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Anesthesia for laparoscopic and abdominal robotic surgery in

adults
Author: Girish P Joshi, MB, BS, MD, FFARCSI
Section Editor: Stephanie B Jones, MD
Subdirector: Marianna Crowley, MD

Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de revisión por pares está
completo.

Revisión de literatura actualizada hasta:  febrero de 2020. | Este tema se actualizó por última vez:  20 de septiembre de
2019.

INTRODUCCIÓN

El abordaje laparoscópico se ha convertido en un estándar de atención para muchos procedimientos

quirúrgicos abdominales. En comparación con la laparotomía, la laparoscopía permite incisiones
más pequeñas, reduce la respuesta al estrés postoperatorio, reduce el dolor postoperatorio y reduce
el tiempo de recuperación. La laparoscopia requiere la insuflación de gas intraperitoneal o
extraperitoneal, generalmente dióxido de carbono (CO 2), to create space for visualization and
surgical maneuvers.

La cirugía robótica generalmente se realiza por vía laparoscópica y se usa con mayor frecuencia para
la cirugía ginecológica y urológica, aunque el uso se está expandiendo en otras especialidades.

Las preocupaciones anestésicas para pacientes sometidos a cirugía laparoscópica y robótica

difieren de las de los pacientes sometidos a cirugía abdominal abierta. Incluyen los efectos
fisiológicos del neumoperitoneo, la absorción de CO 2, and positioning required for surgery. In
addition, some laparoscopic/robotic 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 "Robot-
assisted 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 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 patient-side cart with robotic
arms (figure 1). 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 patient-side 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 anesthesia-directed 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, 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) [2-5]. 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, chronic obstructive pulmonary disease [COPD], 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 [6-10]. 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 [11-13]. 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) [11-13].

Hypercarbia caused by CO2 absorption may also increase SVR and PVR; in most cases,
minute ventilation is increased to prevent hypercarbia, but the increase in intrathoracic
 pressure that accompanies ventilator adjustments 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) end-diastolic 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 head-up (eg, for

cholecystectomy) or head-down (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 head-up 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 – The-head 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 COPD, asthma, and in morbidly obese patients,
especially in Trendelenburg position. In patients with COPD and in older patients, end-tidal 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 [20-22]. Ventilation must be increased to maintain
normal end-tidal and arterial partial pressure of CO2 (figure 2). (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 [21-23]. (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
[21-24].

● 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 [31-33]. 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 [36-38]. 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 head-up position (eg,
diagnostic laparoscopy, laparoscopic cholecystectomy) [39-42]. 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: Overview".)

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
second-generation SGAs for laparoscopic procedures [43-47]. Second-generation SGAs allow the use
of higher airway pressure without leak and have esophageal vents to minimize the chance of
aspiration. (See "Supraglottic devices (including laryngeal mask airways) for airway management for
anesthesia in adults", section on 'Choice of supraglottic airway'.)
Positioning — Laparoscopy is often performed in extreme head-up (ie, reverse Trendelenburg) (eg, for
cholecystectomy or gastric surgery) or head-down (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 may be used for laparoscopic cholecystectomy and other procedures that require
reverse Trendelenburg positioning.

Nonslip padding and cross-body taping are options for preventing the patient from sliding on the
operating table during steep Trendelenburg positioning. We use nonslip padding with cross-body
taping (ie, tape attached to the operating table from over the shoulder to near the opposite hip).
Shoulder supports have been associated with brachial plexus injury; if they are used, they should be
placed laterally, at the acromioclavicular joint, to avoid direct nerve compression (see "Patient
positioning for surgery and anesthesia in adults", section on 'Nerve injuries associated with the
Trendelenburg position'). 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. (See "Maintenance of general
anesthesia: Overview".)

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 – Although N2O is associated with a modestly higher incidence of PONV than other
inhalation anesthetic agents, this can be mitigated by antiemetic prophylactic measures [48].
(See "Postoperative nausea and vomiting", section on 'Anesthetic factors'.)  

● Bowel distention – N2O diffuses into air-containing closed spaces over time and can lead to
bowel distention, which can theoretically impair surgical exposure and dissection [49]. Based on
small studies, N2O does not appear to affect operating conditions during relatively short
procedures. A surgeon-blinded 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 [50]. Similarly, a surgeon-blinded study of the effects
of N2O during 50 laparoscopic gastric bypass surgeries found no noticeable bowel distention
during 90 minutes of anesthesia [51]. 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 gas-filled spaces increases over time. In a surgeon-blinded 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 [52]. 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 train-of-four monitor. (See "Maintenance of general
anesthesia: Overview", section on 'Neuromuscular blocking agents'.)

The literature regarding the need for and optimal level of neuromuscular blockade during
laparoscopic procedures is inconclusive. Some studies have shown improved surgical exposure in
this setting with deep block (ie, train-of-four twitch count of zero but post-tetanic count of 1 to 2)
compared with moderate block (ie, train-of-four twitch count of ≥1) [53-57], while others have shown
no benefit from deeper block [58]. A 2018 meta-analysis of randomized controlled trials that
compared deep with moderate neuromuscular blockade during laparoscopy found insufficient
evidence to support the use of deep neuromuscular blockade [59].

