Advancement of Surgical Technology
The increasing and rapid advancement of surgical technology in recent decades has allowed the introduction of laparoscopic surgery, a very significant surgical revolution in modern medicine. The spectrum of laparoscopic surgery is very broad, encompassing abdominal, gynecological, urological, thoracic and orthopedic surgery, among others. This has created new challenges for modern anesthesiology that conditions a permanent update. For minimally invasive surgery technique many of them have not received practical training with simulators resembling Laparoscopic Training Kit.
In laparoscopic surgery, the abdominal cavity is insufflated with CO2 gas, which leads to a series of physiological changes and complications that do not occur in open surgery. The increase in intra-abdominal pressure affects the normal physiology of different apparatus and systems; As a whole, the adverse effects of intra-abdominal hypertension on the cardiovascular, respiratory and renal systems are called abdominal compartment syndrome.
Anesthesiology in Laparoscopy
The increase in intra-abdominal pressure results in an increase in peripheral vascular resistance, an increase in central venous pressure. An increase in arterial pressure, an increase in intrathoracic pressure, and stimulation of the sympathetic nervous system. Furthermore, the increase in splanchnic circulation is manifested by a decrease in hepatic, gastric, renal and mesenteric arterial flow. Also, peritoneal stress releases acute phase proteins into the peritoneal fluid. Thus it has been determined that there is an inflammatory reaction of the peritoneal fluid with increased levels of interleukins.
These mediators are the ones that initiate the inflammatory process, and intervene in the perception of pain and the subsequent formation of adhesions. In turn, it has been proposed that the decrease in splanchnic arterial flow and the hemodynamic changes described above are the result of the involvement of the central nervous system, related to an increase in intracranial pressure and consequent release of vasoactive hormones, in order to protect the nervous system from ischemia.
Thus, the pneumoperitoneum creates a complex dynamic of change in normal physiological conditions, which have pathophysiological consequences during laparoscopy. It is essential for the anesthesiologist to understand the physiological consequences that occur in these conditions, to avoid or minimize the deleterious effects of CO2 in the patient.
In this article, a review is made of the physiological effects of pneumoperitoneum and its implications in anesthesiology, both in the pre-anesthetic evaluation, as well as in the monitoring and postoperative period.
Physiological Changes During Anesthesia
During anesthesia, in laparoscopic surgery, a series of pathophysiological changes develop that will depend on the insufflation of CO 2 into the abdominal cavity, producing hemodynamic, respiratory, metabolic and other system alterations which we must take into account for their management and understanding. its probable complications.
The gas used to induce pneumoperitoneum is CO 2, due to its high solubility, great diffusion capacity and being physiologically and pharmacologically inert. The peritoneal cavity is covered by an intact continuous sheet of mesothelial cells that has a surface area of approximately 1.5 m 2 and is covered by a thin film of peritoneal fluid at 37 ° C; there is a normal physiological condition with a state of homeostatic, biochemical and physical equilibrium when there is an intra-abdominal pressure of up to 3 mmHg. Creating and maintaining a pneumoperitoneum alters these circumstances, with the consequent physical, chemical and biological effects. Among other effects, the increase in intra-abdominal pressure induces a hemodynamic stress response, alters the venous return of the lower extremities, decreases cardiac output, and there is an increase in mean arterial pressure as well as systemic vascular resistance. A pneumoperitoneum that maintains body temperature, tissue hydration, and integrity during laparoscopic surgery improves clinical outcome.
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