripheral nerve injuries. Head-up position re‐ duces venous return, cardiac output, cardiac index and mean arterial blood pressure as well as an increase in peripheral and pulmonary vascular resistance [5,14]. Head-down position increases volume and cardiac output back towards normal. Respiratory function is impaired because of the cephalad shifting of diaphragm is exaggerated. Intracranial pressure is increased.

### **3. Anesthetic management**

### **3.1. Preoperative assessment**

The general health status of each patient must be evaluated. History and physical examina‐ tions are generally sufficient techniques. The patients with cardiorespiratory diseases re‐ quire additional investigation. To aid in assessment risk, the American Society of Anesthesiologists (ASA) has developed a classification system for patients, which categoriz‐ es individuals on a general health basis. In this preoperative assessment, there are no differ‐ ences in a routine practice between the laparoscopy and the open surgery.

Furthermore, the use of an auditory evoked potential or Bispectral index monitor to titrate the volatile anesthetics leads to a significant reduction in the anesthetic requirement, result‐ ing in a shorter postanesthesia care stay and an improved quality of recovery from the pa‐

Anesthetic Management for Laparoscopic Cholecystectomy

http://dx.doi.org/10.5772/52742

43

Combination of local anesthetic wound infiltration, intraperitoneum spray of local anesthet‐ ic, paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase 2 inhibitors provides the most effective pain relief, which can be supplemented with small doses of

Several advantages of regional anesthesia technique are quicker recovery, decreased postop‐ erative nausea and vomiting, fewer hemodynamic changes, less postoperative pain, shorter hospital stay, early diagnosis of complications, improved patient satisfaction and cost effec‐ tiveness [24]. This anesthetic technique requires a cooperative patient, low IAP to reduce pain and ventilation disturbances, gentle surgical technique and a supportive operating room staff. However, regional anesthesia technique is not commonly used for LC. This tech‐ nique should be performed in combination with other anesthetic techniques. Local anesthet‐ ic infiltration at the trocar site combined with general anesthesia significantly reduces postoperative pain and decreases medication usage costs [25]. Additionally, subcostal trans‐ versusabdominis block provides superior postoperative analgesia, improves theater efficien‐ cy by reducing time to discharge from the recovery unit and reduces opioid requirement following LC [26]. Bilateral paravertebral blockade at T5-6 level combined with general an‐

Mehta and college had been conducted a prospective, randomized, controlled trial to com‐ pare spinal anesthesia with the gold standard general anesthesia for elective LC in the healthy patients. Their study demonstrated that spinal anesthesia was adequate and safe for LC in otherwise healthy patients and offered better postoperative pain control than general anesthesia without limiting the recovery [28]. The interim analysis of a controlled random‐ ized trial is also confirmed [29]. Thoracic epidural anesthesia with 0.75% ropivacaine and fentanyl for elective LC is also efficacious and has preserved ventilation and hemodynamic changes within physiological limits during pneumoperitoneum with minimal treatable side effects [30]. In addition, epidural anesthesia might be applicable for LC. However, the inci‐ dence rate of intraoperative referred pain is high, and so careful patient recruitment and

Misplacement of the needle can lead to intravascular, subcutaneous tissue, preperitoneal space, bowel, and omentum. Inadvertent insufflation of gas into intravascular vessels, tear of abdominal wall or peritoneal vessels, can produce to gas embolism. Although, it is rare but it is a potentially lethal complication and can result in severe hypotension, cyanosis, ar‐

tient's perspective [23].

*3.3.2. Regional anesthesia*

esthesia can be used for LC [27].

management of shoulder pain should be considered [31].

**4. Intraoperative complications**

opioids.

### **3.2. Patient monitoring**

Appropriate patient selection with proper monitoring to detect and reduce complications must be used to ensure optimal anesthesia care during LC. Standard intraoperative monitor‐ ing including noninvasive blood pressure, electrocardiogram, pulse oximeter, airway pres‐ sure, end tidal carbon dioxide (ETCO2), body temperature and peripheral nerve stimulation is routinely used. Invasive hemodynamic monitoring may be appropriate in the patients with hemodynamic unstable or those with compromised cardiopulmonary function [1].

