ANAESTHESIA FOR MINIMALLY INVASIVE SURGERY ANAESTHESIA FOR MINIMALLY INVASIVE SURGERY By Thomas Allen Crozier PUBLISHED BY THE PRESS SYNDICATE OF THE UNIVERSITY OF CAMBRIDGE The Pitt Building, Trumpington Street, Cambridge, United Kingdom CAMBRIDGE UNIVERSITY PRESS The Edinburgh Building, Cambridge CB2 2RU, UK 40 West 20th Street, New York, NY 10011-4211, USA 477 Williamstown Road, Port Melbourne, VIC 3207, Australia Ruiz de Alarcón 13, 28014 Madrid, Spain Dock House, The Waterfront, Cape Town 8001, South Africa http://www.cambridge.org © Cambridge University Press 2004 This book is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2004 Printed in the United Kingdom at the University Press, Cambridge Typeface: Ehrhardt 10/11pt System: QuarkXpress® A catalog record for this book is available from the British Library Library of Congress Cataloging in Publication data ISBN 1 841 10191 5 The publisher has used its best endeavors to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. CONTENTS Preface . vii Foreword . ix Acknowledgements . xi 1. Introduction . 1 2. Physiology . 7 3. Preparing and positioning for laparoscopic surgery . 35 4. Monitoring . 45 5. Anaesthesia for laparoscopic surgery . 55 6. Complications and contraindications of laparoscopic surgery . 75 7. Post-laparoscopy pain and pain relief . 93 8. Laparoscopic bariatric surgery . 99 9. Minimally invasive thoracic surgery . 121 10. Laser surgery of the upper aerodigestive tract . 145 11. Minimally invasive neurosurgery . 177 Index . 189 PREFACE The idea for this book was born during a workshop A format was chosen that starts with what the sur- on anaesthesia for laparoscopic surgery, which I geon is actually doing to the patient, proceeds organized several years ago. What was intended for a through an in-depth look at the patient’s cardiopul- regional audience of perhaps 250 anaesthetists at monary responses to the surgeon’s manipulations, most, turned into an international event with the par- and then distils hands-on practical recommendations ticipants spilling out of the main lecture hall to view and guidelines for anaesthetic management from this the presentations on video screens in adjacent halls. basic information. These include tips on anaesthetic The overwhelming resonance of the workshop and regimens derived from the application of recent phar- the numerous requests for accompanying material macokinetic and pharmacological research results to was ample evidence of the need for a comprehensive the clinical demands of minimally invasive opera- treatise of the subject that merged experimental study tions. Special attention is given to the typical patient data with clinical reality and the requirements of peri- profile for selected operations; what to look for during operative patient care. their preoperative work-up, and what to watch for during and after surgery. With this synoptic founda- This book is designed to fill the gap. It was clear that tion, the reader also has a better grasp of what goes although laparoscopic procedures were the original awry during typical adverse events and complications, focus of attention and should be given the most space, and how these can be prevented and treated. the scope of the book would have to be widened to include other minimally invasive surgical proce- The reader can easily choose just what depth of infor- dures, such as thoracic surgery, laser surgery of the mation is required for the task at hand, be it a how-to- upper airways or neurosurgery, that require adjust- do anaesthetic recipe or a fully-referenced detailed ments and adaptations of routine anaesthetic man- presentation. Important points are summarized in agement, or entail specific risks requiring specific highlighted charts that allow the reader to find perti- precautions. These specialties are presented in sepa- nent information at a glance, and numerous illustra- rate chapters. tions are included to enhance clarity. FOREWORD Minimally invasive surgery is increasingly popular book of this kind. In the early days of minimally invasive with management in the drive to reduce hospital surgery some terrible disasters – unnoticed perfo- expenditure and especially the expense of patients’ rated bowel, massive haemorrhage from damaged ves- stay overnight in hospital after surgical procedures. sels, gas embolism, etc. – befell some patients. Most Moreover, our patients can benefit enormously through often this was due to poor surgery by inexperienced reduced disturbance of their well-being and less surgeons; this hastened the need for absolutely con- interference with metabolic and other physiological tinuous and complete monitoring of the patient by processes. It has been made possible by amazing devel- the anaesthetist on a beat-by-beat and breath-by- opments in surgical techniques such that conventional breath basis, surely the tenet of any form of first-class surgery for many procedures as we used to know them modern anaesthetic care. Fortunately, much of this sur- hardly exists today. Historically, advances in surgery veillance can easily be carried out with modern patient were made possible through advances in anaesthesia; monitoring equipment but it must be backed up by the however, to some extent, at least, the boot is on the attention of the attending anaesthetist and interpreta- other foot because these advances in surgery through tion using all his vital senses. minimally invasive (so-called keyhole) techniques have Minimally invasive surgery continues to expand. How- demanded the refinement and development of exist- ever, now is a good time to consolidate and review ing anaesthetic techniques and the introduction of anaesthetists’ requirements in this area and Tom new drugs. Notably, these methods require keeping Crozier has included consideration of bariatric surgery, the patient safe at all times and returning the patient laser surgery, thoracic surgery and neurosurgery since to full consciousness extremely rapidly, yet with free- these areas nowadays are tending to become minimally dom from pain, immediately the surgical procedure is invasive. He has performed his task extremely well. completed. Prof. Tom Crozier, with long-standing experience of Anthony P Adams this subject, writes from Göttingen – arguably the Emeritus Professor of Anaesthetics in the University of foremost centre of excellence of anaesthesia in Europe. London at Guy’s, King’s & St Thomas’ Hospitals’ Readers will note that, first and foremost, this is an School of Medicine; lately Editor-in-Chief, essentially practical book. He defines the subject in European Journal of Anaesthesiology. terms of practicalities such that some often overlooked aspects, for example surgery of the upper aerodiges- London, UK tive tract, are included. This is eminently sensible in a July 2004. ACKNOWLEDGEMENTS This book was made possible by the support and input I am particularly indebted to Prof. Wolfgang Steiner, of many friends and colleagues from many specialties, chairman of our university’s Department of whose contributed time and resources greatly enriched Otorhinolaryngology, for his critical comments on the the results. Without the initial enthusiasm, innovative first draft of the chapter on laser surgery, and for the activities and cooperation of members of the depart- contribution of numerous illustrations for this chap- ment of general surgery, particularly Dr Thomas ter from his vast photographic archives. Neufang, Dr Gerd Lepsien and Dr Olaf Horstmann, I must extend my thanks to Prof. Michael Buchfelder, for the evolving techniques of laparoscopic surgery, my chairman of the Department of Neurosurgery and experience in the anaesthetic management of these authority on endoscopic pituitary surgery, and his operations would have been very limited, and several of associate Dr Hans Ludwig, specialist for endoscopic our research projects would not have been possible. I neurosurgery, for their useful input on the topic of must thank Dr Arnd Timmermann of the Department minimally invasive neurosurgery. of Anaesthesiology, Emergency and Intensive Care Medicine, Dr Ralph Rödel of the Department of My colleagues in the Department of Anaesthesiology Otorhinolaryngology and Dr Hilmar Dörge of the deserve particularly heartfelt mention for their inter- Department of Cardiothoracic Surgery for contribut- est in this project and their unspoken, amused toler- ing valuable photographic