Laprobotics

3/30/2016 Anesthesia for laparoscopic and abdominal robotic surgery in adults
Official reprint from UpToDate®
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Anesthesia for laparoscopic and abdominal robotic surgery in adults
Author Section Editor Deputy Editor

Girish P Joshi, MB, BS, MD, Stephanie B Jones, MD Marianna Crowley, MD
FFARCSI
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2016. | This topic last updated: Dec 04, 2015.
INTRODUCTION — The laparoscopic approach has become a standard of care for many abdominal surgical
procedures. Compared with laparotomy, laparoscopy can reduce postoperative pain, result in shorter recovery
time, allow smaller incisions, and reduce the postoperative stress response. Laparoscopy requires insufflation
of intraperitoneal or extraperitoneal gas, usually carbon dioxide (CO2), to create space for visualization and
surgical maneuvers.
Robotic surgery is usually performed laparoscopically and is commonly used for gynecologic and urologic
surgery.
Anesthetic concerns for patients undergoing laparoscopic and robotic surgery differ from those for patients
undergoing open abdominal surgery. They include the physiologic effects of the pneumoperitoneum, absorption
of CO2, and positioning required for surgery. In addition, some laparoscopic procedures take longer than the
open alternative.
This topic will discuss the anesthetic management of patients having laparoscopic and robotic abdominal
surgery. Advantages and disadvantages of laparoscopy and robotic surgery, technical aspects of these
techniques, and surgical complications are discussed separately. (See "Robotassisted laparoscopy" and
"Complications of laparoscopic surgery" and "Instruments and devices used in laparoscopic surgery" and
"Laparoscopic cholecystectomy".)
SURGICAL TECHNIQUES — Laparoscopy requires creation of a pneumoperitoneum by insufflation of gas,
usually carbon dioxide (CO2), to open space in the abdomen for visualization and allow surgical manipulation.
CO2 insufflation can be performed blindly using a Veress needle or by placement of a port under direct vision
through a small subumbilical incision. The gas source is connected to the needle or port; intraabdominal
pressure (IAP) is monitored as gas is insufflated, aiming for a pressure ≤15 mmHg to minimize physiologic
effects. For laparoscopic prostatectomy, which is performed in steep Trendelenburg position, the European
Association for Endoscopic Surgery recommends IAP below 12 mmHg [1].
After insufflation, a port is placed, and the laparoscope is inserted. Under direct intraabdominal vision, further
instrument ports are placed. The surgeon uses a video monitor connected to the laparoscope to see
intraabdominal contents and perform the procedure.
In some cases, laparoscopy is used to assist dissection, after which an incision is made to complete the
procedure. In others, a larger port is placed to allow the surgeon to insert one hand to assist the procedure.
The most commonly used robotic system occupies a lot of space in the operating room, and consists of a
surgeon’s control console, a tower holding the optical system, and patientside cart with robotic arms. For
robotic surgery, once the pneumoperitoneum is created, multiple ports are placed for insertion of the camera
and robotic arms, which are connected to the patientside cart. The surgeon operates the camera and the
robotic arms from the control console, remote from the patient, while an assistant is at the patient’s side for
suctioning, retraction, and passage of suture or sponges in and out of the abdomen.
PREOPERATIVE EVALUATION — A medical history and anesthesiadirected physical examination should be
performed for all patients who undergo anesthesia. In anticipation of laparoscopy, we focus the preoperative
evaluation on those medical conditions that may affect the response to physiologic changes associated with
laparoscopy and the surgical procedure. The laparoscopic approach is used for surgical procedures with a
range of risks of perioperative cardiac and pulmonary adverse events and surgical complications. As examples,
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diagnostic laparoscopy may be a brief procedure with minimal tissue trauma, while laparoscopic radical
hysterectomy requires extensive dissection, may take a number of hours, and can result in significant blood
loss.
We believe that preoperative evaluation for laparoscopic procedures should be the same as it would be for the
equivalent open procedure. (See "Evaluation of preoperative pulmonary risk" and "Evaluation of cardiac risk
prior to noncardiac surgery".)
PHYSIOLOGIC EFFECTS OF LAPAROSCOPY
Cardiovascular changes — The cardiovascular changes during laparoscopy are variable and dynamic (table
1) [25]. These effects are generally well tolerated by healthy patients. However, significant intraoperative
cardiac dysfunction can occur in older patients and in those with cardiopulmonary disease (eg, congestive
heart failure, pulmonary hypertension, valvular heart disease). Studies of hemodynamic events during
laparoscopy in patients with significant cardiopulmonary disease have reported an increase in mean arterial
pressure (MAP), systemic vascular resistance (SVR), and central venous pressure (CVP), with decreases in
cardiac output (CO) and stroke volume (SV) during peritoneal insufflation [610]. Compared with healthy
patients, those with cardiopulmonary disease may require more pharmacologic interventions and more
intensive monitoring to respond to these changes.
Cardiovascular changes during laparoscopy relate to the increase in intraabdominal pressure (IAP) associated
with carbon dioxide (CO2) insufflation, effects of positioning, and of absorption of CO2, as follows:
● Effects of pneumoperitoneum – Pneumoperitoneum and the associated increase in IAP result in
neuroendocrine and mechanical effects on cardiovascular physiology.
• Neuroendocrine effects – Increase in IAP results in catecholamine release and activation of the
renin–angiotensin system with vasopressin release [1113]. This increases MAP in most patients
and may contribute to increases in SVR and pulmonary vascular resistance (PVR) [14].
Vagal stimulation, from insertion of the Veress needle or peritoneal stretch with gas insufflation, can
result in bradyarrhythmias. Bradycardia is common in this setting, while atrioventricular dissociation,
nodal rhythm, and asystole have been reported [15].
• Mechanical effects – Mechanical aspects of laparoscopy are dynamic; the resulting cardiovascular
effects depend on the patient’s preexisting volume status, insufflation pressure, and position.
Compression of arterial vasculature with pneumoperitoneum increases SVR and PVR, with variable
effects on CO and blood pressure (BP) [1113].
Hypercarbia caused by CO2 absorption may also increase SVR and PVR; in most cases, minute
ventilation is increased to prevent hypercarbia, but the required increase in intrathoracic pressure
may further increase SVR and PVR.
Cardiovascular effects tend to resolve quickly as pneumoperitoneum is maintained. A study of
hemodynamic data in 38 patients who underwent laparoscopic cholecystectomy reported decreases
in cardiac index, SV, and left ventricular (LV) enddiastolic volume after insufflation of CO2 to 15
mmHg, with normalization of all values within 15 minutes [16].
● Effects of positioning – Laparoscopic surgery is often performed in headup (eg, for cholecystectomy) or
headdown (eg, pelvic surgery) positions to allow the intraabdominal organs to fall away from the surgical
field. Extremes of position can affect cardiovascular function.
• Head up – The headup position (ie, reverse Trendelenburg) leads to venous pooling, tends to
reduce venous return to the heart [12,17], and may result in hypotension, especially in patients who
are hypovolemic.
• Head down – Thehead down position (ie, Trendelenburg) position increases venous return and
cardiac filling pressures. A study of the hemodynamic effects of laparoscopy included 16 patients
who underwent laparoscopic radical prostatectomy with 12 mmHg intraabdominal pressure and a 45
degree Trendelenburg position [5]. CVP, mean pulmonary artery pressure, and pulmonary capillary
wedge pressure increased two to threefold, and mean arterial BP (ABP) increased by 35 percent,
without changes in CO, heart rate (HR), or SV. Cardiac filling pressures normalized immediately
after surgery.
● Effects of hypercarbia – Absorption of CO2 during laparoscopy can have direct and indirect
