腹腔镜手术麻醉

1、The field of abdominal surgery has been radically changed with the introduction of laparoscopy.Recent advance in robotic and video technology have made the use of laparoscopic procedures more widely applicable. With the evolution of laparoscopy，a substantial number of abdominal procedures are being

2、performed using this approach, including cholecystectomy, myomectomy, and so on. Compared with the traditional open abdominal approach.the laparoscopic approach is:less postoperative pain. shorter hospital stay. fewer overall adverse event. more rapid return to normal activity significant cost savin

3、gs.However, it is important that the benefits of laparoscopic procedures be weighed against associated complications. A thorough knowledge of potential perioperative complications is necessary to provide optimal patient carePart I Physiological changes during laparoscopic surgery The first step in l

4、aparoscopy is establishment of pneumoperitoneum.The ideal insufflating gas would be colorless, nonexplosive, Physiologically inert and readily soluble in plasma. Part I Physiological changes during laparoscopic surgeryCO2 is used extensively in clinic. The speed and pressure of the pneumoperitioneum

5、 effect the absorption of CO2. Positioning changes will effect the physiological function. I. Cardiovascular system The pressure of pneumopertioneum effect three aspects . systemic vascular resistance (SVR. Afterloail). venous return (preload ). cardiac function.I. Cardiovascular system During lapar

6、oscopic cholecystectomy If intraabdominal pressure (IAP) 10mmHg CVP PAWP SVR CO and MAP If intraabdominal pressure (IAP) 20mmHg CVP SVR CI CO MAPor normalI. Cardiovascular systemThe cause : Intraabdominal positive pressure intrathoracic pressure cardiac blood flow CO IPPV or PEEP intrathoracic press

7、ure COI. Cardiovascular systemThe arrhythmias during laparoscopy is approximately 14%, Bradyarrhythemias including bradycardia, nodal rhythm are attributed to a vagal response due to rapid insufflations.2.The patients were placed in different body position (Table1)During cholecystectomy , the patien

8、t is placed on head-up about 10-20.2.The patients were placed in different body position (Table1)During gynecological surgery, the patient is placed on head-down position.Table-1 Hemodynamic measurements before and during pneumoperitoneum（PP）during laparoscopic cholecystectomy in healthy patientsSup

9、ine Head-downHead-upSupine with ppHead-down with ppHead-upWith ppHeart rate(beats/min)61753 466 966 1653 370 8MAP(mmHg)69 776 664 991 1187 884 13CVP(mmHg)6.2 2.910.2 3.50.8 3.510.9 2.715.9 4.63.1 2.6MPAP(mmHg)14.1 1.517.4 1.28.5 3.518.4 3.720.0 6.110.8 2.5SVR(dynes/sec/cm5)1310 3021381 3131419 34217

10、95 4441577 3442047 4303. Carbon dioxide absorption The absorption of CO2 is influenced significantly by duration of interoperation insufflations IAP and the solubility of CO2 .3. Carbon dioxide absorption Hypercarbia resulting from CO2 insufflations has direct and indirect homodynamic effects.3. Car

11、bon dioxide absorption The direct effects include peripheral vasodilatation and depression of myocardial contractility.The indirect effects include activation of the central nervous system and sympathizes system, which increase myocardial contractility and causes tachycardia and hypertensionII. Pulm

12、onary function Changes in pulmonary function with pneumoperitoneum : positioning anesthesia Elevation of diaphragm may be associated with reduction in lung volumes. II. Pulmonary function In patients undergoing laparoscopic procedure with 15 degree head-down tilt, the total pulmonary compliance decr

13、eased by 40%. with 20 degree head-up tilt, the total pulmonary compliance decreased by 20%.II. Pulmonary function Increased IAP and upward displacement of the diaphragm can cause alveolar collapse and ventilation/perfusion mismatching, resulting in hypoxemia and hypercarbia.III. The other physiologi

14、cal changesIncreased IAP can result in reduction in splanchenic and renal perfusion. Hepatic blood flow is decreased .III. The other physiological changes Reduction in urine output. the compression of renal vessel increased plasma renin activity . Increased IAP can result in aspiration and regurgita

15、tion. Part II Anesthesia for laparoscopic surgery. Preoperative evaluation and preparation for anesthesia.1. Evaluation Elderly, obesity, hypertension, coronary artery disease. Serious hypertension , cardiac dysfunction , COPD . The open surgery (open cholecystectomy) duo to medical problem (serious

16、 hypercarbia). Preoperative evaluation and preparation for anesthesia. 2. Preparation and premedication Same as general surgery. Meperidine and opioid is thought to cause sphincter of oddi spasm. Atropine may help decease spasm. H2 antagonist (ranitidine) may be given (the patient being at risk for

17、gastric aspiration). To open upper extremity vein.The choice of anesthesia 1.The principle of choice The principle is rapidly, shorter, safety comfortable and return to a normal activity early. General anesthesia is may be more suitable than other anesthesia. .The choice of anesthesia2.Method of ane

18、nthesiaA. General anesthesia Advantage: Proper depths of anesthesia. Effective ventilation. To control the relax of muscle. Adjusting MVV.The choice of anesthesiaAnesthetic Management The endotracheal intubation is suggested. An oral gastric tube should be inserted to ensure that gastric distension

19、does not exist. .The choice of anesthesiaAnesthetic agents. Propofol, Etomidate, Midazolam. Fentanyl, Remifentanyl, Succinyicholine Vecuronium Atracurium. Isoflurane, desflurane. The use of N2O is controversial. It increases bowel distention, and produce conflicting results on the rate of N2O on pos

20、toperative nausea. .The choice of anesthesiaB.Epidural anesthesia。 A high level is required for complete muscle relaxation。 70prevent diaphragmatic irritation caused by gas insufflation and surgical manipulations.The choice of anesthesiaB.Epidural anesthesia。 Serious respiratorg depression is possib

21、le * a high regional block * the use of opioid * the diaphragm is rised during insufflation. The occasional occurrence of referred shoulder pain.The choice of anesthesia C. General Aesthesia and Epidural anesthesia. D. Regional anesthesia.Perioprative monitoringCardiovascular functionRespiratory fun

22、ctionUrinary volume Neuromuscular transmission.Special considerations in the anesthesiaControl of intra-abdominal pressure * laparoscopic cholecystetomy, IAP10-15mmHgPrevention of aspiration of gastric contents. * Gynecologic laparoscopy，IAP20- 40mmHg * obesity，abdominal wall lift is used.Special co

23、nsiderations in the anesthesia Position Laparoscopic cholecystetomy ，supine is placed，reverse trendelenburg with right side elevates. Gynecologic laparoscopy, head-down and feet-up.Special considerations in the anesthesia * Enhance respiratory management during operation * The use of neuromuscular b

24、lockers and complete muscle relaxation are required.Special considerations in the anesthesiaIf it is not possible to complete the laparoscopic procedure, for exle : a major abdominal vessel lacerated ,peritonitis and hemorrhage, a open surgery will be performed.Special considerations in the anesthesiaEpidural anesthesia represent alternative for laparoscopic surgery. But a high level is required. A disadvantage is the occurrence of referred shoulder pain.Special considerations in the anesthesiaAfter operation, the residual pheumoperitoneum should b