Anesthesiology

Pelvic laparoscopy

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What the Anesthesiologist Should Know before the Operative Procedure

Pelvic laparoscopy may be done by gynecologists, obstetricians, urologists or colon and rectal surgeons. Sometimes it may also be performed by transplant surgeons working on the urinary bladder after kidney or pancreas transplants draining into the bladder.

It will be important to know if the patient will be in the supine or steep Trendlenburg position and the goals of the procedure. It will also be important to know if this will be done robotically or by the traditional laparoscopic approach. Some viscera and/or vascular structures could be at risk for injury.

1. What is the urgency of the surgery?

Some operations will be required to be done urgently. An example is ruptured ectopic pregnancy. There may also be urgency to evaluate acute adnexial torsion or other causes of acute pelvic pain such as tubo-ovarian abscess, acute appendicitis, hemorrhgic ovarian cysts, mesenteric lymphadenitis, cystitis,and others. Surgeons skilled in laparoscopy are now even performing diagnostic laparoscopy for surgical situations associated with acute hemorrhage.

What is the risk of delay in order to obtain additional preoperative information?

This depends upon the urgency of the procedure. For example ovarian or adnexial torsion and ectopic pregnancy will require immediate attention to prevent further necrosis or bleeding. Severe pain associated with these conditions can also be a reason to proceed urgently. It is paramount in females to make sure that a viable uterine pregnancy is excluded when the pain is from other causes as previously suggested. In most instances, however, practitioners should aim for performing a detailed preoperative evaluation to minimize morbidity and maximize patient safety and intraoperative planning. Some patients may need to be operated urgently because of a perforated viscus that could result in spreading inflammation and sepsis if delayed.

During evaluation of a pelvic emergency requiring a laparoscopic procedure, in addition to a high index of suspicion of the possible diagnosis, it is paramount for practitioners to conduct a thorough physical examination. Note the duration of the acute problem and associated systems involvement (does the patient have significant primary health problem related to this presenting complaint, for e.g. hemorrhagic cystitis can be secondary to chemotherapy for someone with leukemia). For women of child-bearing age, a pregnancy test must be done because in women a common cause of pelvic and lower abdominal pain is ectopic pregnancy. Note that the pregnancy test can also be positive when there are other reasons for acute pelvic and lower abdominal discomfort. Acute appendicitis, adhesions, and intestinal obstruction are examples of other causes.

Emergent- For emergent surgery, make sure that blood is available because it may be a ruptured ectopic pregnancy. So, send a stat type and screen. Note NPO status of the patient. Send routine labs such as hemoglobin, platelets, and a coagulation battery. For those with blood dyscrasia, platelet transfusion may be needed during the perioperative period. A ruptured ectopic pregnancy is truly emergent amongst all the conditions listed and the patient needs to go to the O.R. as soon as possible because the key to success is to surgically stop the hemorrhage. The facility should be prepared to open the abdomen if successful ligation via a laparoscope is not going to be possible. Emergency pelvic laparoscopy may also be done for perforated sigmoid diverticulitis. This is done to do peritoneal lavage as treatment for the generalized peritonitis that is often present.

Urgent- During urgent procedures, the patient can be stabilized prior to the surgical procedure. In these situations, fluid balance should be optimized and if there is sepsis, antibiotics will need to be started. If the patient is stable, then additional studies like CT or MRI may be undertaken.

Elective- Elective pelvic laparoscopy allows for optimal preparation of patients. The patients can be scheduled for preoperative assessment in a pre-anesthesia clinic. Relevant preparation regimens may be employed. The patients are instructed about the surgical procedure and the need for bowel prep when required for colo-rectal and complicated gynecological and urological operations. Many operations may require special materials, for example special surgical mesh to repair the pelvic floor using minimally invasive approaches for vaginal surgery.