cardiovascular effects. The direct effects of hypercarbia and associated acidosis include decreased
cardiac contractility, sensitization to arrhythmias, and systemic vasodilation. Indirect effects are the result
of sympathetic stimulation, and include tachycardia and vasoconstriction, which may counteract
vasodilation [12]. (See 'Pulmonary changes' below.)
Pulmonary changes — Pneumoperitoneum with CO2 and surgical positioning are associated with changes in
pulmonary function and gas exchange (table 2). These changes can result from increased IAP with
pneumoperitoneum and from absorption of CO2.
During laparoscopy, minute ventilation must be increased to compensate for absorption of CO2.
Hyperventilation may be difficult for patients with chronic obstructive pulmonary disease (COPD), asthma, and
in morbidly obese patients, especially in Trendelenburg position. In patients with COPD and in older patients,
endtidal CO2 (ETCO2) may not accurately reflect arterial partial pressure of CO2; in such patients, arterial
blood gases may be required to monitor ventilation.
The absorption and elimination of CO2 in the morbidly obese appears to be similar to nonobese patients [18].
Arterial oxygenation decreases and alveolar–arterial oxygen gradient increases in obese anesthetized patients
when placed in Trendelenburg position, though CO2 insufflation tends to slightly reverse these effects [19].
● Changes in pulmonary mechanics – Pneumoperitoneum causes cephalad displacement of the
diaphragm and mediastinal structures, which reduces functional residual capacity (FRC) and pulmonary
compliance, resulting in atelectasis and increased peak airway pressures. These effects are exacerbated
with steep Trendelenburg positioning (eg, during pelvic surgery) and are reduced with reverse
Trendelenburg positioning (eg, during cholecystectomy and gastric surgery). The changes in pulmonary
compliance may be less with retroperitoneal insufflation (eg, during renal or adrenal procedures) compared
with intraperitoneal insufflation [20].
● CO2 absorption – CO2 is highly soluble and is rapidly absorbed into the circulation during insufflation for
laparoscopy. CO2 absorption increases quickly and reaches a plateau at approximately 60 minutes of
insufflation [2022]. Ventilation must be increased to maintain normal endtidal and arterial partial pressure
of CO2 (figure 1). (See 'Mechanical ventilation' below.)
Surgical technique may influence the degree of CO2 absorption. Multiple studies have found that
subcutaneous emphysema, a possible complication of laparoscopy, is associated with increased
absorption of CO2 [2123]. (See 'Subcutaneous emphysema' below.)
Subcutaneous emphysema may be more common during retroperitoneal insufflation of CO2 compared
with intraperitoneal insufflation, but it is not clear whether the retroperitoneal approach itself increases
CO2 absorption. Findings from studies that compared CO2 absorption with these two techniques without
subcutaneous emphysema have reported conflicting results [2124].
● Ventilation/perfusion matching – The reduction in FRC and atelectasis associated with laparoscopy
may theoretically lead to shunting and ventilation/perfusion mismatch; however, in healthy patients, these
effects are minimal and well tolerated, even with steep Trendelenburg positioning [4,5,25].
● Endotracheal tube – Pneumoperitoneum and Trendelenburg positioning may cause cephalad movement
of the carina, which can result in mainstem endobronchial migration of the endotracheal tube, hypoxia,
and high inspiratory pressure [26,27]. In addition, endotracheal tube cuff pressure increases in some
patients during laparoscopy [28].
Regional circulatory changes
● Splanchnic blood flow – The mechanical and neuroendocrine effects of pneumoperitoneum can
decrease splanchnic circulation, resulting in reduced total hepatic blood flow and bowel perfusion.
However, hypercapnia can cause direct splanchnic vasodilatation. Thus, the overall effects on splanchnic
circulation are not clinically significant [29,30].
● Renal blood flow – The creation of a pneumoperitoneum results in reduction in renal perfusion and urine
output associated with renal parenchymal compression, reduced renal vein flow, and increased levels of
vasopressin [3133]. When IAP is kept under 15 mmHg, renal function and urine output generally
normalize soon after pneumoperitoneum deflation, without histologic evidence of pathologic changes.
The effects of laparoscopy on renal function for patients with preexisting renal disease have not been
studied. In most cases, we believe that the benefits of a minimally invasive surgical approach outweigh
theoretical concerns about the effect of increased intraabdominal pressure on renal function.
● Cerebral blood flow – Increased intraabdominal and intrathoracic pressures, hypercarbia, and
Trendelenburg positioning can all increase cerebral blood flow (CBF) and intracranial pressures (ICP) [34].
In healthy patients undergoing prolonged pneumoperitoneum and steep Trendelenburg position, cerebral
oxygenation and cerebral perfusion remain within safe limits [35]. In patients with intracranial mass
lesions or significant cerebrovascular disorders (eg, carotid atherosclerosis and cerebral aneurysm), the
increase in ICP may have clinical consequences. Therefore, in this patient population, we maintain strict
normocapnia during laparoscopy.
● Intraocular pressure – Intraocular pressure (IOP) increases with pneumoperitoneum and increases
further when the patient is positioned in Trendelenburg [3638]. A prospective observational study of IOP
in patients who underwent robotic laparoscopic prostatectomy in steep Trendelenburg position found that
IOP increased by an average of 13 mmHg from baseline at the end of the procedure (29 mmHg versus 16
mmHg, upper limit of normal 20 mmHg) [36]. The clinical implications of this degree of increase are
unknown, though increased IOP may play a role in the rarely reported postoperative visual loss in patients
with prolonged cases. (See 'Complications related to positioning' below and "Postoperative visual loss
after anesthesia for nonocular surgery", section on 'Postoperative ischemic optic neuropathy'.)
ANESTHETIC MANAGEMENT
Choice of anesthetic — In most cases, we perform general anesthesia for laparoscopy and robotic surgery.
For procedures performed in Trendelenburg position, general anesthesia with endotracheal intubation allows
optimal ventilatory control and support.
Others use spinal or epidural anesthesia for short procedures in the supine or headup position (eg, diagnostic
laparoscopy, laparoscopic cholecystectomy) [3942]. A sensory level of T4 to T6 is required for adequate
neuraxial anesthesia.
Monitoring and intravenous access — As for any anesthetic, standard American Society of
Anesthesiologists (ASA) monitors (eg, blood pressure [BP], electrocardiography, oxygen saturation,
capnography, and temperature) are applied prior to laparoscopy. Further monitoring (eg, continuous intraarterial
pressure) should be added as required by the patient’s medical condition, the expected blood loss, and the
duration of surgery.
All patients require placement of at least one venous catheter for anesthesia. The need for additional or high
capacity venous access should be dictated by the expected blood loss.
Many robotic procedures and some laparoscopic procedures are performed with the patient’s arms tucked at
the sides, limiting access for blood sampling, placement of an arterial catheter, or additional venous access
during the procedure.
Induction of anesthesia — A variety of medications and techniques can be used for induction of anesthesia
and are chosen based on patient factors. For most adults, intravenous (IV) induction is performed. (See
"Induction of general anesthesia".)
After induction, the eyes should be closed and covered (ie, with tape or adhesive transparent dressing) to avoid
corneal damage. An orogastric tube should be placed and suctioned to decompress the stomach prior to needle
or trochar insertion and to minimize stomach injury.
Choice of airway device — We place an endotracheal tube for airway management for laparoscopy, rather
than a supraglottic airway (SGA), to provide optimal control of ventilation for elimination of carbon dioxide
(CO2) and to protect against aspiration. A cuffed endotracheal tube allows the use of positive end expiratory
pressure (PEEP) and the high peak airway pressures that may be required during pneumoperitoneum,
especially with Trendelenburg positioning.
