by Lisa K. Jacobs, MD, Vafa Shayani, MD, Jonathan M. Sackier, MD, FRCS, FACS
INTRODUCTION
Initially, laparoscopic surgery was embraced by gynecologists as a minimally invasive diagnostic and therapeutic technique. While it was known that insufflation of the abdomen had marked cardiovascular effects, these were well tolerated because the patient population was young and the cases were of short duration.1
The patient population has changed dramatically as general surgeons have applied laparoscopic technology to other operative procedures. One third of patients undergoing laparoscopic cholecystectomy are over the age of 55, one fourth are over the age of 65, and one twelfth are over the age of 75.2 Age, cardiovascular disease, and pulmonary disease are not considered contraindications for laparoscopic surgery. However, as the effects of insufflation of the abdomen on cardiovascular disease and pulmonary disease are striking, they are tolerated less well in this older population3 with an increased mortality in patients over 80 years of age.4
GENERAL CONSIDERATIONS
The routine preoperative evaluation required for all patients undergoing general anesthesia in most institutions is based on two age categories: 1) under 35 years and 2) over 35 years. Patients under 35 years of age with no previous medical history require a history and physical examination and a measurement of the hemoglobin level. If the patient is a woman of child-bearing potential, a urine pregnancy test is performed. For patients over the age of 35 a thorough history and physical examination, complete blood count, electrolytes, electrocardiogram, and a chest x-ray are recommended. In both age groups, additional investigations are based on history and physical examination findings. In addition to the above laboratory tests, all patients are questioned preoperatively about hematologic disorders leading to hypercoagulable states or bleeding tendencies.
Patients with sickle cell disease should be evaluated preoperatively for sickle cell lung disease. Laparoscopy performed on patients with sickle cell disease can result in sickle cell crisis and hypoxia if sickle cell lung disease is present.5 To avoid painful vaso-occlusive complications, preoperative erythrocyte transfusions can be given.6 To determine which patients require additional testing, the history should include questions addressing exercise tolerance, smoking history, and chest pain. A thorough cardiac evaluation should be performed if the patient reports any cardiac symptoms. Patients who develop shortness of breath after climbing one flight of stairs, those with a smoking history, and any patient with a history of pulmonary disease should have pulmonary function tests and an arterial blood gas preoperatively.5,7
The elderly require further preoperative evaluation for laparoscopic surgery because of the hemodynamic and pulmonary effects of pneumoperitoneum. Usually, the pneumoperitoneum required for laparoscopic surgery is well tolerated; however, preoperative evaluation allows the anesthesiologist to make appropriate management decisions to compensate for the marked changes in cardiac and pulmonary parameters that are induced by pneumoperitoneum.5,8-11 Mean arterial pressure, systemic vascular resistance, inferior vena caval resistance and heart rate are all increased in the presence of pneumoperitoneum.3,7,8,10,12-18 Additionally, cardiac output and stroke volume changes can be variable depending on the patient’s volume status at the time of institution of pneumoperitoneum.16,19 Pulmonary changes that occur with pneumoperitoneum include an increased peak inspiratory pressure and intrathoracic pressure and decreased pulmonary compliance, vital capacity, and functional residual capacity.20-23 These changes, and the use of carbon dioxide to create the pneumoperitoneum, can lead to hypercarbia if an adequate minute ventilation is not maintained.8,9,24-26 Hypercarbia is exacerbated if the patient has a history of pulmonary disease. Therefore, it may be beneficial to place a radial artery catheter preoperatively in these patients to allow monitoring of arterial oxygen and carbon dioxide levels. If any changes occur in the pulmonary or cardiac status of the patient during the procedure, pneumoperitoneum should be released and the patient stabilized.