2. Preoperative evaluation

All standard preoperative assessments must be accomplished as for any other surgery. Except for very brief procedures like tubal ligation and routine straight-forward short gynecological operations, almost all patients will require endotracheal intubation. The preoperative assessment must focus on systemic implications of increased intraabdominal pressure and the required Trendlenburg and steep Trendlenburg positions for the operation. Robotic pelvic laparoscopic procedures especially radical cystectomy and radical prostatectomy are usually long and require the extreme Trendlenburg position. Patients with raised intracranial pressure and/ or intraocular pressure (IOP) may not be able to tolerate the Trendlenburg position and the accompanying increase in intracranial pressure and intraocular pressures. This is compounded by the increase in superior vena cava pressure from the abdominal insufflation.

Although increasing age is no longer a contraindication, co-morbid conditions do increase with age and will need to be recognized, documented, and evaluated. In one study related to age, the authors found that with increasing age there was an increase in the use of blood products and also time spent in the ICU and hospital. Pathologic changes in ECG and abnormal spirometry were more frequent in those older than age 70 years (Schwandner, et al.). Because patients subjected to pelvic laparoscopy will have to tolerate increases in systemic and pulmonary vascular resistance due to abdominal insufflation and position changes, their cardiopulmonary systems must be thoroughly evaluated. This may require a stress ECHO and EKG evaluation. Any valvular disease must be investigated to plan the need for pharmacological therapy during intraoperative care (possible need for milrinone or vasodilators) because of the increases in SVR and left ventricular end-diastolic volumes that accompany the procedure. All patients must have their upper airway evaluated in detail. Following pelvic laparoscopy in the Trendlenburg and steep Trendlenburg position, it is not uncommon for the occurrence of significant laryngeal, aryepiglottic, and lingual swelling and facial edema. Extubation is hazardous unless these swollen entities have returned to baseline levels upon reversing the Trendlenburg position following surgery and adopting a gradually applied reversed trendlenburg position. This may take several hours following surgery. The presence of a difficult upper airway will magnify the detrimental positioning-related consequences of pelvic laparoscopic surgery.

Medically unstable conditions warranting further evaluation include: Patients need to be hemodynamically stable and be able to tolerate the ventilatory compromise due to abdominal distension. Hypovolemic hypotension, shock, and severe cardiovascular disease (hypertension, congestive heart failure) must be corrected or optimized before the procedure begins. Pre-existing glaucoma must be well controlled and treated. Patients with bronchial asthma or COPD must be in a stable state with optimal bronchodilation before surgery.

Delaying surgery may be indicated if: there is significant cerebro-vascular compromise (increased intracranial pressure). Similarly, uncontrolled glaucoma, reactive airway disease, and poorly compensated COPD must be treated before pelvic laparoscopy is undertaken. This may require intense bronchodilator therapy along with a short course of steroids in the immediate preoperative period.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation- One needs to focus on the upper airway status, cardiovascular risk, pulmonary problems, and pre-existing cervical bone disease, or peripheral nerve-related problems.

Perioperative risk reduction strategies- Patients may have pre-existing hypertension. Drugs used to treat hypertension are typically continued until the day before surgery and beta-blockers are also administered on the day of surgery. Inhaled bronchodilators for reactive airway disease and/or COPD are continued on the day of surgery and may also be administered intraoperatively. Patients who have drug-eluting coronary stents that were placed more than a year ago and are on platelet-inhibiting drugs may have these drugs withheld for several days before surgery with the exception of low-dose aspirin that may be continued. This should be discussed with the patient's cardiologist well in advance of surgery. The other platelet-inhibiting drugs must be started as soon as surgery is completed and there are no bleeding complications in the immediate post-operative period.

b. Cardiovascular system

Acute/unstable conditions: Those patients with acute and/or unstable coronary artery disease must be stabilized prior to pelvic laparoscopy. This may include the administration of beta-blocker therapy or a visit to the cardiac catheterization lab for coronary angiography for coronary stenting or angioplasty.

