Prolonged pneumoperitoneum in exaggerated trendlenburg position; anesthetic implications

ABSTRACT

Laparoscopic radical cystectomy is a relatively new surgical procedure. Being a procedure of long duration, performed with pneumoperitonium in exaggerated Trendlenberg position; it is expected to pose unfavorable effects. We report pulmonary and haemodynamic changes in addition to postoperative outcome following laparoscopic radical cystectomy in the exaggerated head-down position. A prospective study was conducted on 31 patients anaesthetized with a combination of epidural and total intravenous anaesthesia [using midazolam, fentanyl, ketamine and vecuronium]. Surgery was done while the patient in head down position [40o]. Lungs were ventilated using air-oxygen [FiO2 = 0.35] with a tidal volume of 8 ml kg[-1] at a rate of 12-14 min[-1]. Lung mechanics, gasometric and haemodynamic variables were recorded at different strategic points. Recovery and postoperative outcome were also evaluated. Two patients discontinued because of conversion to open surgery and 29 completed the procedure. Fourteen of 29 patients [48.2%] had preoperative medical diseases and 11 patients [38%] received blood. There were significant decrease in lung compliance and significant increase in peak pressures after pneumoperitoneum and Trendelenburg. Concomitantly, heart rate, arterial pressure and carbon dioxide tension increased significantly. Three patients suffered postextubation airway obstruction and were reintubated. On the first postoperative day, one patient desaturated and one patient suffered severe nausea and vomiting. Laparoscopic radical cystectomy in exaggerated head down position is associated with brisk consequences and potential risks