Laparoscopic cholecystectomy is a relatively new
surgical procedure which is enjoying ever-increasing popularity and presenting new
anesthetic challenges. The advantages of shorter
hospital stay and more rapid return to normal activities are combined with less
pain associated with the small limited incisions and less postoperative
ileus compared with the traditional open
cholecystectomy. The efficacy of laparoscopic
appendectomy and
hemicolectomy has been recently evaluated. However, there have been no prospective randomized studies to date comparing laparoscopic with traditional
laparotomy techniques. The physiological effects of prolonged
pneumoperitoneum and the longer duration of surgery with the laparoscopic techniques are of concern. The application of laparoscopic
inguinal hernia repair may be limited because, unlike traditional surgical hepair,
general anesthesia is required and concerns have been expressed about the duration of surgery and the possibility of
hernia recurrence. Notwithstanding case reports and series describing successful diaphragmatic and
hiatus hernia repair using a laparoscopic surgical technique, the frequently encountered complications of cervical surgical
emphysema,
pneumothorax, and
pneumomediastinum, attributed to passage of insufflating gas through weak points or defects in the diaphragm, must be of major concern. Anesthesiologists must maintain a high index of suspicion for these potential complication and must undertake appropriate monitoring. If there is clinical evidence of a
tension pneumothorax, immediate
chest tube decompression is indicated.
Intraoperative complications of laparoscopic surgery are mostly due to traumatic
injuries sustained during blind
trocar insertion and physiological changes associated with
patient positioning and
pneumoperitoneum creation. The choice of
anesthetic technique for upper abdominal laparoscopic procedures is most frequently limited to
general anesthesia. Controlled ventilation avoids hypercarbia, and an
anesthetic technique incorporating
antiemetics and
nonsteroidal anti-inflammatory agents has reduced
postoperative nausea and vomiting following
laparoscopic cholecystectomy. The use of
nitrous oxide during laparoscopic procedures remains controversial.
Laparoscopic cholecystectomy is a major advance in the management of patients with symptomatic
gall-bladder disease. However, in the present era of cost containment, older and sicker patients may present for this procedure on the day of surgery without adequate preoperative evaluation. Anesthesiologists should thus be prepared to recommend deflation of the
pneumoperitoneum and possibly
conversion to an open procedure if hemodynamic, oxygenation, or ventilation difficulties arise during the procedure.