ETCO2 is most commonly used as a noninvasive indicator of PaCO2 in evaluating the ade‐ quacy of ventilation. Careful consideration should be taken for the gradient between PaCO2 and the tension of CO2 in expired gas (PECO2) because of V/Q mismatch. However, in the patients with compromised cardiopulmonary function, the gradient between PaCO2 and PE‐ CO2 increases to become unpredictable. Direct arterial blood gas analysis may be considered to detect hypercarbia. Generally, the airway pressure monitor is routinely used during inter‐ mittent positive pressure ventilation. The high airway pressure can help detection of exces‐ sive elevation in IAP.

#### **3.3. Anesthetic techniques**

Various anesthetic techniques can be performed for LC. However, general anesthesia with endotracheal intubation for controlled ventilation is the most common anesthetic technique. In short procedures and in certain patients, ventilation using supraglottic airway device can be used as an alternative. General anesthesia without endotracheal intubation can be used safely and effectively with a ProSeal laryngeal mask airway in non-obese patients [15]. The use of laryngeal mask airway results in less sore throat and provide smoother emergence with less post-extubation coughing compared with endotracheal intubation [16].

#### *3.3.1. General anesthesia*

General anesthesia using balanced anesthesia technique including inhalation agents, intra‐ venous drugs and muscle relaxant drugs is usually used. The uses of rapid and short acting volatile anesthetics such as sevoflurane and desflurane as well as rapid and short acting in‐ travenous drugs such as propofol, etomidate, remifentanil, fentanyl, atracurium, vecuroni‐ um and rocuronium are commonly used and have allowed anesthesiologists to more consistently achieve a recovery profile. Propofol is effective and safe even in children and elderly patients [17-21].

Ventilation should be adjusted to keep ETCO2 of around 35 mmHg by adjusting the minute ventilation [1]. In patients with chronic obstructive pulmonary disease and in patients with a history of spontaneous pneumothorax or bullous emphysema, an increase in respiratory rate rather than tidal volume is preferable to avoid increased alveolar inflation and reduce the risk of pneumothorax [22].

Furthermore, the use of an auditory evoked potential or Bispectral index monitor to titrate the volatile anesthetics leads to a significant reduction in the anesthetic requirement, result‐ ing in a shorter postanesthesia care stay and an improved quality of recovery from the pa‐ tient's perspective [23].

Combination of local anesthetic wound infiltration, intraperitoneum spray of local anesthet‐ ic, paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase 2 inhibitors provides the most effective pain relief, which can be supplemented with small doses of opioids.

### *3.3.2. Regional anesthesia*

es individuals on a general health basis. In this preoperative assessment, there are no differ‐

Appropriate patient selection with proper monitoring to detect and reduce complications must be used to ensure optimal anesthesia care during LC. Standard intraoperative monitor‐ ing including noninvasive blood pressure, electrocardiogram, pulse oximeter, airway pres‐ sure, end tidal carbon dioxide (ETCO2), body temperature and peripheral nerve stimulation is routinely used. Invasive hemodynamic monitoring may be appropriate in the patients with hemodynamic unstable or those with compromised cardiopulmonary function [1].