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 deep-pelvic 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 lung-protective 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 [60-63]. 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 [64].

We accept mild hypercapnia (ie, end-tidal 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 [65-67].

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 [68].
 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 conditions, 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 [69,70]. 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 head-down position, excessive fluid
administration may result in facial, pharyngeal, and laryngeal edema. In this setting, restrictive or
goal-directed 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 [69]. However,
dynamic indicators such as stroke volume (SV) or systolic pressure variation may also be unreliable,
and use of invasive or noninvasive monitors for goal-directed 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. (See "Intraoperative fluid management", section on 'Dynamic
hemodynamic parameters'.)

Nausea and vomiting prophylaxis — Laparoscopy has been identified as a risk factor for PONV,
though the literature on this issue is conflicting [71]. Although risk-based approaches for antiemetic
therapy have been proposed, the compliance with these strategies is poor [72]. Therefore, routine
prophylactic multimodal antiemetic therapy should be utilized in all patients undergoing
laparoscopic/robotic surgery. The number of antiemetic medications 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 5-HT3

antagonists (eg, ondansetron 4 mg at the end of surgical procedure).

● High-risk patients – For patients at very high risk of PONV (eg, female patients, history of motion
sickness, history of previous PONV, high opioid requirements for pain relief), we administer
additional antiemetic therapy with preoperative transdermal scopolamine (1.5 mg transdermal
patch) [72,73]. In addition, we use total IV anesthesia (TIVA) with propofol.

● Rescue therapy – For rescue therapy in the immediate postoperative period, we administer low-
dose promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV).

The management of PONV is discussed in more detail separately. (See "Postoperative nausea and
vomiting".)

Postoperative pain management — The origins of pain after laparoscopic and robotic surgical
procedures may be both somatic (ie, from port-site 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 [74,75] and is less than the corresponding open procedure, but the degree of
pain depends on the specific surgery. For example, pain after laparoscopic nephrectomy can usually
be managed adequately with parenteral opioids without regional analgesia [76]. (See "Management of
acute perioperative pain".)

We follow a procedure-specific, multimodal approach to the management of postoperative pain,

starting prior to and continuing in the OR [77]. 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
[78-83]. We routinely infiltrate the incisions with local anesthetic (LA) at the time of wound closure. In
the postoperative period, if necessary, low- to moderate-intensity pain may be treated with weak
opioids (eg, tramadol), and moderate- to high-intensity pain may be treated with strong opioids (eg,
hydrocodone and oxycodone) [79].
For hybrid or laparoscopy-assisted surgical procedures with longer incisions, regional analgesia with
a transversus abdominis plane (TAP) block may be beneficial [79]. (See "Abdominal nerve block
techniques", section on 'Transversus abdominis plane (TAP) block'.)

The author does not use neuraxial analgesia (ie, continuous epidural analgesia or intrathecal opioids)
for postoperative pain after laparoscopic surgery, while others may use these techniques in selected
patients. Neuraxial analgesia is usually unnecessary and not beneficial [79], and retrospective studies
suggest that epidural analgesia may delay ambulation and increase the length of stay. 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) [84].
Similarly, a database review of approximately 192,000 laparoscopic colorectal procedures reported an
increase in mean length of stay in patients who had epidural analgesia (six days versus five days,
mean difference 0.6 days, 95% CI 0.27-0.93 days) [85].

Intraperitoneal instillation of LAs (eg, bupivacaine and ropivacaine) may reduce the intensity of
postlaparoscopic pain [86], 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,
access-related injury; vascular, solid-organ, or bowel injury; carbon dioxide [CO2] spread to
subcutaneous and intrathoracic spaces; gas embolism), and patient positioning [87-92]. 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 (table 3). (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.

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 – Head-up 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) (table
4 and table 5).

● 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 (table 4).

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 (table 5).

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) [23,93]. In rare cases, gas can track
into the thorax and mediastinum, thereby resulting in capnothorax, capnomediastinum, and
capnopericardium [94] (table 6). (See 'Capnothorax' below.)

The following have been identified as risk factors for subcutaneous emphysema during laparoscopy
[95]:

● 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 [21-23]. 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
in adults", section on 'Extubation'.)
● Delayed extubation for several hours, with the patient positioned head-up, to allow resorption of
CO2.

Absorption of CO2 from subcutaneous emphysema may continue for up to several hours after surgery
[96]. Healthy patients are able to increase ventilation to eliminate CO2, but those with chronic lung
disease or with opioid-induced 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 post-anesthesia care unit (PACU) for
several hours, until swelling begins to subside and vital signs are normal.

Capnothorax — Capnothorax, although rare, can be potentially life-threatening [88,97]. Causes of

capnothorax are presented in a table (table 6). 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) [98]. If necessary, a chest radiograph or
transthoracic ultrasound can confirm the diagnosis of capno- or pneumothorax [99].

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 [98].

However, hemodynamic compromise can occur, requiring placement of an intrathoracic needle or a

chest tube for decompression and to allow completion of surgery [100-103]. 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 [104-107].

