What is the recommended anesthesia approach for laparoscopic surgery?

Recommended Anesthesia Approach for Laparoscopic Surgery

For laparoscopic surgery, a general anesthesia approach with short-acting agents, adequate neuromuscular blockade, and multimodal strategies for PONV prevention is strongly recommended. 1

General Anesthesia Components

Induction

• Use short-acting induction agents such as propofol combined with short-acting opioids (fentanyl, alfentanil, or remifentanil infusion) 1, 2
• For emergency laparoscopic procedures, rapid sequence induction with fast-acting muscle relaxants (succinylcholine 1-2 mg/kg or rocuronium 0.9-1.2 mg/kg) is recommended 1
• Short-acting benzodiazepines (e.g., midazolam) can be used to facilitate patient positioning but long-acting benzodiazepines should be avoided, especially in elderly patients (>60 years) 1

Maintenance

• Either short-acting inhalational anesthetics (sevoflurane or desflurane in oxygen-enriched air) or total intravenous anesthesia (TIVA) can be used 1, 3
• TIVA with propofol may be particularly beneficial in patients with high risk of PONV 1, 4
• There is no strong evidence to recommend one anesthetic agent over another for maintenance of anesthesia 1

Neuromuscular Management

• Maintain deep neuromuscular block during surgery to facilitate vision and surgical access 1
• Monitor neuromuscular blockade using quantitative peripheral nerve monitoring to ensure adequate reversal before extubation 1
• Consider sugammadex for reversal of profound muscle relaxation, especially with rocuronium 1

Depth of Anesthesia Monitoring

• Use bispectral index (BIS) monitoring to titrate depth of anesthesia, particularly in patients over 60 years of age 1, 5
• Target BIS of approximately 50 in elderly patients to reduce risk of postoperative delirium 5
• Avoid deep levels of anesthesia (BIS < 30), particularly in elderly patients 1, 5

Regional Anesthesia Considerations

• Consider thoracic epidural for open or assisted laparoscopic procedures to attenuate stress response and provide better postoperative pain relief 1
• For laparoscopic procedures, alternatives to epidural include:
  • Intravenous lidocaine (1.5 mg/kg at induction followed by 2 mg/kg/h infusion) 1
  • Spinal anesthesia with local anesthetics and opioids 1, 6
  • Intraperitoneal administration of local anesthetics at the beginning and end of surgery 7

Ventilation Strategy

• Use low tidal volume (6-8 ml/kg predicted body weight) with positive end-expiratory pressure (PEEP ≥ 5 cm H2O) 1
• Adjust ventilation parameters when patients are in Trendelenburg position to reduce risk of atelectasis 1
• Consider using inspired oxygen concentration >80% to decrease surgical site infection risk 1

PONV Prevention

• Implement multimodal PONV prevention strategies for all laparoscopic procedures 1
• Consider TIVA with propofol as it may reduce PONV compared to inhalational anesthetics 3, 4
• Use prophylactic antiemetics based on patient risk factors 1

Common Pitfalls and Caveats

• Avoid excessive depth of anesthesia in elderly patients as it increases risk of postoperative delirium and hypotension 5
• Monitor and maintain normothermia using active warming devices and warming of intravenous fluids 1
• Monitor blood glucose levels during surgery and keep <10 mmol/l using intravenous insulin when needed 1
• Maintain adequate gut perfusion by targeting appropriate mean arterial pressure (60-65 mmHg) and cardiac index (≥2.2 L/min/m²) 1
• Be cautious with opioid doses in elderly patients (>70 years) due to risk of postoperative respiratory depression 1

While regional techniques like spinal anesthesia have been studied for laparoscopic procedures 6, general anesthesia remains the standard approach due to the need for controlled ventilation during pneumoperitoneum and positioning requirements for most laparoscopic surgeries 8.