Baseline coronary artery disease or cardiac dysfunction - Goals of management: Here, one should make sure that vasodilator therapy and beta-blockers are continued during the perioperative period. Baby aspirin should also be continued. Other platelet -inhibiting drugs should be stopped several days in advance of the surgical procedure (provided a drug-eluting stent was not inserted within the last year or a bare metal stent within the last month) and reinstituted soon after surgery. Again, the cardiologist should be consulted in advance of surgery.

Some patients may have an ICD/pacemaker device. This should be tested and interrogated preoperatively. The possibility of needing monopolar electrocautery should be discussed with the surgeon. If this will be needed, the ICD should have the high voltage therapy device disabled for the procedure. If magnet use is planned for this function, the interrogation should ensure that a magnet is present and enabled. If the ICD was reprogrammed preoperatively, then ICD interrogation/reprogramming will be required postoperatively.

c. Pulmonary

COPD: Patients must be instructed in the proper use of spirometry; their bronchodilator therapy must be up-to-date and inhaled bronchodilators must be continued perioperatively.

Reactive airway disease (Asthma): Obtain a thorough history and note if the patient is well-controlled and is on stable bronchodilator therapy. Some may require a short course of steroids in the immediate preoperative period.

d. Renal-GI:

Significant renal compromise occurs during pelvic laparoscopy. There is an increase in ADH, endothelin, renin, and aldosteone with the induction of pneumoperitoneum. Low levels of hydration will further compromise the kidneys, as will the Trendlenburg position. Preoperative evaluation of renal function is, therefore, important. Unfortunately, there is little that one can do to reverse this with the exception of decreasing the duration of surgery. During pelvic laparoscopy, intraoperative third-space losses are less than with open procedures and therefore one must be careful with fluid replacement. Splanchnic vasoconstriction has been reported to occur during pelvic laparoscopy. This is due to vasopressin release.

e. Neurologic:

The intracranial effects of increased intraocular and intracranial pressures should be considered during pelvic laparoscopy. The effects on cranial tissue oxygenation are controversial. Although most individuals tolerate the changes occurring secondary to increases in abdominal pressure and positioning, there are case reports of ischemic optic neuropathy with visual loss following pelvic laparoscopy and the Trendlenburg position. Similarly, due to this position there can be significant stretching of the brachial plexus at the shoulders. Brachial plexus injury, ulnar nerve injury, and femoral and peroneal nerve injury can occur due to positioning for pelvic laparoscopy. Special attention must be paid to proper positioning, padding, and support of these structures before surgery is begun.

Acute issues: The presence of symptomatic GERD must be controlled with the use of proton pump inhibitors because positioning and increase in abdominal pressure will significantly increase gastric acidity. Any acute pathophysiology due to the need for urgent pelvic laparoscopy must be defined and corrected, for example correction of dehydration due to a perforated viscus and pain control necessary for acute torsion of an adnexial mass. Patients who are on coumadin for any reason will require rapid correction with fresh frozen plasma prior to surgery.

Chronic disease: This is usually not a problem for pelvic laparoscopy unless it constitutes a contraindication. For example, significantly advanced liver disease with ascites is considered a contraindication. Chronic coagulopathy due to a factor deficiency disorder is no longer considered a contraindication because of available replacement therapy by recombinant factors.

f. Endocrine:

Of all the endocrine problems, diabetes is the most common followed by chronic hypothyroidism. Patients who are chronically hypothyroid are usually on thyroid replacement therapy. This must be continued perioperatively and does not require any special attention. The care of diabetes on the other hand requires efforts to ensure euglycemia or mild hyperglycemia during the perioperative period. Frequent glucose monitoring at the bedside is essential and can be easily accomplished. A target perioperative blood glucose between 120 to 150 mg/dl is acceptable. Oral hypoglycemics or insulin therapy is adjusted accordingly.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Pelvic laparoscopy can be difficult in patients with significant intraabdominal adhesions or the presence of a prior use of a surgical mesh within the abdomen. This can complicate and prolong the intraoperative pelvic laparoscopic procedure and the possibility of converting to an open operation increases significantly.