ETCO2 is most commonly used as a noninvasive indicator of PaCO2 in evaluating the ade‐ quacy of ventilation. Careful consideration should be taken for the gradient between PaCO2 and the tension of CO2 in expired gas (PECO2) because of V/Q mismatch. However, in the patients with compromised cardiopulmonary function, the gradient between PaCO2 and PE‐ CO2 increases to become unpredictable. Direct arterial blood gas analysis may be considered to detect hypercarbia. Generally, the airway pressure monitor is routinely used during inter‐ mittent positive pressure ventilation. The high airway pressure can help detection of exces‐

Various anesthetic techniques can be performed for LC. However, general anesthesia with endotracheal intubation for controlled ventilation is the most common anesthetic technique. In short procedures and in certain patients, ventilation using supraglottic airway device can be used as an alternative. General anesthesia without endotracheal intubation can be used safely and effectively with a ProSeal laryngeal mask airway in non-obese patients [15]. The use of laryngeal mask airway results in less sore throat and provide smoother emergence

General anesthesia using balanced anesthesia technique including inhalation agents, intra‐ venous drugs and muscle relaxant drugs is usually used. The uses of rapid and short acting volatile anesthetics such as sevoflurane and desflurane as well as rapid and short acting in‐ travenous drugs such as propofol, etomidate, remifentanil, fentanyl, atracurium, vecuroni‐ um and rocuronium are commonly used and have allowed anesthesiologists to more consistently achieve a recovery profile. Propofol is effective and safe even in children and

Ventilation should be adjusted to keep ETCO2 of around 35 mmHg by adjusting the minute ventilation [1]. In patients with chronic obstructive pulmonary disease and in patients with a history of spontaneous pneumothorax or bullous emphysema, an increase in respiratory rate rather than tidal volume is preferable to avoid increased alveolar inflation and reduce

with less post-extubation coughing compared with endotracheal intubation [16].

ences in a routine practice between the laparoscopy and the open surgery.

**3.2. Patient monitoring**

42 Endoscopy

sive elevation in IAP.

*3.3.1. General anesthesia*

elderly patients [17-21].

the risk of pneumothorax [22].

**3.3. Anesthetic techniques**

Several advantages of regional anesthesia technique are quicker recovery, decreased postop‐ erative nausea and vomiting, fewer hemodynamic changes, less postoperative pain, shorter hospital stay, early diagnosis of complications, improved patient satisfaction and cost effec‐ tiveness [24]. This anesthetic technique requires a cooperative patient, low IAP to reduce pain and ventilation disturbances, gentle surgical technique and a supportive operating room staff. However, regional anesthesia technique is not commonly used for LC. This tech‐ nique should be performed in combination with other anesthetic techniques. Local anesthet‐ ic infiltration at the trocar site combined with general anesthesia significantly reduces postoperative pain and decreases medication usage costs [25]. Additionally, subcostal trans‐ versusabdominis block provides superior postoperative analgesia, improves theater efficien‐ cy by reducing time to discharge from the recovery unit and reduces opioid requirement following LC [26]. Bilateral paravertebral blockade at T5-6 level combined with general an‐ esthesia can be used for LC [27].

Mehta and college had been conducted a prospective, randomized, controlled trial to com‐ pare spinal anesthesia with the gold standard general anesthesia for elective LC in the healthy patients. Their study demonstrated that spinal anesthesia was adequate and safe for LC in otherwise healthy patients and offered better postoperative pain control than general anesthesia without limiting the recovery [28]. The interim analysis of a controlled random‐ ized trial is also confirmed [29]. Thoracic epidural anesthesia with 0.75% ropivacaine and fentanyl for elective LC is also efficacious and has preserved ventilation and hemodynamic changes within physiological limits during pneumoperitoneum with minimal treatable side effects [30]. In addition, epidural anesthesia might be applicable for LC. However, the inci‐ dence rate of intraoperative referred pain is high, and so careful patient recruitment and management of shoulder pain should be considered [31].

### **4. Intraoperative complications**

Misplacement of the needle can lead to intravascular, subcutaneous tissue, preperitoneal space, bowel, and omentum. Inadvertent insufflation of gas into intravascular vessels, tear of abdominal wall or peritoneal vessels, can produce to gas embolism. Although, it is rare but it is a potentially lethal complication and can result in severe hypotension, cyanosis, ar‐ rhythmias and asystole. Subcutaneous emphysema may occur after direct subcutaneous gas insufflations. The majority of subcutaneous emphysema has no specific intervention. It can resolve soon after the abdomen is deflated and nitrous oxide is discontinued to ovoid expan‐ sion of closed space.