SGAs are commonly used for airway management for anesthesia and can be used with positive pressure
ventilation. The use of SGAs for laparoscopy is controversial. These devices do not fully protect against
aspiration of stomach contents and are ordinarily used with lower peak inspiratory pressures. However, there
are a number of studies and case reports describing the safe use of secondgeneration SGAs for laparoscopic
procedures [4346]. Secondgeneration SGAs allow the use of higher airway pressure without leak and have
esophageal vents to minimize the chance of aspiration. (See "Techniques and devices for airway management
for anesthesia: Supraglottic devices (including laryngeal mask airways)", section on 'Choice of laryngeal mask
airway'.)
Positioning — Laparoscopy is often performed in extreme headup (ie, reverse Trendelenburg) (eg, for
cholecystectomy or gastric surgery) or headdown (ie, Trendelenburg) (eg, pelvic surgery) positions to allow the
intraabdominal organs to fall away from the surgical field. In addition, any of the positions used for open
procedures may be required (ie, lithotomy, lateral decubitus, operating room [OR] table flexion or rotation). The
arms are often tucked at the patient’s sides for laparoscopic and robotic surgery. As for all longer surgical
procedures, a goal for positioning and padding is the prevention of injuries to peripheral nerves and bony
prominences. Pressure points should be padded, as should the plastic connectors on IV tubing and monitoring
devices. (See 'Complications related to positioning' below.)
Positioning devices are often used to avoid having the patient slide on the operating table with steep
Trendelenburg or reverse Trendelenburg positioning. A foot support attached to the end of the operating table is
used for laparoscopic cholecystectomy and other procedures that require reverse Trendelenburg positioning.
Nonslip padding, crossbody taping, and padded shoulder supports are options for steep Trendelenburg
positioning. We use nonslip padding with crossbody taping (ie, tape attached to the operating table from over
the shoulder to near the opposite hip). We test for sliding with maximal Trendelenburg positioning prior to
surgical prep and drape and confirm that taping does not restrict chest excursion or affect ventilation.
For robotic surgery, once the robotic device is docked with the arms connected to the instruments, the position
of the operating table must not be changed. With instruments in fixed position, patient movement can result in
injury to the abdominal wall and intraabdominal structures.
Maintenance of anesthesia
Use of nitrous oxide — As for open abdominal procedures, various inhalation and IV anesthetics can be
used for maintenance of general anesthesia for laparoscopy.
The use of nitrous oxide (N2O) for maintenance during laparoscopy is controversial. In our view, the balance of
the literature on the use of N2O along with prophylaxis for postoperative nausea and vomiting (PONV) for
laparoscopy supports its use when clinically indicated. For longer procedures, if the surgeon reports difficulty
with exposure related to bowel distention, N2O may be discontinued.
Concerns regarding the use of N2O for laparoscopy include an increase in PONV and bowel distention.
● PONV – Findings from studies of the relationship between N2O and PONV after laparoscopy have been
inconsistent, with some showing an increase in PONV with N2O and others not [4749]. A metaanalysis
of randomized trials that investigated PONV after general anesthesia with and without N2O found a higher
incidence of PONV with N2O, but the absolute difference was small (33 versus 27 percent) [50].
Intraoperative administration of propofol and prophylactic antiemetic medication eliminated the emetic
effect of N2O.
● Bowel distention – N2O diffuses into aircontaining closed spaces over time and can lead to bowel
distention, which can theoretically impair surgical exposure and dissection [51]. Based on small studies,
N2O does not appear to affect operating conditions during relatively short procedures. A surgeonblinded
study of operating conditions during laparoscopic cholecystectomy lasting an average of 75 minutes with
and without N2O found no difference in technical difficulty with N2O administration [47]. Similarly, a
surgeonblinded study of the effects of N2O during 50 laparoscopic gastric bypass surgeries found no
noticeable bowel distention during 90 minutes of anesthesia [52]. In both of these studies, the surgeons
correctly determined that N2O was being used less than half of the time.
Bowel distention with laparoscopy may be a more significant concern during longer procedures since
diffusion of N2O into gasfilled spaces increases over time. In a surgeonblinded study of approximately
350 patients who underwent colon surgery lasting 3 to 3.5 hours, surgeons were asked to rate
intraoperative bowel distention at the end of surgery [53]. Moderate or severe bowel distention occurred
more than twice as often when N2O was administered compared with air (23 percent versus 9 percent),
but there was no reported bowel distention in the majority of cases in both groups.
Neuromuscular blockade — Neuromuscular blocking agents (NMBAs) are administered during abdominal
surgery to facilitate endotracheal intubation and to improve surgical conditions. At the end of surgery,
neuromuscular blockade is reversed either by metabolism and excretion of the NMBA or by administration of
reversal medication. The speed of reversal with neostigmine depends on the degree of block; if deep block is
maintained until the end of the procedure, reversal may not be complete after the brief wound closure of most
laparoscopic procedures, and emergence and extubation may be delayed. Where sugammadex is available,
even deep block can be reversed quickly. As with any general anesthetic, reversal of NMBAs must be
confirmed objectively prior to tracheal extubation, preferably with a quantitative trainoffour monitor.
The literature regarding the need for and optimal level of neuromuscular blockade during laparoscopic
procedures is inconsistent. Some studies show improved surgical exposure in this setting with deep block
(ie, trainoffour twitch count of zero but posttetanic count of 1 to 2) compared with moderate block (ie, trainof
four twitch count of ≥1) [5458]. A review of the literature found methodologic flaws in most studies and
concluded that there was no evidence to support deep compared with moderate neuromuscular block for
laparoscopy [54].
We administer NMBAs as required by the clinical situation, aiming for the least degree of block necessary for
the clinical situation. The need for neuromuscular blockade may depend on the surgical procedure, positioning,
and the patient’s body habitus. As examples, exposure during laparoscopic cholecystectomy in a lean patient
may be adequate with minimal neuromuscular block, while laparoscopic deeppelvic surgery may require
relatively deep block to optimize surgical conditions.
During robotic procedures, deep neuromuscular block should be maintained as long as the robotic device is
docked with intraabdominal instruments attached. In this setting, any degree of unexpected patient movement
can result in injury.
Mechanical ventilation — The dynamic changes in pulmonary function during laparoscopy require
intraoperative adjustment of mechanical ventilation. (See 'Pulmonary changes' above.)
Modes of ventilation — We follow a lungprotective intraoperative ventilatory strategy, using a tidal
volume of 6 to 8 mL/kg ideal body weight and 5 to 10 cmH2O PEEP. Such a strategy may reduce
postoperative pulmonary complications and improve oxygenation during laparoscopy [5962]. We prefer to
increase the respiratory rate, rather than the tidal volume, to increase minute ventilation and compensate for
CO2 absorption while avoiding barotrauma.
Various modes of ventilation have been used in an attempt to reduce peak inspiratory pressure during
laparoscopy. While pressure support ventilation may reduce the chance of high inspiratory pressure compared
with volume control, changes in intraabdominal pressure (IAP) during surgery can result in varied minute
ventilation with pressure control settings. Pressure support with volume guarantee, where available, can be
used to limit peak airway pressure while maintaining constant ventilation [63].
We accept mild hypercapnia (ie, endtidal CO2 [ETCO2] approximately 40 mmHg) if necessary to maintain
peak airway pressures under 50 cmH2O in order to avoid barotrauma. In addition, mild hypercarbia can improve