4. What are the patient's medications and how should they be managed in the perioperative period?

Most medications may be taken and continued in the perioperative period. Of particular concern are those who are on beta-blockers, coumadin, and platelet inhibitors other than baby aspirin. Baby aspirin and beta-blockers must be continued during the perioperative period. Other platelet inhibitors (usually thienopyridines like clopidogrel and prasugrel) should be stopped several days in advance of the surgical procedure provided the window of vulnerability after insertion of a drug-eluting or bare metal stent has passed. Consultation with a cardiologist should be sought. These agents should be reinstituted soon after surgery when patients are stable and there is no evidence of surgical bleeding. Coumadin will have to be stopped several days before the procedure and the INR will need to be tracked. A short period of heparin infusion during the preoperative period may be necessary in those patients with bioartificial cardiac valves.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

This may include medications specific to diseases associated with surgery- Some patients may be on immunosuppression for their prior transplant procedure. If they are on steroids, then a booster dose of hydrocortisone will be needed.

i. What should be recommended with regard to continuation of medications taken chronically?

Beta-blockers used for blood pressure control must be continued perioperatively. Inhaled bronchodilators for COPD and bronchial asthma are given as usual. Baby aspirin can be continued during the perioperative period. With regard to other platelet inhibitors, please see above.

Neurologic

  1. Anti-platelet

  2. Psychiatric

j. How To modify care for patients with known allergies -

During the preoperative examination a list of allergies to medications is noted. It is not uncommon to note allergies to drugs like morphine. In such cases, alternative opioids may be used. Moreover, it is not uncommon for patients to consider side effects such as nausea, for example, to be an allergic response when it is not.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Those who have an allergy to latex must be done in latex-free environment. Most operating rooms are now latex-free. For those with a history of latex-induced anaphylaxis, in addition to ensuring a latex free environment, the patients may be prepared with preoperative administration of antihistamines and steroids.

l. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)

It is also not uncommon to see patients with allergies to several antibiotics. Allergy to pencillin-like drugs and cephalosporins is handled by using other antibiotics, such as vancomycin with or without gentamicin.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia:

  1. Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

    1. Proposed general anesthetic plan: use TIVA (total intravenous anesthesia) with a propofol infusion along with an opioid infusion such as remifentanil. A flushed anesthesia machine must be used.

    2. Insure MH cart available: Make sure that there is adequate dantrolene available (at least 36 vials).

      [- MH protocol]

  2. Family history or risk factors for MH:

  1. Local anesthetics/ muscle relaxants: for those with a history of malignant hyperthermia or suspected malignant hyperthermia susceptibility, it is imperative to avoid succinyl-choline. Non-depolarizing muscle relaxants are safe.

5. What laboratory tests should be obtained and has everything been reviewed?

A pregnancy test must be done for those of child-bearing age who are undergoing a pelvic laparoscopic procedure. The results will influence further surgical care. Major operations like radical cystectomy, radical prostatectomy, uterine operations, and node dissection and sampling must have a blood type and screen. For a ruptured ectopic pregnancy, blood products must be available. Those on diuretic therapy should have a serum electrolyte panel. Patients with coronary artery disease should have a 12-lead ECG and further studies based upon history, such as stress ECHO or echocardiographic evaluation for valve disease.

The laboratory values should be inthe normal range. For pelvic laparoscopy these values usually are thesame regardless of age.

  1. Hemoglobin levels: 11-14 g/dL

  2. Electrolytes: Serum K must be 3.5-5.5 mEq/L

  3. Coagulation panel: Normal INR, normal platelet count ,and TEG profile if available

  4. Imaging: A Stress ECHO is indicated for those with ischemic heart disease. etc.

  5. Other tests: a pregnancy test for women of child-bearing age undergoing pelvic laparoscopy

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

The majority of patients are done under general anesthesia with an endotracheal tube. For brief gynecological operations, such as tubal ligation or elective adnexial mass surgery, an LMA may be used provided there is no history of symptomatic GERD or morbid obesity. Because PONV is a significant problem following laparoscopy, using a propofol-based anesthetic is preferable. Propofol has also been shown to reduce vasopressin release following abdominal insufflation. To minimize the use of opioids, the surgeon must infiltrate the skin points of entry with long-acting local anesthetics. For many patients undergoing robotic surgery, access to the upper and lower extremities during surgery is almost impossible. Thus, one should have a low threshold for placing an arterial catheter to allow for continuous blood pressure monitoring and blood sampling for ensuring adequate ventilation.

