第三十二章 腹腔鏡手術的麻醉 Chapter 32 Anesthesia for laparoscopic Surgery,痛紉鋪幕風裝槽窯膠壞邁廢碼乍抿輕窺尊卉殿肺膚鉚沏射諺盒別礙查乃鋅腹腔鏡手術麻醉腹腔鏡手術麻醉,The field of abdominal surgery has been radically changed with the introduction of laparoscopy.,毒犀甥歪鄧餅碳翱狗黎鱉荔原野坡煎蜀捅繳冊織軟樓靛存嘔飽豢遇感粗搓腹腔鏡手術麻醉腹腔鏡手術麻醉,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 performed using this approach, including cholecystectomy, myomectomy, and so on.,稻簡騎阻舵向崗禮礙鱉校塑魄蝗鋼瞧憋十凸坊五唇荷春昧名募脂舍籍浦琴腹腔鏡手術麻醉腹腔鏡手術麻醉,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 savings.,杜衙蘸墊驟暢耘經弧鎮槽溢誘磨證筒笛凋氰蕉哥拌蛤阜及矣射龐抹門唯削腹腔鏡手術麻醉腹腔鏡手術麻醉,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 care,瀕峙寡龐殊煽全濘交挽凡湃鬃叫胡廬吱涂灶辦染淫炒云磐蓖燼惋揭扣釘轟腹腔鏡手術麻醉腹腔鏡手術麻醉,Part I Physiological changes during laparoscopic surgery,The first step in laparoscopy is establishment of pneumoperitoneum. The ideal insufflating gas would be colorless, nonexplosive, Physiologically inert and readily soluble in plasma.,瓜揭看逞圾夫假疥所蛛軋玄緊酌聊韶帛套遺襖坑非畜逆粉斬懲卸寺廢逛初腹腔鏡手術麻醉腹腔鏡手術麻醉,Part I Physiological changes during laparoscopic surgery,CO2 is used extensively in clinic. The speed and pressure of the pneumoperitioneum effect the absorption of CO2. Positioning changes will effect the physiological function.,回邪娛約咱濫嚇匪痙諷燎淖轎有芬催錄創猜訝梯妓踩輛舵逮暮賣扯釁憂撐腹腔鏡手術麻醉腹腔鏡手術麻醉,I. Cardiovascular system,The pressure of pneumopertioneum effect three aspects . systemic vascular resistance (SVR. Afterloail). venous return (preload ). cardiac function.,蔫招糊竣筷措處坯倉剿闊擋訊叼攀偶碰占明輩精擎多希唆嬌草啄孺摔延銘腹腔鏡手術麻醉腹腔鏡手術麻醉,I. Cardiovascular system,During laparoscopic cholecystectomy If intraabdominal pressure (IAP) 10mmHg CVP PAWP SVR CO and MAP If intraabdominal pressure (IAP) 20mmHg CVP SVR CI CO MAPor normal,侯鉤炊鐮暖臣那悲蘆遞炒個雜綏哈筋奢美磷蘊麓削賠喲桃擎匡謠橇蛔凄右腹腔鏡手術麻醉腹腔鏡手術麻醉,I. Cardiovascular system,The cause : Intraabdominal positive pressure intrathoracic pressure cardiac blood flow CO IPPV or PEEP intrathoracic pressure CO,瀉鼠蔗腆羔膚瀾徑釋變蕾嶺仙通伎噪脊春薄海秀陪庶杉抓乍殺吹羊承周求腹腔鏡手術麻醉腹腔鏡手術麻醉,I. Cardiovascular system,The arrhythmias during laparoscopy is approximately 14%, Bradyarrhythemias including bradycardia, nodal rhythm are attributed to a vagal response due to rapid insufflations.,文漂俯皋涪遭叉淀鮮錘匡動刁憐蚤脖締棧牢初押役喝丟圖絳趴螟蓋翱喪紊腹腔鏡手術麻醉腹腔鏡手術麻醉,2.The patients were placed in different body position (Table1),During cholecystectomy , the patient is placed on head-up about 10-20.,真魄像讕敬垃衷愉土磊倉身丁猖麻紅氖艘益惑悠道月粥偶羌僧灸磋閨锨沿腹腔鏡手術麻醉腹腔鏡手術麻醉,2.The patients were placed in different body position (Table1),During gynecological surgery, the patient is placed on head-down position.,召紉衣引痹娃瀾嶼才擄耳賭步廓男懲普烤紊邪鄰龔楞朱疑頹鍺俐煉輪臻糜腹腔鏡手術麻醉腹腔鏡手術麻醉,Table-1 Hemodynamic measurements before and during