tissue oxygenation by increasing cardiac output (CO) and vasodilation, and a shift to the right of the
oxyhemoglobin dissociation curve [6466].
Increasing the inspiratory to expiratory (I:E) ratio may be beneficial in steep Trendelenburg position during
laparoscopy. A study of ventilatory strategy in 80 patients who underwent robotic laparoscopy found that an I:E
ratio of 1:1 reduced peak inspiratory pressure compared with a ratio of 1:2, without a change in CO, though
there was no difference in oxygenation [67].
Our strategy for ventilation — We ventilate with a starting fraction of inspired oxygen (FiO2) of 0.5,
tidal volume of 6 to 8 mL/kg ideal body weight, and with PEEP of 5 to 10 cmH2O, at a respiratory rate of 8
breaths/minute, adjusted to maintain ETCO2 at approximately 40 mmHg and oxygen saturation (SaO2) >90
percent.
For patients who develop the following complications, we modify ventilation during laparoscopy as follows:
● For peak pressures over 50 mmHg, we ventilate with pressure control with volume guarantee. If peak
pressure remains over 50 mmHg, we set the I:E ratio at 1:1.
● For hypoxia (ie, SaO2 <90 percent), we auscultate breath sounds bilaterally to rule out bronchospasm and
endobronchial intubation. We increase the FiO2 and perform a recruitment maneuver (maintain peak
airway pressures at 30 cmH2O for 20 to 30 seconds if arterial BPs [ABPs] permit); if oxygenation
improves, we increase PEEP values and perform periodic recruitment maneuvers (eg, every 30 minutes).
(See 'Pulmonary complications' below.)
● If hypoxemia and/or high peak airway pressures persist, for patients in Trendelenburg position, we reduce
the degree of tilt and/or reduce the insufflation pressure (eg, from 15 to 12 mmHg).
● For hypercarbia (ie, ETCO2 >50 mmHg) despite hyperventilation, we examine for signs of subcutaneous
emphysema. (See 'Subcutaneous emphysema' below.)
● If hypercarbia and/or hypoxia persist, we discuss conversion to open surgery.
Fluid management — Perioperative fluid therapy is one of the major factors known to influence
postoperative outcomes after abdominal surgery [68,69]. Restrictive fluid therapy with avoidance of fluid
excess improves outcome after major gastrointestinal surgery, with avoidance of bowel edema and interstitial
fluid accumulation. Intraoperative fluid therapy is discussed in greater depth separately. (See "Intraoperative
fluid management".)
In patients undergoing robotic surgery in prolonged steep headdown position, excessive fluid administration
may result in facial, pharyngeal, and laryngeal edema. In this setting, restrictive or goaldirected fluid therapy is
essential. Traditional indicators used to guide fluid therapy (eg, heart rate [HR], ABP, central venous pressures
[CVPs], and urine output) are unreliable [68]. Therefore, dynamic indicators such as stroke volume (SV) or
systolic pressure variation are preferred. Optimization of dynamic indicators can be achieved by administration
of small fluid boluses as necessary. Use of invasive or noninvasive monitors for goaldirected therapy in
laparoscopic procedures remains controversial. The cardiopulmonary changes resulting from intraabdominal
CO2 insufflation interfere with interpretation of the dynamic variables (eg, SV variation, pulse pressure
variation, systolic pressure variation). We use these monitors or place arterial lines selectively in patients with
significant cardiopulmonary disease.
Nausea and vomiting prophylaxis — Laparoscopy has been identified as a risk factor for PONV [70].
Although riskbased approaches for antiemetic therapy have been proposed, the compliance with these
strategies is poor [70]. Therefore, routine prophylactic multimodal antiemetic therapy should be utilized in all
patients undergoing laparoscopic/robotic surgery. The number of antiemetic combinations can be based on the
patient’s level of risk. Our approach to antiemetic prophylaxis in this setting is as follows:
● All patients – We administer dexamethasone (4 to 8 mg IV after induction) and 5HT3 antagonists (eg,
ondansetron 4 mg at the end of surgical procedure).
● Highrisk patients – For patients at very high risk of PONV (eg, history of motion sickness, history of
previous PONV, high opioid requirements for pain relief), we administer additional antiemetic therapy with
preoperative transdermal scopolamine or a neurokinin1 (NK1) antagonist [70,71]. In addition, we use total
IV anesthesia (TIVA) with propofol.
● Rescue therapy – For rescue therapy in the immediate postoperative period, we administer lowdose
promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV).
Plan for postoperative pain management — The origins of pain after laparoscopic and robotic surgical
procedures may be both somatic (ie, from portsite incisions) and visceral (ie, from peritoneal stretch and
manipulation of abdominal tissues). The degree of pain after laparoscopic and robotic surgery is usually low to
moderate [72,73] and is less than the corresponding open procedure, but the degree of pain depends on the
specific surgery. For example, laparoscopic nephrectomy can result in pain that requires parenteral opioids in
the absence of regional analgesia [74]. (See "Management of acute perioperative pain".)
We follow a procedurespecific, multimodal approach to the management of postoperative pain, starting prior to
and continuing in the OR. We aim to minimize postoperative administration of opioids. Pain after laparoscopy
can often be managed effectively with acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs) or
cyclooxygenase2 (COX2)specific inhibitors, and dexamethasone [7580]. We routinely infiltrate the incisions
with local anesthetic (LA) at the time of wound closure. In the postoperative period, if necessary, low to
moderateintensity pain may be treated with weak opioids (eg, tramadol), and moderate to highintensity pain
may be treated with strong opioids (eg, hydrocodone and oxycodone) [76].
For hybrid or laparoscopyassisted surgical procedures with longer incisions, regional analgesia with a
transversus abdominis plane (TAP) block may be beneficial [76]. (See "Nerve blocks of the scalp, neck, and
trunk: Techniques", section on 'Transversus abdominis plane block'.)
For most laparoscopic and robotic surgical procedures, neuraxial analgesia (ie, epidural analgesia and
intrathecal morphine) is unnecessary and may not be beneficial [76]. A review of registry data from an
enhanced recovery after surgery (ERAS) protocol for colon surgery found that, while the laparoscopic approach
reduced the hospital length of stay (odds ratio [OR] 0.83), the addition of epidural analgesia to laparoscopy
modestly increased the length of stay (OR 1.1) [81]. Epidural analgesia can be considered for laparoscopic
assisted procedures, which may include a significant abdominal incision.
Intraperitoneal instillation of LAs (eg, bupivacaine and ropivacaine) may reduce the intensity of
postlaparoscopic pain [82], but the concentration and dose of the LA, as well as optimal timing of
administration, remain unknown. Management of postoperative pain is discussed in more depth separately.
(See "Management of acute perioperative pain".)
INTRAOPERATIVE COMPLICATIONS — Complications during laparoscopy include those related to the
physiologic effects of the laparoscopic approach (eg, hemodynamic compromise, respiratory decompensation),
surgical maneuvers (eg, accessrelated injury; vascular, solidorgan, or bowel injury; carbon dioxide [CO2]
spread to subcutaneous and intrathoracic spaces; gas embolism), and patient positioning [8388]. The impact
of intraoperative complications on the anesthetic management of patients is discussed in the following
sections. Further details regarding the complications of laparoscopic surgery are discussed separately. (See
"Complications of laparoscopic surgery".)
Hemodynamic complications — Hypotension, hypertension, and arrhythmias can occur during laparoscopy
as a result of the physiologic effects of the technique. (See 'Cardiovascular changes' above.)
● During insufflation – Surgical injury during abdominal access (eg, gas embolism, vascular or solid organ
injury with hemorrhage) can cause rapid cardiovascular decompensation. Initial abdominal insufflation is a
time for hypervigilance with regard to blood pressure (BP), heart rate (HR), peak inspiratory pressures,
end tidal CO2 (ETCO2), and oxygen saturation. Changes in vital signs should be immediately discussed
with the surgeon to allow reevaluation of the position of the needle or port and possible release of the
pneumoperitoneum.