**6. Summary**

**Author details**

**References**

Somchai Amornyotin

Hospital, Mahidol University, Bangkok, Thailand

view. Journal of Clinical Anesthesia 2001; 18(1): 67-78.

nal of American College of Surgeons 2006; 203(5): 723-728.

bon dioxide insufflations. Digestive Surgery 2004; 21(2): 95-105.

Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gall bladder diseases. Several advantages from this procedure are mini‐ mal tissue trauma, reduction of postoperative pain, quicker recovery, shortening the hospi‐ tal stay. Pneumoperitoneum induces intraoperative cardiorespiratory changes. Arterial CO2 increases because of CO2 absorption from the pneumoperitoneum. Improved knowledge of pathophysiological changes in the patients allows for successful anesthetic management. Proper patient selection and preparation as well as adequate monitoring should be per‐ formed. General anesthesia and controlled ventilation comprise the accepted anesthetic technique. Balanced anesthesia technique including inhalation agent, intravenous drug and muscle relaxant is commonly used. Intraoperative complications may arise due to physio‐ logic changes associated with patient positioning and pneumoperitoneum. Multimodal an‐ algesic regimen combining opioids, non-steroidal anti-inflammatory drugs, and local anesthetic infiltration is the most effective regimen for postoperative pain management.

Anesthetic Management for Laparoscopic Cholecystectomy

http://dx.doi.org/10.5772/52742

45

Department of Anesthesiology and Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj

[1] Gerges FJ, Kanazi GE, Jabbour-Khoury SI. (2006). Anesthesia for laparoscopy: a re‐

[2] Leonard IE, Cunningham AJ. Anesthetic consideration for laparoscopic cholecystec‐

[3] McMahon AJ, Fischbacher CM, Frame SH, MacLeod MC. Impact of laparoscopic cholecystectomy: a population-based study. Lancet 2000; 356(11): 1632-1637.

[4] Giger UF, Michel JM, Opitz I, et al. Risk factors for perioperative complications in pa‐ tients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of laparoscopic and thoracoscopic surgery database. Jour‐

[5] Gutt CN, Oniu T, Mehrabi A, et al. Circulatory and respiratory complications of car‐

tomy. Best Practice & Research Clinical Anesthesiology 2002; 16(1): 1-20.

Pneumothorax can occur when the airway pressure is high. The gas traverses into the thorax through the tear of visceral peritoneum, parietal pleura during dissection, or spontaneous rupture of pre-existing emphysematous bulla [1]. Pneumothorax can be asymptomatic or can increase the peak airway pressure, decrease oxygen saturation, hypotension, and even cardiac arrest in severe cases. The treatment is according to the severity of cardiopulmonary compromise [32].

Extension of subcutaneous emphysema into thorax and mediastinum can lead to pneumo‐ mediastinum. Pneumopericardium can occur when the gas is forced through the inferior vena cava into the mediastinum and pericardium. Their managements depend on the se‐ verity of the cardiovascular dysfunction.

The other complications can be presented. Accidental insertion of the trocar or needle in‐ to the major or minor vessels, gastrointestinal tract injuries and urinary tract injuries can occur [32].

### **5. Postoperative period**

The efficacy of post-anesthesia care units is therefore important to facilitate return to normal functions. In the early postoperative period, respiratory rate and ETC02 of laparoscopic pa‐ tients breathing spontaneously are higher as compared with open surgery. So, the ventila‐ tion requirement is increased. The patients with respiratory dysfunction can have problems excreting excessive CO2 load, which results in more hypercapnia. Additionally, the patients with cardiovascular diseases are more prone to hemodynamic changes and instabilities.