Both the Trendelenburg position, used for placement of the Veress needle, and insufflation of the abdomen, which results in increased intra-abdominal pressure, puts the patients with risk factors for aspiration in even greater peril.27,28 These risk factors include hiatal hernia, diabetes, renal failure, pregnancy, obesity, bowel obstruction, and decreased gastric motility.29 Such patients require to be kept with nothing by mouth for 8 hours prior to surgery, close monitoring, placement of a nasogastric tube, and endotracheal intubation with a cuffed endotracheal tube. To decrease the likelihood that the urinary bladder will be injured with Veress needle placement, the patient should urinate just prior to the operation or the bladder should be emptied by a Foley catheter.
Subcutaneous emphysema is a possible complication of insufflation of the abdomen. This results from improper placement of the Veress needle prior to insufflation, dislodgement of the Veress needle during insufflation, or from diffusion of carbon dioxide through tissue planes. Pneumoscrotum can occur if the patient has a patent processus vaginalis or inguinal hernia; therefore, all patients should be evaluated preoperatively for hernias.
Decreased venous return from the lower extremities may be caused by pneumoperitoneum.30,31 Therefore, all patients must have prophylaxis for deep venous thrombosis prior to induction of anesthesia. If the patient has no risk factors for deep venous thrombosis other than laparoscopic operation, sequential compression stockings on the lower extremities are recommended. Patients with additional risk factors for deep venous thrombosis (obesity, paralysis, trauma, malignancy, hypercoagulable states, or operative positioning in the lithotomy position) may have sequential compression stockings and subcutaneous heparin prior to the induction of anesthesia.
PREOPERATIVE EVALUATION FOR
LAPAROSCOPIC CHOLECYSTECTOMY
All patients with benign gallbladder diseases are candidates for laparoscopic cholecystectomy. Questions regarding jaundice, change in the color of the urine or stool, pain in the midabdomen that radiates to the back, and fever should be included in the history. If any of these findings are positive, the patient should be evaluated preoperatively for common bile duct stones. These studies should include liver function tests, bilirubin level, and possibly preoperative endoscopic retrograde cholangiography depending on institutional facilities and the surgeon’s preference. The preoperative use of endoscopic retrograde cholangiography is dependent on the skill of the gastroenterologist or surgeon who performs the procedure and his or her success rate in removing common bile duct stones. Patients who have symptoms of cholangitis should have a white blood cell count in addition to a hematocrit. Because cirrhotic liver disease is a relative contraindication for laparoscopic cholecystectomy, all patients who are to undergo laparoscopic cholecystectomy should be asked about etiologic factors for liver disease to include a history of hepatitis, blood transfusion or alcoholism.
PREOPERATIVE PREPARATION FOR
LAPAROSCOPIC CHOLECYSTECTOMY
Most patients presenting for laparoscopic cholecystectomy are admitted on the day of surgery. The history, physical examination, and laboratory evaluation should be completed prior to the day of operation. On the day of surgery, the patients must be questioned regarding any changes in their condition since their most recent exam. All patients are given preoperative antibiotics and have sequential compression stockings placed prior to the induction of anesthesia. Operating equipment should be checked by the surgeon prior to induction of anesthesia. This includes checking the carbon dioxide tank, the operating camera, the video equipment, and the operating instruments. After induction of anesthesia and endotracheal intubation, a nasogastric tube is passed and a Foley catheter is placed. The nasogastric tube should be on intermittent suction for the entire procedure. The patient is secured to the operating table with a leg strap, and a foot board is placed on the table to ensure stability when the operating table position is changed. After the abdomen is prepared and draped, the patient is placed in a Trendelenburg position for placement of the Veress needle. After confirming the position of the Veress needle, the abdomen is insufflated with carbon dioxide gas. The patient position is then changed to reverse Trendelenburg with the left side down. The operation may now proceed from this point.
PREOPERATIVE EVALUATION FOR
LAPAROSCOPIC NISSEN FUNDOPLICATION
Preoperative evaluation for Nissen fundoplication focuses on ensuring good postoperative results. Patients who will be most successful Nissen fundoplication candidates have normal esophageal motility, normal gastric motility and elevated esophageal pH. These are evaluated by esophageal manometry, esophageal endoscopy, barium swallow and gastric motility studies. To ensure that the patient’s symptoms are due to esophageal reflux disease, esophageal pH studies are performed. The indications for Nissen fundoplication are patients who have a Barrett’s esophagus without atypia, symptoms of esophageal reflux disease that are controlled by medical therapy, symptoms of esophageal reflux disease which have recurred after stopping medical therapy, or patients with symptoms of esophageal reflux disease who prefer surgery over long term medical management.