For similar reasons, the i.v. must be properly secured and taped. If there is doubtful peripheral venous access, a central venous catheter must be placed. Special attention must be paid to positioning because peripheral nerve injury, particularly to the ulnar, femoral and peroneal nerves, is not uncommon. These areas must be properly positioned and padded. For the arms, one must ensure there is adequate foam padding at the ulna area and the hands with the palms facing the body and the thumb facing anteriorly. The shoulders must be secured with adequate supports and padding with a tape to prevent brachial plexus stretching. For longer operations and for patients who will remain in the steep Trendlenburg position, the head must be protected and supported. It is helpful to measure the head circumference hourly. When this increase exceeds 2 to 2.5 cms, it may be worthwhile to alert the surgeon. In such patients extubation must be delayed until return of the circumference to baseline values. Severe oropharyngeal and perilaryngeal edema can also occur and should alert practitioners to delay extubation.

a. Regional anesthesia

Regional anesthesia alone is rarely employed for pelvic laparoscopy. However it may serve as an adjuvant to help minimize the use of opioids that may contribute to postoperative ileus and intensified PONV.

Both single-shot spinal and continuous epidural analgesia along with general anesthesia have been used for pelvic laparoscopy. Thoracic epidural analgesia is more efficacious because it has a more profound sympathectomy with resulting decrease in bowel size. Single-shot dosing with extended release epidural morphine has been shown to be beneficial for up to 48 hours postoperatively. These patients will need to be monitored for respiratory depression, but using neuraxial approaches for pain control has the benefit of decreasing postoperative ileus and reducing the likelihood of PONV.

The main problem with the use of neuraxial approaches is that these patients will also usually require a general anesthetic because of the positional needs and duration of the surgery. Also, antiplatelet therapy or other anticoagulant situations may be contraindications to central neuraxial block. Surgical infiltration of the trocar and camera ports in the skin has been shown to be helpful in decreasing postoperative pain. Similarly, performance of a transabdominal (TAP) block may be of benefit in terms of postoperative pain relief.

  1. Neuraxial

    1. Benefits

    2. Drawbacks

  2. Issues

  3. Peripheral Nerve Block

    1. Benefits

    2. Drawbacks

    3. Issues

b. General Anesthesia

General anesthesia is the preferred approach for pelvic laparoscopy. Ventilatory and positioning needs can be met for surgical success and there is greater flexibility for the duration of surgery. For short and easy gynecological procedures, the use of a laryngeal mask airway (both classic and proseal) has been successfully used without the occurrence of aspiration or ventilatory difficulties in those who are not-obese and do not have symptomatic GERD. For longer operations and those requiring steep Trendlenburg position, a cuffed endotracheal tube provides a proper seal and allows stable ventilation during surgery. However, one should know that endotracheal displacement with abdominal distension and position changes can occur and result in either endobronchial intubation or the tube moving upwards resulting in an air leak. The presence of an endotracheal tube also ensures a satisfactory airway in the presence of increasing upper airway edema related to position and duration of surgery. Endotracheal intubation also helps with increasing ventilation that will be required for CO2 elimination during laparoscopy. Although muscle relaxation is not a requirement, it allows for ease of ventilation during the use of balanced anesthesia care for this procedure.

  1. Benefits

  2. Drawbacks

  3. Other issues

  4. Airway concerns

c. Monitored Anesthesia Care

Monitored anesthesia care is rarely employed for pelvic laparoscopy. Even though some procedures may be brief, most patients are unable to tolerate the need for Trendlenburg position and abdominal distension.