Although LC results in less discomfort compared with the open surgery, postoperative pain still can be considerable. Several medications used intraoperatively for prevention and treat‐ ment of postoperative pain are the uses of local anesthesia, opioids, nonsteroidal anti-in‐ flammatory drugs, and multimodal analgesia techniques. Additionally, preprocedure administration of parecoxib is clinically effective [33].

Postoperative nausea and vomiting (PONV) is a common and distressing symptom follow‐ ing LC. The use of multimodal analgesia regimens and the reduction of opioid doses are likely to reduce the incidence of PONV. Propofol-based anesthesia has been associated with reduced PONV [34]. Ondansetron has been found to provide effective prophylaxis against PONV [35]. Administration of ondansetron at the end of surgery produces a significantly greater anti-emetic effect compared to pre-induction dosing. Reduced preoperative anxiety by providing more information should also relieve postoperative adverse effects in order to promote faster and better postoperative recovery period.

### **6. Summary**

rhythmias and asystole. Subcutaneous emphysema may occur after direct subcutaneous gas insufflations. The majority of subcutaneous emphysema has no specific intervention. It can resolve soon after the abdomen is deflated and nitrous oxide is discontinued to ovoid expan‐

Pneumothorax can occur when the airway pressure is high. The gas traverses into the thorax through the tear of visceral peritoneum, parietal pleura during dissection, or spontaneous rupture of pre-existing emphysematous bulla [1]. Pneumothorax can be asymptomatic or can increase the peak airway pressure, decrease oxygen saturation, hypotension, and even cardiac arrest in severe cases. The treatment is according to the severity of cardiopulmonary

Extension of subcutaneous emphysema into thorax and mediastinum can lead to pneumo‐ mediastinum. Pneumopericardium can occur when the gas is forced through the inferior vena cava into the mediastinum and pericardium. Their managements depend on the se‐

The other complications can be presented. Accidental insertion of the trocar or needle in‐ to the major or minor vessels, gastrointestinal tract injuries and urinary tract injuries can

The efficacy of post-anesthesia care units is therefore important to facilitate return to normal functions. In the early postoperative period, respiratory rate and ETC02 of laparoscopic pa‐ tients breathing spontaneously are higher as compared with open surgery. So, the ventila‐ tion requirement is increased. The patients with respiratory dysfunction can have problems excreting excessive CO2 load, which results in more hypercapnia. Additionally, the patients with cardiovascular diseases are more prone to hemodynamic changes and instabilities.

Although LC results in less discomfort compared with the open surgery, postoperative pain still can be considerable. Several medications used intraoperatively for prevention and treat‐ ment of postoperative pain are the uses of local anesthesia, opioids, nonsteroidal anti-in‐ flammatory drugs, and multimodal analgesia techniques. Additionally, preprocedure

Postoperative nausea and vomiting (PONV) is a common and distressing symptom follow‐ ing LC. The use of multimodal analgesia regimens and the reduction of opioid doses are likely to reduce the incidence of PONV. Propofol-based anesthesia has been associated with reduced PONV [34]. Ondansetron has been found to provide effective prophylaxis against PONV [35]. Administration of ondansetron at the end of surgery produces a significantly greater anti-emetic effect compared to pre-induction dosing. Reduced preoperative anxiety by providing more information should also relieve postoperative adverse effects in order to

sion of closed space.

44 Endoscopy

compromise [32].

occur [32].

verity of the cardiovascular dysfunction.

administration of parecoxib is clinically effective [33].

promote faster and better postoperative recovery period.

**5. Postoperative period**

Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gall bladder diseases. Several advantages from this procedure are mini‐ mal tissue trauma, reduction of postoperative pain, quicker recovery, shortening the hospi‐ tal stay. Pneumoperitoneum induces intraoperative cardiorespiratory changes. Arterial CO2 increases because of CO2 absorption from the pneumoperitoneum. Improved knowledge of pathophysiological changes in the patients allows for successful anesthetic management. Proper patient selection and preparation as well as adequate monitoring should be per‐ formed. General anesthesia and controlled ventilation comprise the accepted anesthetic technique. Balanced anesthesia technique including inhalation agent, intravenous drug and muscle relaxant is commonly used. Intraoperative complications may arise due to physio‐ logic changes associated with patient positioning and pneumoperitoneum. Multimodal an‐ algesic regimen combining opioids, non-steroidal anti-inflammatory drugs, and local anesthetic infiltration is the most effective regimen for postoperative pain management.