(table 3)Treatment of hemodynamic dysfunction includes confirmation that intraabdominal pressure (IAP)
is within acceptable limits; exclusion of treatable causes; and supportive therapy including reduction in
anesthetics, fluid administration, and pharmacologic interventions. If supportive therapy is ineffective,
deflation of the abdomen may be necessary. After cardiopulmonary stabilization, cautious, slow re
insufflation may then be attempted using lower IAP. However, with persistent signs of significant
cardiopulmonary impairment, it may be necessary to convert to an open procedure.
● During surgery – During surgery, hemodynamic instability can occur for a variety of reasons and may be
more likely in patients with cardiac comorbidities. (See 'Cardiovascular changes' above.)
• Hemorrhage – Hemorrhage may be less obvious during laparoscopic procedures because of the
limited and focused surgical field. Unexplained hypotension should be discussed with the surgeon.
• Hyperventilation – When ventilation is increased to compensate for CO2 absorption, venous return
to the heart may be compromised and result in hypotension, especially with the use of positive end
expiratory pressure (PEEP). Fluid administration and/or change in ventilatory settings may improve
BP. (See 'Mechanical ventilation' above.)
• Positioning – Headup positioning can cause venous pooling and reduced venous return to the
heart. Vasopressor administration (eg, phenylephrine) and/or fluid administration may be required.
Pulmonary complications — Pulmonary complications during laparoscopy, including hypercarbia and
hypoxemia, can relate to the physiologic effects of the technique (eg, altered respiratory mechanics, CO2
absorption, ventilation perfusion mismatch) or surgical injury (eg, diaphragm or lung injury).
● Hypercarbia – It may be necessary to increase ventilation during laparoscopy to compensate for CO2
absorption. When hypercarbia or an increase in ETCO2 occurs despite increase in ventilation, causes for
increased absorption or decreased elimination of CO2 should be considered, including both those that
may occur during any anesthetic and those specific to laparoscopy.
When severe hypercarbia occurs during laparoscopy, the patient should be examined for signs of
subcutaneous emphysema (ie, crepitus over the abdomen, chest, clavicles and neck). (See
'Subcutaneous emphysema' below.)
When high ETCO2 persists despite aggressive hyperventilation (eg, peak airway pressures >50 cmH2O),
reduced insufflation pressure or conversion to open surgery may be required.
● Hypoxia – Oxygen desaturation can occur during laparoscopy as a result of the physiologic changes of
the technique, surgical positioning, or for reasons that hypoxia can occur during any anesthetic.
The chest should be auscultated for the quality and presence of bilateral breath sounds to rule out
bronchospasm and endobronchial intubation. Initial treatment includes an increase in inspired oxygen
concentration. Unless the patient is hypotensive, a recruitment maneuver should be performed (ie,
manual breath with plateau pressure 30 cmH2O, held for 20 to 30 seconds duration, if BP permits), and
PEEP should be optimized. If refractory hypoxemia occurs, the pneumoperitoneum should be released.
Carbon dioxide insufflation
Subcutaneous emphysema — Subcutaneous emphysema can occur during laparoscopy when CO2 is
insufflated into subcutaneous tissues. This can occur during intraperitoneal insufflation with an improperly
placed Veress needle or trocar, during extraperitoneal laparoscopy (eg, renal surgery), or during upper
abdominal laparoscopy (eg, Nissen fundoplication) [23,89]. In rare cases, gas can track into the thorax and
mediastinum, thereby resulting in capnothorax, capnomediastinum, and capnopericardium [90]. (See
'Capnothorax' below.)
The following have been identified as risk factors for subcutaneous emphysema during laparoscopy [91]:
● Surgery lasting longer than 200 minutes
● The use of six or more surgical ports
● Patient age >65
● Nissen fundoplication surgery
Multiple studies have found that subcutaneous emphysema is associated with increased absorption of CO2
[2123]. When hypercarbia occurs despite hyperventilation, the patient should be examined for signs of
subcutaneous gas over the abdomen, chest, and neck. If crepitus or swelling is found, the surgeon should be
notified; readjustment of ports, reduction of insufflation pressure, or conversion to open surgery may be
required.
In most cases, subcutaneous emphysema resolves after the abdomen is deflated, and no specific intervention
is required. When crepitus or swelling occurs in the head, neck, or upper chest, the potential for airway
compromise after extubation is increased, especially for patients who may be edematous after prolonged
procedures in Trendelenburg position. In most cases, subcutaneous CO2 is superficial and does not
compromise the airway lumen. When external swelling is severe, options include the following:
● Laryngoscopy to assess airway edema while the patient is anesthetized.
● Extubation over a tube changer. (See "Management of the difficult airway for general anesthesia", section
on 'Extubation'.)
● Delayed extubation for several hours, with the patient positioned headup, to allow resorption of CO2.
Absorption of CO2 from subcutaneous emphysema may continue for up to several hours after surgery [92].
Healthy patients are able to increase ventilation to eliminate CO2, but those with chronic lung disease or with
opioidinduced respiratory depression can remain hypercarbic and acidotic early in the postoperative period.
Somnolence, hypertension, and tachycardia may occur.
For symptomatic patients with subcutaneous emphysema of the head and neck region, a postoperative chest
radiograph should be performed to rule out capnothorax. Patients with significant subcutaneous emphysema
should be observed in the postanesthesia care unit (PACU) for several hours, until swelling begins to subside
and vital signs are normal.
Capnothorax — Capnothorax, although rare, can be potentially lifethreatening [84,93]. Capnothorax should
be suspected in the setting of an unexplained increase in airway pressure, hypoxemia, and hypercapnia,
especially during Nissen fundoplication. Other signs suggestive of capnothorax include subcutaneous
emphysema of the head and neck, inequality in chest expansion, reduced air entry, and a bulging diaphragm
(visualized by directing the videoscope towards the diaphragm) [94]. If necessary, a chest radiograph or
transthoracic ultrasound can confirm the diagnosis of capno or pneumothorax [95].
In this setting, treatment depends on the patient’s hemodynamic and respiratory status and the stage of the
surgery. If stable, reduction of insufflation pressure, hyperventilation, and increase in PEEP may be sufficient;
CO2 is resorbed quickly after even large capnothorax. In one reported case of near total capnothorax during
Nissen fundoplication, the gas resorbed within one hour postoperatively, with no specific treatment [94].
However, hemodynamic compromise can occur, requiring placement of an intrathoracic needle or a chest tube
for decompression and to allow completion of surgery [9699]. If tension capnothorax persists despite these
measures, conversion to open surgery may be required.
Capnomediastinum and capnopericardium — Capnomediastinum and capnopericardium, although rare,
can be associated with significant hemodynamic compromise. Risk factors for these complications are similar
to the risk factors for capnothorax. The diagnosis is made by chest radiograph (ie, air is visible in the
mediastinum or pericardium). Management depends on the degree of hemodynamic compromise. In most
patients, deflation of the pneumoperitoneum and close observation is adequate, while others might require
supportive therapy along with hyperventilation.
Gas embolism — Venous gas embolism is extremely common during laparoscopy, though clinically
significant emboli are rare. Studies using transesophageal echocardiography (TEE) during laparoscopic surgery
have reported an incidence of subclinical gas embolism between 17 and 100 percent [100103].
In this setting, gas embolism can occur via two mechanisms. Rarely, direct venous injection of CO2 with the
Veress needle can result in rapid, highvolume CO2 embolism at the time of abdominal insufflation.
Alternatively, CO2 entrainment is possible if a vein is severed or disrupted during surgery, allowing the gas
under pressure access to the circulation.
