《《腹腔镜手术麻醉》ppt课件》由会员分享，可在线阅读，更多相关《《腹腔镜手术麻醉》ppt课件（44页珍藏版）》请在金锄头文库上搜索。
1、第三十二章 腹腔镜手术的麻醉 Chapter 32 Anesthesia for laparoscopic Surgery,The field of abdominal surgery has been radically changed with the introduction of laparoscopy.,Recent advance in robotic and video technology have made the use of laparoscopic procedures more widely applicable. With the evolution of lapa
2、roscopy，a substantial number of abdominal procedures are being performed using this approach, including cholecystectomy, myomectomy, and so on.,Compared with the traditional open abdominal approach.the laparoscopic approach is: less postoperative pain. shorter hospital stay. fewer overall adverse ev
3、ent. more rapid return to normal activity significant cost savings.,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,Part I Phy
4、siological 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.,Part I Physiological changes during laparoscopic surgery,CO2 is used ex
5、tensively in clinic. The speed and pressure of the pneumoperitioneum effect the absorption of CO2. Positioning changes will effect the physiological function.,I. Cardiovascular system,The pressure of pneumopertioneum effect three aspects . systemic vascular resistance (SVR. Afterloail). venous retur
6、n (preload ). cardiac function.,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,I. Cardiovascular system,The cause : Intraabdominal positive pressure intrat
7、horacic pressure cardiac blood flow CO IPPV or PEEP intrathoracic pressure CO,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.,2.The patients were pla
8、ced in different body position (Table1),During cholecystectomy , the patient is placed on head-up about 10-20.,2.The patients were placed in different body position (Table1),During gynecological surgery, the patient is placed on head-down position.,Table-1 Hemodynamic measurements before and during
9、pneumoperitoneum（PP）during laparoscopic cholecystectomy in healthy patients,3. Carbon dioxide absorption,The absorption of CO2 is influenced significantly by duration of interoperation insufflations IAP and the solubility of CO2 .,3. Carbon dioxide absorption,Hypercarbia resulting from CO2 insufflat
10、ions has direct and indirect homodynamic effects.,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 cont
11、ractility and causes tachycardia and hypertension,II. Pulmonary function,Changes in pulmonary function with pneumoperitoneum : positioning anesthesia Elevation of diaphragm may be associated with reduction in lung volumes.,II. Pulmonary function,In patients undergoing laparoscopic procedure with 15
12、degree head-down tilt, the total pulmonary compliance decreased by 40%. with 20 degree head-up tilt, the total pulmonary compliance decreased by 20%.,II. Pulmonary function,Increased IAP and upward displacement of the diaphragm can cause alveolar collapse and ventilation/perfusion mismatching, resul
13、ting in hypoxemia and hypercarbia.,III. The other physiological changes,Increased IAP can result in reduction in splanchenic and renal perfusion. Hepatic blood flow is decreased .,III. The other physiological changes,Reduction in urine output. the compression of renal vessel increased plasma renin a
14、ctivity . Increased IAP can result in aspiration and regurgitation.,Part II Anesthesia for laparoscopic surgery,. Preoperative evaluation and preparation for anesthesia.,1. Evaluation Elderly, obesity, hypertension, coronary artery disease. Serious hypertension , cardiac dysfunction , COPD . The ope
15、n surgery (open cholecystectomy) duo to medical problem (serious hypercarbia).,. 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 an
16、tagonist (ranitidine) may be given (the patient being at risk for gastric aspiration). To open upper extremity vein.,.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.,.The choice of anesthesia,2.Method of ane