PREOPERATIVE PREPARATION FOR
LAPAROSCOPIC NISSEN FUNDOPLICATION
As with laparoscopic cholecystectomy, most patients are admitted the day of the operation with the history, physical examination, and laboratory evaluation already completed. These patients should receive preoperative antibiotics and have sequential compression stockings placed prior to the induction of anesthesia. The surgeon should again check all of the laparoscopic equipment prior to induction of anesthesia and ensure a consultant anesthesiologist is available to pass a large bougie at the appropriate phase of the operation. This is particularly important if this is a procedure that is not commonly performed at the institution. The abdomen is insufflated in the same manner as with the laparoscopic cholecystectomy. After insufflation of the abdomen, the patient is placed in a reverse Trendelenburg position. The operation then proceeds.
PREOPERATIVE EVALUATION FOR
LAPAROSCOPIC COLON RESECTION
Laparoscopic colectomy is performed for patients with benign disease or those with a malignancy who are enrolled in a randomized protocol. There is no change in the preoperative evaluation for laparoscopic colon resection which differs from open colon resection.
PREOPERATIVE PREPARATION FOR
LAPAROSCOPIC COLON RESECTION
The day prior to surgery the patient will undergo a bowel preparation. This should not include the use of mannitol as it can increase bowel distention. The patient will receive preoperative antibiotics and have sequential compression stockings placed prior to induction of anesthesia. The patient is placed in lithotomy position for most laparoscopic colon resections. This positioning is to allow the performance of intraoperative colonoscopy in the event that the lesion cannot be identified laparoscopically, as well as the use of transanal stapling devices. A Foley catheter is placed and the abdomen insufflated.
PREOPERATIVE EVALUATION FOR
LAPAROSCOPIC HERNIA REPAIR
The preperitoneal approach to hernia repair is of advantage as it does not require violation of the peritoneum. It is indicated in bilateral inguinal hernias, those with hernia recurrences, and when requested specifically by the patient. However, such a patient cannot have a previous lower midline abdominal incision.
PREOPERATIVE PREPARATION FOR
LAPAROSCOPIC HERNIA REPAIR
The patient should receive preoperative antibiotics and the placement of sequential compression stockings prior to induction of anesthesia. Preoperative antibiotics are required because mesh is used in the hernia repair. Because there is no insufflation of the abdomen, a nasograstric tube is not necessary. A Foley catheter should be placed to keep the bladder decompressed during the hernia repair.
PREOPERATIVE EVALUATION FOR
APPENDECTOMY
Preoperative evaluation for laparoscopic appendectomy is no different than for open appendectomy.
PREOPERATIVE PREPARATION FOR
APPENDECTOMY
All patients undergoing appendectomy should receive preoperative antibiotics. The choice of antibiotics depends on the likelihood that the appendix has ruptured prior to the start of the operation. The patients should also have sequential compression stockings placed prior to induction of anesthesia. A nasogastric tube and Foley catheter should be placed prior to insufflation of the abdomen. The nasogastric tube is necessary as these patients frequently have an ileus and have eaten in the 8 hours prior to the operation. The Foley catheter is necessary to keep the bladder decompressed and because the lower trocar is frequently placed in the suprapubic area. The positioning for insufflation of the abdomen is the same as for the other procedures.
CONCLUSION
Preoperative evaluation and preparation for laparoscopic surgery is similar to open procedures except for the specific changes required because of insufflation of the abdomen. These include evaluation of the cardiac and pulmonary status, particularly in the elderly; increased risk of aspiration due to pneumoperitoneum; decompression of the urinary bladder to allow safe placement of trocars; and the use of sequential stockings due to decreased venous return from the lower extremities probably caused by the pneumopertioneum.
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