Signs of gas embolism include unexplained hypotension, abrupt reduction of ETCO2, hypoxemia, and
arrhythmias. The electrocardiogram (ECG) may show right heart strain with a widened QRS complex.
http://www.uptodate.com/contents/anesthesiaforlaparoscopicandabdominalroboticsurgeryinadults?topicKey=ANEST%2F100120&elapsedTimeMs… 10/23
Paradoxical embolism through a patent foramen ovale (PFO) or atrial septal defect (ASD) can occur, with
cerebral or coronary ischemia.
If gas embolism is suspected, the abdomen should be deflated to reduce CO2 entrainment, and ventilation
should be increased to reduce the size of CO2 bubbles, though hyperventilation may worsen hypotension.
Since gas embolism results from a vascular injury, hemorrhage is possible when the intraabdominal pressure is
reduced. Therefore, reinsufflation or open surgery may be required to stop hemorrhage if hemodynamic
instability persists.
Treatment is otherwise supportive, with fluid and vasopressor administration and, if necessary,
cardiopulmonary resuscitation. The leftlateral, headdown position may allow the gas bubble to float to the
apex of the right heart, away from the pulmonary artery.
Complications from surgical instrumentation — Complications of surgical instrumentation can occur during
abdominal access or during the surgical procedure. The complications of most concern to the anesthesiologist
include vascular and abdominal organ injury, both of which can result in significant hemorrhage.
Up to half of serious surgical complications occur during placement of the Veress needle or an access port
[104]. Therefore, significant injury and major hemorrhage can occur even during relatively lowrisk procedures
(eg, diagnostic laparoscopy, laparoscopic appendectomy). In this setting, surgical access to a bleeding vessel
or organ may take time; BP should be supported with IV fluid and vasopressor administration, as necessary.
As with open surgical procedures, injury to intraabdominal structures can occur during dissection. Bleeding
may be less obvious during laparoscopy than it is during open procedures. The view of the surgical field is
limited, and blood can pool away from the surgical field when patients are in headup or headdown position.
Signs of hypovolemia (ie, hypotension, tachycardia) may suggest occult bleeding and should be brought to the
surgeon’s attention.
The incidence, risk factors, and technical aspects of surgical complications are discussed in more detail
separately. (See "Complications of laparoscopic surgery".)
Complications related to positioning — Prolonged steep Trendelenburg positioning can cause conjunctival,
nasal, and laryngopharyngeal edema and may result in increased upper airway resistance [26] and, rarely,
postextubation laryngospasm and airway obstruction.
Both minor (ie, corneal abrasion) and significant (ie, ischemic optic neuropathy) ocular injuries have been
reported after laparoscopy performed in steep Trendelenburg position. Postoperative visual loss and ocular
injury are discussed in more detail separately. (See "Postoperative visual loss after anesthesia for nonocular
surgery".)
As for other long surgical procedures, patients who undergo prolonged laparoscopy are at risk for position
related nerve injury and even compartment syndrome [105,106]. Pressure points, plastic tubing connectors,
monitoring cables, and leg supports for lithotomy positioning should all be padded. With steep Trendelenburg
positioning, the arms should be positioned without caudad pull on the shoulders in order to reduce the chance
of brachial plexus stretch injury.
Shoulder braces may be used to prevent sliding during Trendelenburg positioning; their use has been
associated with brachial plexus injury in this setting, though the incidence is unknown [107].
SUMMARY AND RECOMMENDATIONS
● The laparoscopic approach has become the standard of care for many surgical procedures. Robotic
surgery is typically performed laparoscopically; anesthetic concerns for conventional laparoscopy and
robotic surgery are similar.
● Laparoscopy requires insufflation of CO2 to create space for visualization and surgical maneuvers. The
associated increase in intraabdominal pressure (IAP), along with absorption of CO2 and effects of
surgical positioning, result in neuroendocrine and mechanical changes that affect cardiopulmonary
function. (See 'Physiologic effects of laparoscopy' above.)
Cardiopulmonary physiologic changes include the following:
• Cardiovascular changes – Increased systemic vascular resistance (SVR), arterial blood pressure
(ABP), and cardiac filling pressures. (See 'Cardiovascular changes' above.)
• Pulmonary changes – Increased intrathoracic pressure, reduced functional residual capacity (FRC),
and increased airway pressures. (See 'Pulmonary changes' above.)
● We perform general anesthesia with endotracheal intubation for laparoscopy, though others have used
regional anesthesia safely for short laparoscopic procedures. (See 'Choice of anesthetic' above.)
● When indicated, we administer nitrous oxide (N2O) as part of a balanced general anesthetic, along with
prophylaxis for postoperative nausea and vomiting (PONV). (See 'Use of nitrous oxide' above.)
● For laparoscopy, we administer neuromuscular blocking agents (NMBAs) based on clinical need, aiming
for the least degree of block necessary for the clinical situation. For robotic surgery, we maintain deep
neuromuscular blockade (ie, one twitch with trainoffour peripheral nerve stimulator) until the robotic
device is undocked. (See 'Neuromuscular blockade' above.)
● We ventilate with a fraction of inspired oxygen (FiO2) of 0.5, a starting tidal volume of 6 to 8 mL/kg ideal
body weight, with positive end expiratory pressure (PEEP) of 5 to 10 cmH2O, and at a respiratory rate of
8 breaths/minute, adjusted to maintain end tidal CO2 (ETCO2) at approximately 40 mmHg and oxygen
saturation (SaO2) >90 percent. We modify ventilation during laparoscopy as follows:
• For peak pressures over 50 mmHg, we ventilate with pressure control with volume guarantee. (See
'Mechanical ventilation' above.)
• For hypoxia (ie, SaO2 <90 percent), we increase the FiO2, auscultate bilaterally for breath sounds,
and perform a recruitment maneuver (maintain peak airway pressures at 30 cmH2O for 20 to 30
seconds if ABPs permit); if oxygenation improves, we increase PEEP values and perform periodic
recruitment maneuvers (eg, every 30 minutes). (See 'Pulmonary complications' above.)
• If hypoxemia and/or high peak airway pressures persist, for patients in Trendelenburg position, we
reduce the degree of tilt and/or reduce the insufflation pressure (eg, from 15 to 12 mmHg).
• For hypercarbia (ie, ETCO2 >50 mmHg) despite hyperventilation, we examine for signs of
subcutaneous emphysema. (See 'Subcutaneous emphysema' above.)
• If hypercarbia and/or hypoxia persist, we discuss conversion to open surgery.
● Laparoscopic surgery results in less pain than the corresponding open procedure. We follow a multimodal
approach to postoperative pain control, including acetaminophen, nonsteroidal antiinflammatory drugs,
and local/regional analgesia, with the addition of opioid medication only as necessary. (See 'Plan for
postoperative pain management' above.)
● We suggest prophylaxis for PONV for all patients who undergo laparoscopy (Grade 2C). We use the
following approach (see 'Nausea and vomiting prophylaxis' above):
• All patients – We administer dexamethasone (4 to 8 mg IV after induction) and 5HT3 antagonists
(eg, ondansetron 4 mg at the end of surgical procedure).
• Highrisk patients – For patients at very high risk of PONV (eg, history of motion sickness, history
of previous PONV, high opioid requirements for pain relief), we administer additional antiemetic
therapy with preoperative transdermal scopolamine or a neurokinin1 (NK1) antagonist. In addition,
we use total intravenous anesthesia (TIVA) with propofol.
• Rescue therapy – For rescue therapy in the immediate postoperative period, we administer lowdose
promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV).
● Rare but significant complications can occur during laparoscopy, including traumatic vascular and organ
injury, CO2 embolism, capnothorax, and capnomediastinum. Treatment requires supportive measures and
may require release of the pneumoperitoneum and conversion to open surgery. (See 'Intraoperative
complications' above.)
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Topic 100120 Version 4.0
GRAPHICS
Cardiovascular changes during laparoscopy
Parameters Change Causes
Systemic vascular resistance Increased Hypercarbia

