Chapter 3

Anesthetic Management for Laparoscopic

Cholecystectomy

Somchai Amornyotin

Additional information is available at the end of the chapter

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

1. Introduction

Laparoscopic surgery aims to minimize trauma of the interventional process but still ach‐
ieve a satisfactory therapeutic result. It is commonly performed because of various advan‐
tages such as reduced postoperative pain, faster recovery and more rapid return to normal
activities, shorter hospital stay, and reduced postoperative pulmonary complications. The
operative technique requires inflating gas into the abdominal cavity to provide a surgical
procedure. An intra-abdominal pressure (IAP) of 10-15 mmHg is used. Carbon dioxide
(CO2) is commonly used because it does not support combustion, is cleared more rapidly
than other gases, and is highly soluble in blood. However, the disadvantage of CO2 is that
the absorption of CO2 can cause hypercapnia and respiratory acidosis [1].
Laparoscopic cholecystectomy (LC) procedure offers several advantages such as a reduction
in stress response, postoperative pain, postoperative wound infection rate, intraoperative
bleeding, impairment of respiratory function and pulmonary complications, short recovery
time, and cosmetic appearance [1,2]. LC reduces hospital stay but has no overall effect on
postoperative mortality [3]. The risk factors for perioperative complications in patients un‐
dergoing LC can be estimated based on patient characteristics, clinical findings and the sur‐
geon’s experience [4]. The advantages should to be balanced with potential adverse effects
caused by CO2 pneumoperitoneum.
The physiological effects of intra-abdominal CO2 insufflation combined with the variations
in patient positioning can have a major impact on cardiorespiratory function. In addition,
the sequential effects of anesthesia combine to produce a characteristic hemodynamic re‐
sponse. A thorough understanding of these physiological changes is fundamental for opti‐
mal anesthetic care. Several anesthetic techniques can be performed for LC. General
anesthesia using balanced anesthetic technique including intravenous drugs, inhalation

© 2013 Amornyotin; licensee InTech. This is an open access article distributed under the terms of the Creative
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distribution, and reproduction in any medium, provided the original work is properly cited.
40 Endoscopy

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

2. Pathophysiological effects during laparoscopic cholecystectomy

2.1. Physiological effects of pneumoperitoneum

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

2.2. Respiratory effects

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

2.3. Cardiovascular effects

Hemodynamic changes include the alterations in arterial blood pressure, arrhythmias and
cardiac arrest. These cardiovascular changes depend on the interaction of several factors in‐
cluding patient positioning, neurohumoral response and the patient factors such as cardior‐
espiratory status and intravascular volume. The principal responses are an increase in
systemic vascular resistance, mean arterial blood pressure and myocardial filling pressures,
with little change in heart rate [2]. CO2 pneumoperitoneum is associated with increased pre‐
load and afterload in patients undergoing LC. It also decreased heart performance (fraction‐
al shortening), but does not affect cardiac output [8]. The patients with normal
cardiovascular function are able to well tolerate these hemodynamic changes. At IAP levels
greater than 15 mmHg, venous return decreases leading to decreased cardiac output and hy‐
potension [9]. However, these changes are short lived and have no statistical significance at
10 minutes from the time that the patient undergoes pneumoperitoneum [10].
 Anesthetic Management for Laparoscopic Cholecystectomy 41
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Bradyarrhythmias are attributed to vagal stimulation caused by insertion of the needle or

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

2.4. Effects of other systems

Increases in IAP, cardiovascular responses to peritoneal insufflations, changes in patient po‐

sition and alterations in CO2 concentration can alter intracranial pressure (ICP) and cerebral
perfusion. ICP shows a significant further increase. Cerebral blood flow has been shown to
increase significantly during CO2 insufflation.

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

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

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

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

3. Anesthetic management

3.1. Preoperative assessment

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

es individuals on a general health basis. In this preoperative assessment, there are no differ‐
ences in a routine practice between the laparoscopy and the open surgery.

3.2. Patient monitoring

Appropriate patient selection with proper monitoring to detect and reduce complications
must be used to ensure optimal anesthesia care during LC. Standard intraoperative monitor‐
ing including noninvasive blood pressure, electrocardiogram, pulse oximeter, airway pres‐
sure, end tidal carbon dioxide (ETCO2), body temperature and peripheral nerve stimulation
is routinely used. Invasive hemodynamic monitoring may be appropriate in the patients
with hemodynamic unstable or those with compromised cardiopulmonary function [1].
ETCO2 is most commonly used as a noninvasive indicator of PaCO2 in evaluating the ade‐
quacy of ventilation. Careful consideration should be taken for the gradient between PaCO2
and the tension of CO2 in expired gas (PECO2) because of V/Q mismatch. However, in the
patients with compromised cardiopulmonary function, the gradient between PaCO2 and PE‐
CO2 increases to become unpredictable. Direct arterial blood gas analysis may be considered
to detect hypercarbia. Generally, the airway pressure monitor is routinely used during inter‐
mittent positive pressure ventilation. The high airway pressure can help detection of exces‐
sive elevation in IAP.