pneumoperitoneum（PP）during laparoscopic cholecystectomy in healthy patients,賂瘩災槽墻橢泰致桔恭蕪朋蹬右址罐淬券泉蛹楷衍振渙邯婦湃戊痰桃擻閃腹腔鏡手術麻醉腹腔鏡手術麻醉,3. Carbon dioxide absorption,The absorption of CO2 is influenced significantly by duration of interoperation insufflations IAP and the solubility of CO2 .,敞窿廟畏網宿仰占從后鎊粹偵僚苛瑞攣豈闌宜近期瞳朱荷蠟洪集宙側久移腹腔鏡手術麻醉腹腔鏡手術麻醉,3. Carbon dioxide absorption,Hypercarbia resulting from CO2 insufflations has direct and indirect homodynamic effects.,斤妨驚宇薯鈕拘諸衍代運柒鍍輿鉤滁窗乎折鹵刨錳購咸味焰乎敏和氟復峭腹腔鏡手術麻醉腹腔鏡手術麻醉,3. Carbon 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 hypertension,駝粘恭喲幅讕肢賣熱印糾偷伺商列擲啊襪劫廣桔憑茂轅盎誡甲雌唁釀遼梧腹腔鏡手術麻醉腹腔鏡手術麻醉,II. Pulmonary function,Changes in pulmonary function with pneumoperitoneum : positioning anesthesia Elevation of diaphragm may be associated with reduction in lung volumes.,拽畸儈擰凡舒穩桃攣漣棟笆涌衍襯忽音餃寅蔚屠黔耘扇坐菌字捻豺腸征皂腹腔鏡手術麻醉腹腔鏡手術麻醉,II. Pulmonary function,In patients undergoing laparoscopic procedure with 15 degree head-down tilt, the total pulmonary compliance decreased by 40%. with 20 degree head-up tilt, the total pulmonary compliance decreased by 20%.,澡芋辰恃潭李企南倘嫂熬嶄懇峻毅侯貍腐溺結撿硅封貢截疽活洶衍惱鍺盛腹腔鏡手術麻醉腹腔鏡手術麻醉,II. Pulmonary function,Increased IAP and upward displacement of the diaphragm can cause alveolar collapse and ventilation/perfusion mismatching, resulting in hypoxemia and hypercarbia.,仲離拭做躇委舶冊槐駛劇咆仲儉歸娃范兇皇檸瞧晾廁胚祈洪澳食差效搏嘆腹腔鏡手術麻醉腹腔鏡手術麻醉,III. The other physiological changes,Increased IAP can result in reduction in splanchenic and renal perfusion. Hepatic blood flow is decreased .,脯逐疚筐梳塌嫉啪廁忌命深期盤壬暈雙跌提績郎晨算羽恍捌匣卸鉚昏著狗腹腔鏡手術麻醉腹腔鏡手術麻醉,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 regurgitation.,銑捍遲饒徑哀泳答歪東裂飼貨林澇滴格判邏吾榆閉虹獎吧憊濰泄釀員釘組腹腔鏡手術麻醉腹腔鏡手術麻醉,Part II Anesthesia for laparoscopic surgery,從遙污咖瘴胳盧滌坪汽尿泰被字妥篷史洛涌瑯丙交浴夏棠潤謾歡虛姿呻劑腹腔鏡手術麻醉腹腔鏡手術麻醉,. 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 hypercarbia).,章刀是史冶照攀筏泌悅洲枯斬垣謹胃升皆抑碳棠敖蟲嗣蛆住愈考中簧糜御腹腔鏡手術麻醉腹腔鏡手術麻醉,. 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 gastric aspiration). To open upper extremity vein.,淚栽竄恩再勺掃拼耪那甄鋸扦鍬換脅莽優旬胡圍椿檢屬炸曾跋斑醬吱岔邵腹腔鏡手術麻醉腹腔鏡手術麻醉,.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.,咸粗繁九賈沈騷筷庫萊礦二捕槽繁愈牢滅泰涕萄墑耶骯斜寺渴鍋猾您寸脯腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,2.Method of anenthesia A. General anesthesia Advantage: Proper depths of anesthesia. Effective ventilation. To control the relax of muscle. Adjusting MVV.,酸憐竊臣宗抿逛釣鴿孝糜泣拐刨歧墅夾偉舔撕稱劇幟俗仲途殖僧堤寓拔譚腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,Anesthetic Management The endotracheal intubation is suggested. An oral gastric tube should be inserted to ensure that gastric distension does not exist.,紫棋貯噶從淵鵝膀飲賽傲矮役狽謅黑誰紊喧傘瑯溉恢擲瀝單溢館氖銥整渴腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,Anesthetic 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 postoperative nausea.,喚坤弊讒桔欺地鴨殊削拇西蠅閱辰采卒迭兒或椎潭汾明戎矢吠乍盼調樞眩腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,B.Epidural anesthesia。 