### **Author details**

#### Somchai Amornyotin

Department of Anesthesiology and Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

### **References**


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[19] Amornyotin S. Chalayonnawin W, Kongphlay S. Propofol-based sedation does not increase rate of complication during percutaneous endosopic gastrostomy proce‐ dure. Gastroenterology Research and Practice 2011 Article ID 134819; 6 pages, doi:

Anesthetic Management for Laparoscopic Cholecystectomy

http://dx.doi.org/10.5772/52742

47

[20] Amornyotin S, Srikureja W, Pausawasdi N, Prakanrattana U, Kachintorn U. Intrave‐ nous sedation for gastrointestinal endoscopy in very elderly patients of Thailand.

[21] Amornyotin S. Kachintorn U, Chalayonnawin W, Kongphlay S. Propofol-based deep sedation for endoscopic retrograde cholangiopancreatography procedure in sick eld‐ erly patients in a developing country. Therapeutics and Clinical Risk Management

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[26] Tolchard S, Davies R, Martindale S. Efficacy of the subcostal transversusabdominis plane block in laparoscopic cholecystectomy: comparison with conventional port-site infiltration. Journal of Anaesthesiology Clinical Pharmacology 2012; 28(3): 339-343. [27] Naja MZ, Ziade MF, Lonnqvist PA. General anesthesia combined with bilateral para‐ vertebral blockade (T5-6) vs. general anesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. European Journal of Anaesthesiology 2004;

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**Chapter 4**

**Adhesion Prevention Strategies in**

George Pados, Anastasios Makedos and

Additional information is available at the end of the chapter

Adhesions are defined as abnormal attachments between tissues and organs [1]. Intra-ab‐ dominal adhesions may be classified as congenital or acquired [2]. Congenital adhesions are a consequence of embryological anomaly in the development of the peritoneal cavity. Ac‐ quired adhesions result from the inflammatory response of the peritoneum that arises after intra-abdominal inflammatory processes (e.g. acute appendicitis, pelvic inflammatory dis‐ ease, exposure to intestinal contents and previous use of intrauterine contraceptive devices), radiation and surgical trauma [3]. It has been reported that the majority of acquired adhe‐

Factors associated with the formation of post-surgical adhesions include tissue trauma, in‐ fection, ischaemia,reaction to foreign bodies (sutures, powder from gloves, gauze particles etc.), haemorrhage, tissue overheating or desiccation and exposure to irrigation fluids [4]. The incidence of intra-abdominal adhesions ranges from 67% to 93% after general surgical abdominal operations and from 60% to 90% after gynecological procedures. Not unexpect‐ edly, adhesion formation is considered one of the most common post-operative complica‐ tions [2,5]. Post-surgically, many adhesions may be asymptomatic or can lead to a broad spectrum of clinical problems, including intestinal obstruction, chronic pelvic or abdominal pain and female infertility, requiring re-admission and often additional surgery, while at the same time they can complicate future surgical procedures [6]. Adhesion-related re-opera‐ tions are a common consequence of gynecological procedures and adhesiolysis is followed

by a high incidence of adhesion reformation and *de-novo* adhesion formation [7].

The major strategies for adhesion prevention in gynecological surgery aim at the optimiza‐ tion of surgical technique and use of adhesion-prevention agents. Laparoscopic surgery in

and reproduction in any medium, provided the original work is properly cited.

© 2013 Pados et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Laparoscopic Surgery**

http://dx.doi.org/10.5772/52694

sions (about 90%) are post-surgical [2].

Basil Tarlatzis

**1. Introduction**


**Chapter 4**