and Neuroendocrine response
mean arterial pressure (ie, increased
catecholamines,
vasopressin, and cortisol)
Mechanical factors (ie,
direct compression of
aorta)
Cardiac filling pressures Increased Increased intrathoracic

pressure secondary to
pneumoperitoneum
Increased sympathetic
output due to
neuroendocrine response
and hypercarbia
Cardiac filling volumes Variable; increased or no Interaction among:

change Increased intravascular
volume resulting from
compression of liver and
spleen
Reduced preload and
venous return
Positioning
Patient's preexisting
status
Cardiac index Variable; decreased or no Interaction among:

change Increased afterload
Decreased venous
return
Decreased cardiac filling
Increased intravascular
volume
Positioning
Patient's preexisting
status
Cardiac rhythm Bradyarrhythmias Peritoneal stretch vagal
Tachyarrhythmias Hypercarbia
Hypoxia
Capnothorax
Pulmonary embolism
Adapted from: Joshi G, Cunningham A. Anesthesia for laparoscopic and robotic surgeries. In: Clinical
Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins,
Philadelphia 2013.
Graphic 105517 Version 1.0
Pulmonary changes during laparoscopic and robotic surgery
Parameter Change Causes
Lung volume (ie, functional Decrease Elevation of diaphragm

residual capacity) Increased intraabdominal
pressure
Positioning
Lung compliance Decreased Elevation of diaphragm