In this setting, gas embolism can occur via two mechanisms. Rarely, direct venous injection of CO2
with the Veress needle can result in rapid, high-volume 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.
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, re-insufflation 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 left-lateral, head-down 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 [108]. Therefore, significant injury and major hemorrhage can occur even during relatively
low-risk 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 head-up
or head-down 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 [109,110]. 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 [111].

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 train-of-four 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 '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 5-HT3

antagonists (eg, ondansetron 4 mg at the end of surgical procedure).

• High-risk 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 (1.5 mg transdermal patch).
In addition, we use total intravenous anesthesia (TIVA) with propofol.

• Rescue therapy – For rescue therapy in the immediate postoperative period, we administer
low-dose 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 17.0

GRAPHICS

Operating room layout during robotic surgery

The most commonly used robotic system occupies a lot of operating room space. This graphic shows one
configuration, with the robotic cart positioned at the patient's head. The cart may be placed at the patient's side (eg,
for kidney surgery), and is often placed between the patient's legs in the lithotomy position for gynecologic and
urologic surgery.

Reproduced with permission from: Horgan S, Sedrak MF. Robotic surgery. In: Fischer's Mastery of Surgery, 6th ed, Fischer JE,
Jones DB, Pomposelli FB, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. Copyright © 2012 Lippincott Williams &
Wilkins (www.lww.com). Unauthorized reproduction of this material is prohibited.

Graphic 104766 Version 4.0

Cardiovascular changes during laparoscopy

Parameters Change Causes

Systemic vascular resistance and Increased Hypercarbia

mean arterial pressure Neuroendocrine response (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 change Interaction among:

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 change Interaction among:

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 2.0

Pulmonary changes during laparoscopic and robotic surgery

Parameter Change Causes

Lung volume (ie, functional residual Decrease Elevation of diaphragm

capacity) Increased intraabdominal pressure
Positioning

Lung compliance Decreased Elevation of diaphragm

Increased pleural pressure Increased intraabdominal pressure
Increased airway pressure

PCO 2 Increased, depending on ventilation CO 2 absorption

PO 2 Variable Interaction among:

Atelectasis
Hypoxic pulmonary vasoconstriction
Preoperative pulmonary status

Tracheal position Cephalad displacement, possible mainstem Increased intraabdominal pressure

intubation Trendelenburg position

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

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 105522 Version 2.0

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.

Graphic 105217 Version 2.0

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.

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 105520 Version 2.0

Differential diagnosis of hypercarbia during laparoscopic and robotic surgery

Increased CO 2 absorption

CO 2 insufflation (extraperitoneal insufflation > intraperitoneal insufflation)

Subcutaneous emphysema
CO 2 embolism
Capnothorax, capnomediastinum, capnopericardium

Decreased CO 2 removal (ie, hypoventilation, V/Q mismatch)

Endobronchial intubation
Atelectasis
Airway obstruction
Reduced cardiac output

Increased CO 2 production

Obesity
Malignant hyperthermia
Fever
Thyrotoxicosis

CO 2 rebreathing

Defective CO 2 absorber
Malfunctioning breathing circuit valves

CO 2 : carbon dioxide; V/Q: ventilation/perfusion.

Adapted with permission 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. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105521 Version 5.0

Causes of hypoxemia during laparoscopic and robotic surgery

Patient factors

Preexisting cardiopulmonary dysfunction

Morbid obesity

Intraoperative ventilation

Low FiO 2
Hypoventilation

V/Q mismatch

Endobronchial intubation
Atelectasis
Capno (pneumo) thorax
Pulmonary embolism
Patient position (eg, lateral decubitus)

Reduced cardiac output

Inferior vena cava compression

Dysrhythmias
Myocardial depression (eg, anesthetic drug effects)
Hemorrhage

Anemia

Pre-existing anemia
Hemorrhage

FiO 2 : fraction of inspired oxygen; V/Q: ventilation/perfusion.

Adapted with permission 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. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105518 Version 4.0

Causes of subcutaneous emphysema, capnothorax, and capnomediastinum during laparoscopy and
robotic surgery

Inadvertent peritoneal breach

Retroperitoneal insufflation
Misdirected Veress needle or peritoneal port (eg, damage to falciform ligament, subcutaneous needle or port placement)
Specific to capnothorax and capnomediastinum:
Gas tracked through fascial planes from neck and thorax into the mediastinum and pleural space
Dissection around the diaphragm (eg, during Nissen fundoplication, gastric bypass surgery)
Passage of gas through the pleuroperitoneal hiatus (ie, foramen of Bochdalek)
Passage of gas through congenital defects (ie, foramen of Morgagni)

Adapted with permission 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. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 105519 Version 4.0

Contributor Disclosures
Girish P Joshi, MB, BS, MD, FFARCSI Speaker's Bureau: Baxter [anesthesia (desflurane)]. Consultant/Advisory
Boards: Pacira Pharmaceuticals [pain management (bupivacaine)]. Stephanie B Jones, MD Spouse/Partner
Disclosure: Consultant/Advisory Board: Allurion Inc [gastric balloon for non-surgical weight loss]. Marianna
Crowley, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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