Laparoscopic surgery

Laparosopic surgery is a minimally-invasive approach which requires insufflation of gas, most commonly carbon dioxide (CO2), to allow for visualization through laparoscopic instruments. Compared to open surgery, laparoscopic approaches generate multiple different physiologic effects. Most concerning are increased intra-abdominal pressure and its hemodynamic effects as well as hypercapnia from CO2 absorption. Laparoscopic procedures also tend to require increased time vs an open procedure.

Airway management

Generally an endotracheal tube is required as it allows for the optimal control of ventilation as well as aspiration protection.

Natural airway should be avoided given the increased intra abdominal pressure and concern for aspiration.

Supraglottic airway devices such as the laryngeal mask airway (LMA) are also typically avoided. Increased airway pressures are required to overcome the increased intra abdominal pressures generated by insufflation. Second generation LMA devices theoretically can hols a seal at these elevated pressures, however they do not protect against aspiration.

Regional and neuraxial anesthesia

While laparoscopic procedures have been successfully preformed under neuraxial, this is less commonly done. Abdominal insufflation is generally less well tolerated in an awake patient and positioning (trendelenburg vs reverse trendelenburg) can also limit this technique. If done, usually a T4-T6 level is required.

Post induction or pre emergence truncal blocks, such as a transversus abdominis plane (TAP) block or quadratus lumborum (QL) block can help reduce post operative pain.