3.3. Anesthetic techniques

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

3.3.1. General anesthesia

General anesthesia using balanced anesthesia technique including inhalation agents, intra‐
venous drugs and muscle relaxant drugs is usually used. The uses of rapid and short acting
volatile anesthetics such as sevoflurane and desflurane as well as rapid and short acting in‐
travenous drugs such as propofol, etomidate, remifentanil, fentanyl, atracurium, vecuroni‐
um and rocuronium are commonly used and have allowed anesthesiologists to more
consistently achieve a recovery profile. Propofol is effective and safe even in children and
elderly patients [17-21].
Ventilation should be adjusted to keep ETCO2 of around 35 mmHg by adjusting the minute
ventilation [1]. In patients with chronic obstructive pulmonary disease and in patients with
a history of spontaneous pneumothorax or bullous emphysema, an increase in respiratory
rate rather than tidal volume is preferable to avoid increased alveolar inflation and reduce
the risk of pneumothorax [22].
 Anesthetic Management for Laparoscopic Cholecystectomy 43
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Furthermore, the use of an auditory evoked potential or Bispectral index monitor to titrate
the volatile anesthetics leads to a significant reduction in the anesthetic requirement, result‐
ing in a shorter postanesthesia care stay and an improved quality of recovery from the pa‐
tient’s perspective [23].
Combination of local anesthetic wound infiltration, intraperitoneum spray of local anesthet‐
ic, paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase 2 inhibitors
provides the most effective pain relief, which can be supplemented with small doses of
opioids.

3.3.2. Regional anesthesia

Several advantages of regional anesthesia technique are quicker recovery, decreased postop‐
erative nausea and vomiting, fewer hemodynamic changes, less postoperative pain, shorter
hospital stay, early diagnosis of complications, improved patient satisfaction and cost effec‐
tiveness [24]. This anesthetic technique requires a cooperative patient, low IAP to reduce
pain and ventilation disturbances, gentle surgical technique and a supportive operating
room staff. However, regional anesthesia technique is not commonly used for LC. This tech‐
nique should be performed in combination with other anesthetic techniques. Local anesthet‐
ic infiltration at the trocar site combined with general anesthesia significantly reduces
postoperative pain and decreases medication usage costs [25]. Additionally, subcostal trans‐
versusabdominis block provides superior postoperative analgesia, improves theater efficien‐
cy by reducing time to discharge from the recovery unit and reduces opioid requirement
following LC [26]. Bilateral paravertebral blockade at T5-6 level combined with general an‐
esthesia can be used for LC [27].
Mehta and college had been conducted a prospective, randomized, controlled trial to com‐
pare spinal anesthesia with the gold standard general anesthesia for elective LC in the
healthy patients. Their study demonstrated that spinal anesthesia was adequate and safe for
LC in otherwise healthy patients and offered better postoperative pain control than general
anesthesia without limiting the recovery [28]. The interim analysis of a controlled random‐
ized trial is also confirmed [29]. Thoracic epidural anesthesia with 0.75% ropivacaine and
fentanyl for elective LC is also efficacious and has preserved ventilation and hemodynamic
changes within physiological limits during pneumoperitoneum with minimal treatable side
effects [30]. In addition, epidural anesthesia might be applicable for LC. However, the inci‐
dence rate of intraoperative referred pain is high, and so careful patient recruitment and
management of shoulder pain should be considered [31].

4. Intraoperative complications

Misplacement of the needle can lead to intravascular, subcutaneous tissue, preperitoneal

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

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

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

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

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

5. Postoperative period

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

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

Postoperative nausea and vomiting (PONV) is a common and distressing symptom follow‐
ing LC. The use of multimodal analgesia regimens and the reduction of opioid doses are
likely to reduce the incidence of PONV. Propofol-based anesthesia has been associated with
reduced PONV [34]. Ondansetron has been found to provide effective prophylaxis against
PONV [35]. Administration of ondansetron at the end of surgery produces a significantly
greater anti-emetic effect compared to pre-induction dosing. Reduced preoperative anxiety
by providing more information should also relieve postoperative adverse effects in order to
promote faster and better postoperative recovery period.
 Anesthetic Management for Laparoscopic Cholecystectomy 45
http://dx.doi.org/10.5772/52742

6. Summary

Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients

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

Author details

Somchai Amornyotin

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

Hospital, Mahidol University, Bangkok, Thailand

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