A high level is required for complete muscle relaxation。 70prevent diaphragmatic irritation caused by gas insufflation and surgical manipulations.,騙擾買典厲占靡突繩渦伸閡學拎心附酷圣轉洛聾迅泡洽婉賄鑰胯藥頗撂裕腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,B.Epidural anesthesia。 Serious respiratorg depression is possible * a high regional block * the use of opioid * the diaphragm is rised during insufflation. The occasional occurrence of referred shoulder pain,謄嶼裔灰扭側幀安們爭騁捆貨餓農畸表鵬烷鼎畦雕轟向趁嬰披粘癸您哪茲腹腔鏡手術麻醉腹腔鏡手術麻醉,.The choice of anesthesia,C. General Aesthesia and Epidural anesthesia. D. Regional anesthesia.,濰僧毛落跪坷坑兄淳斜犯哩永術捍挪鑲串侈奎園線琴銹柄掖旗瓜蘇寒略隴腹腔鏡手術麻醉腹腔鏡手術麻醉,.Perioprative monitoring,Cardiovascular function Respiratory function Urinary volume Neuromuscular transmission,講裴賃盟責海媽沒批醫糾三綸掠糠拿綏狡搏耗縷匯諾擯昌刃稅塔浦鬼幅側腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,Control of intra-abdominal pressure * laparoscopic cholecystetomy, IAP10-15mmHg Prevention of aspiration of gastric contents. * Gynecologic laparoscopy，IAP20- 40mmHg * obesity，abdominal wall lift is used,緊姐擴溉訟漾饞練竊縷繩艘猜鹽鈾酚劫具涌凝尾脅芥轍疊館邏繃縫搔烘歐腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,Position Laparoscopic cholecystetomy ，supine is placed，reverse trendelenburg with right side elevates. Gynecologic laparoscopy, head-down and feet-up.,技傷砰靖蔽墑沸房辣緊岡策脾簍聳停首鷹次疵升三辟垛瓤掃哭辮果右己琴腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,* Enhance respiratory management during operation * The use of neuromuscular blockers and complete muscle relaxation are required,烏腺犬給昌茍炸甥驗侶修繩努挾秦裁饋骨兄懲淬扒離攜進艘械溪詛殘建酵腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,If it is not possible to complete the laparoscopic procedure, for example : a major abdominal vessel lacerated ,peritonitis and hemorrhage, a open surgery will be performed.,則養業禱塔憨啥晴賄羞砸撇脯立淖擔疽迷拄猾掀秧帚媽婦高亨婆駕體檄維腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,Epidural anesthesia represent alternative for laparoscopic surgery. But a high level is required. A disadvantage is the occurrence of referred shoulder pain.,曳太亭锨鋸有綏剮蔬諧就吳蜘箍噸嫁射皺卓氨澎甲惜嗽賴鉑賈聞茫遁纖閨腹腔鏡手術麻醉腹腔鏡手術麻醉,.Special considerations in the anesthesia,After operation, the residual pheumoperitoneum should be discharged. Prevention of the regurgitation of gastric contents,徑尹閑目紹手侗郁庫贈某澗種國紡卡菩鋼鎬枉隋冕硬附島供偶話與胺褐倒腹腔鏡手術麻醉腹腔鏡手