ANAESTHETIC CONSIDERATIONS IN PAEDIATRIC LAPAROSCOPIC SURGERIES

Dr. Ketaki Marodkar
Associate Professor, Dept. Of Anaesthesiology, NKPSIMS, Nagpur

Recently with its numerous benefits over open surgical procedures, laparoscopic surgery has gained immense popularity in paediatric surgeries.⁰¹ Some of these benefits include lesser pain due to smaller incisions, in turn giving better cosmetic result, faster recovery and lesser number of days in hospital with earlier ambulation.⁰²

Although there are numerous studies in adults focusing upon the physiological changes associated with laparoscopic surgery, there is a dearth of literature studying the same in paediatric population. During routine laparoscopic surgeries in paediatric patients, Verres cannula peritoneal insufflation is conducted with CO₂, insufflation being done at the rate of 0.5 L/min using electronic endoflator to maintain an intra-abdominal pressure of 10-12 mm of Hg. The patient is positioned in 15 degrees Trendelenburg tilt after stabilization of the pneumoperitoneum.

   The anaesthetic plan usually includes general anaesthesia with or without a caudal epidural analgesia depending upon the feasibility for achieving the regional block. Standard fasting and monitoring protocols are followed including 6 hours fasting before surgery and intra-operative monitors including electrocardiography, non-invasive blood pressure, pulse oximetry and end tidal capnography. The ventilator parameters are adjusted to maintain an EtCO2 levels between 30 and 35 mm Hg.

The important haemodynamic repercussions which occur during and immediately after pneumoperitoneum include a significant and sustained increase in the systolic, diastolic and mean arterial blood pressure readings which remain high even till 10 minutes post-extubation.⁰³This increase is around 10-20 % of baseline pressures. In addition, there is a significant (15-20% of baseline) increase in peak, plateau and mean airway pressures following pneumoperitoneum and Trendelenburg position.⁰⁴ The rise in IAP causes a decrease in lung compliance with a proportionate increase in both peak and plateau pressures. Kinking of the endotracheal tube, endobronchial intubation, tracheal tube abutting on carina also adds to a selective increase in peak pressure.

The EtCO₂ values progressively increase from the beginning of insufflations and plateau at around 15-20 minutes after insufflation. To counter-balance this, one needs to increase the respiratory rate in order to maintain an EtCO2 below 45 mm Hg. Though not very common with slow insufflations, cardiac arrhythmias may also present and need a change in ventilator settings. Similarly significant changes in heart rate are not much seen in paediatric laparoscopies.  

Although there are claims of a reduced post-operative pain in laparoscopic surgeries due to smaller incisions, the post-operative nausea and vomiting scores are higher in these patients owing to peritoneal irritation by carbondioxide. Air embolism, subcutaneous emphysema and capnothorax are also some grave but rare known complications of laparoscopic surgeries.

Lastly though claimed to be ideal technique in children, even recurrence rates are sometimes found to be higher in laparoscopic surgeries as compared to open ones. This in turn may be due to lack of surgical expertise or due to inadequate records due to loss to follow up in children.

Thus to summarise, though claimed to be ideal surgical modalities, many haemodynamic repercussions are associated with paediatric laparoscopies. Detailed knowledge of these changes, vigilant monitoring and prompt action can therefore prevent any untoward events.

Bibliography:

1. Baroncini S, Gentili A, Pigna A, Fae M, Tonini C, Tognù A, et al. Anaesthesia for laparoscopic surgery in paediatrics. Minerva Anestesiol 2002;68:406-13.
2. Wedgewood J, Doyle E. Anaesthesia and laparoscopic surgery in children. Paediatr Anaesth 2001;11:391‑
3. Garg, et al.: A comparison of cardiorespiratory changes and perioperative outcome in laparoscopic versus open pediatric inguinal herniorrhaphy. Anesthesia: Essays and Researches ¦ Volume 12 ¦ Issue 1 ¦ January-March 2018
4. Bergesio R, Habre W, Lanteri C, Sly P. Changes in respiratory mechanics during abdominal laparoscopic surgery in children. Anaesth Intensive Care 1999;27:245‑8.