Increased pleural Increased intraabdominal
pressure pressure
Increased airway
pressure
PCO 2 Increased, depending on CO 2 absorption

ventilation
PO 2 Variable Interaction among:
Atelectasis
Hypoxic pulmonary
vasoconstriction
Preoperative pulmonary
status
Tracheal position Cephalad displacement, Increased intraabdominal

possible mainstem intubation pressure
Trendelenburg position
PO 2 : partial pressure of oxygen; PCO 2 : partial pressure of carbon dioxide; CO 2 : carbon

dioxide.
Philadelphia 2013.
CO 2 absorption during laparoscopy
Mean CO 2 elimination versus time in patients with transperitoneal and retroperitoneal
laparoscopic approaches.
CO 2 : carbon dioxide; VCO 2 : mean CO 2 elimination.
Reproduced from: Kadam PG, Marda M, Shah VR. Carbon Dioxide Absorption During Laparoscopic Donor
Nephrectomy: A Comparison Between Retroperitoneal and Transperitoneal Approaches. Transplant Proc
2008; 40:1119. Illustration used with the permission of Elsevier Inc. All rights reserved.
Differential diagnosis of hemodynamic collapse during
laparoscopy
Decreased cardiac preload:
Hemorrhage
Positional blood pooling
Gas embolism
Excessive intraabdominal pressure
Capnothorax
Cardiac tamponade due to capnomediastinum or capnopericardium
Decreased cardiac contractility:
Anesthetic medication effect
Myocardial ischemia or infarction
Acidosis due to hypercarbia
Decreased SVR:
Anesthetic overdose
Acidosis due to hypercarbia
Anaphylaxis
Sepsis
Bradycardia:
Vagal stimulation
SVR: systemic vascular resistance.
Philadelphia 2013.
Disclosures
Disclosures: Girish P Joshi, MB, BS, MD, FFARCSI Speaker's Bureau: Mallinckrodt Pharmaceuticals [pain management
(intravenous acetaminophen)]; Baxter [pain management (desflurane)]. Consultant/Advisory Boards: Pacira Pharmaceuticals [pain
management (bupivacaine)]. Stephanie B Jones, MD Nothing to disclose. Marianna Crowley, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multilevel review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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3/30/2016 Anesthesia for laparoscopic and abdominal robotic surgery in adults

Author Section Editor Deputy Editor

Parameters Change Causes

Systemic vascular resistance Increased Hypercarbia

Cardiac filling pressures Increased Increased intrathoracic

Cardiac filling volumes Variable; increased or no Interaction among:

Cardiac index Variable; decreased or no Interaction among:

Cardiac rhythm Bradyarrhythmias Peritoneal stretch vagal

Parameter Change Causes

Lung volume (ie, functional Decrease Elevation of diaphragm

Lung compliance Decreased Elevation of diaphragm

PCO 2 Increased, depending on CO 2 absorption

Tracheal position Cephalad displacement, Increased intraabdominal

PO 2 : partial pressure of oxygen; PCO 2 : partial pressure of carbon dioxide; CO 2 : carbon

CO 2 : carbon dioxide; VCO 2 : mean CO 2 elimination.

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Laprobotics

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3/30/2016 Anesthesia for laparoscopic and abdominal robotic surgery in adults

Author Section Editor Deputy Editor

Parameters Change Causes

Systemic vascular resistance Increased Hypercarbia

Cardiac filling pressures Increased Increased intrathoracic

Cardiac filling volumes Variable; increased or no Interaction among:

Cardiac index Variable; decreased or no Interaction among:

Cardiac rhythm Bradyarrhythmias Peritoneal stretch ­ vagal

Parameter Change Causes

Lung volume (ie, functional Decrease Elevation of diaphragm

Lung compliance Decreased Elevation of diaphragm

PCO 2 Increased, depending on CO 2 absorption

Tracheal position Cephalad displacement, Increased intraabdominal

PO 2 : partial pressure of oxygen; PCO 2 : partial pressure of carbon dioxide; CO 2 : carbon

CO 2 : carbon dioxide; VCO 2 : mean CO 2 elimination.

Potrebbero piacerti anche

Cardiac rhythm Bradyarrhythmias Peritoneal stretch vagal