Surgical Innovation

Laparoscopic surgery presents attendant challenges for the anesthesiologist. Cardiovascular and respiratory function may be affected adversely by the presence of a pneumoperitoneum; airway management may be difficult because of the patient's position; and postoperative pain, although less than that experienced after traditional, open surgery, can still result in considerable discomfort. These complications, and several choices of anesthetic technique, are discussed.

Impressive advances in laparoscopic surgical technique have taken place, especially since the late 1980s. These developments have motivated patients as well as surgeons, institutions, and payers; accordingly, the variety and frequency of these procedures have vastly increased. In the rush to expand the frontiers of laparoscopic surgery, we must not lose sight of the potential pitfalls resulting either from the physiological effects of the procedure itself or from the influence of underlying disease processes.

An appreciation of the physiological changes and possible complications of thoracoscopic surgery is required by the medical team caring for the patient. The alteration of ventilatory and cardiac status under anesthesia can have significant impact on the morbidity and mortality of the patient. Considerations of the interaction between surgical and anesthetic effects may help to identify the problems early and avoid deleterious changes.

Laporoscopic surgery is minimally invasive surgery designed to reduce tissue damage. The pleural and peritoneal anatomy can develop nocioceptive afferent impulses. Common pain pathways are described, and therapeutic options based on physiology are discussed. The underlying anatomical basis of the pain pathway is described.

The potential complications of laparoscopic surgery generally result from insertion of the needle and trocar, creation of the pneumoperitoneum, positioning of the patient, and insertion and manipulation of the instruments. By promptly recognizing and treating these complications, the surgical and anesthesia teams can minimize morbidity and mortality.

Laparoscopy has come to be used for a large variety of surgical procedures. This has necessarily led to its use in patients who have a variety of interrelated diseases. While the postoperative course tends to be more benign than in traditional "open" procedures, the intraoperative period may be even more stressful to the patient from a physiological perspective. Use of sophisticated monitoring techniques in selected patients can help yield the optimal postoperative outcome.

Although physiological changes during laparoscopy and thoracoscopy generally are similar to those seen during standard open procedures, these minimally invasive techniques are accompanied by some unique changes. General, regional, and local anesthesia during laparoscopy and thoracoscopy, and potential complications, are discussed. The physiological responses that are discussed include hemodynamic effects, acid-base and pulmonary effects, and hormonal effects.

Denervation of the sympathetic nerve can be accomplished with much less operative trauma by using the endoscopic surgical approach. Although endoscopic thoracic sympathectomy is not new, the techniques and the extent of denervation have not been standardized. The anatomic appearances and configurations of the sympathetic chain are explained, and various procedures, including ramisections, interganglionic sympathectomy, and ganglionectomy, are reviewed. Thoracoscopic approaches, operative techniques, and potential complications are discussed.