  1. Benefits

  2. Drawbacks

  3. Other Issues

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered?

Antibiotics of the cephalosporin group (Cefotetan, Cefoxitin or Cefmetazole) are administered within an hour of surgery.

What do I need to know about the surgical technique to optimize my anesthetic care?

Placement of an orogastric tube will help to decrease the stomach size. Placement of a urinary bladder catheter will also increase room in the abdomen to improve visualization.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Avoiding nitrous oxide to prevent bowel distention is arguably helpful. Minimizing fluid loading will also decrease bowel edema and prevent surgical leakage from bowel anastomosis. A single-shot subarachnoid block prior to induction of general anesthesia when feasible helps to decrease the bowel size due to sympathetic blockade.

What are the most common intraoperative complications and how can they be avoided/treated?

Intense vagal stimulation during abdominal insufflation may induce cardiovascular collapse. The likelihood can be decreased by ensuring a proper plane of anesthesia before surgery begins. Administration of glycopyrrolate in a timely fashion can prevent the occurrence of collapse. One should be vigilant for unintended CO2 embolism from trocar entry into a vein. Injury to major blood vessels can always occur, and it is prudent to have reliable vascular access for emergent fluid replacement if this complication occurs during pelvic laparoscopy. A sudden decrease in abdominal pressure with improvement in ventilating pressure may be due to perforation of a viscus or urinary bladder. The surgeon should be notified immediately of this occurrence so the injury site can be immediately recognized and repaired.

Complications

Cardiac: Tachycardia, increase in afterload, and effects of catecholamine release following CO2 stimulation of the adrenal medulla can impose significant cardiac stress. This could be detrimental in those with limited cardiac reserve. Vigilant monitoring and short-term use of drugs such as esmolol or vasodilators like hydralazine may be needed.

Pulmonary: The increase in abdominal pressure and the Trendlenburg position with upward displacement of the diaphragm will result in a reduction of FRC and the need for increased airway pressure and ventilation to achieve normocarbia. The increase in ETCO2 from CO2 insufflation will also pose a significant challenge. Aggressive efforts to achieve normocarbia may result in acute pneumothorax. This can be further complicated by the possibility of pneumomediastinum from pneumoperitoneal gas. Upward displacement of the diaphragm can push up the lungs and trachea and slide the endotracheal tube into an endobronchial location further compromising the ability to eliminate CO2. Thus, bronchoscopic confirmation of the endotracheal position in the midtrachea will be helpful in preventing the occurrence of this problem.

Neurologic: Unique to procedure: Position-related nerve injury to the ulna nerve, femoral nerve, brachial plexus, and peroneal nerves has been reported. In some patients with a VP shunt, occlusion of the shunt with resultant increase in ICP can occur. Patients are also at risk of increased intracranial and intraocular pressure from the position, abdominal pressure, increase in caval pressure, and interference of CSF turn-over secondary to lumbar vein compression from the increased abdominal pressure. Blindness has been reported to occur on rare occasions.

a. Neurologic:

During pelvic laparoscopy one should be prepared for the sudden occurrence of severe bradycardia and cardiac arrest due to a vagal response during abdominal insufflation. During the procedure, acute CO2 embolism can also occur from the insufflation gas entrained in an unrecognized open vessel. Similarly, trocar-related injury to a blood vessel can result in significant hemorrhage. Bladder and colon injury can also occur, as can injury to other structures like the ureter.

b. If the patient is intubated, are there any special criteria for extubation?

Positioning and procedure-related upper airway and oropharyngeal and facial edema is quite common in these patients following pelvic laparoscopy. Patients may require reintubation if they are extubated when this edema is present. Patients who were difficult to intubate at the beginning of the procedure will be impossible to reintubate when this edema is present. Thus, when there is significant facial edema, the patients should be placed gradually in a reversed Trendlenburg position and receive ventilatory support until the edema has subsided. This can take anywhere from 1 to 6 hours. A leak-test may be necessary prior to extubation. To do this one deflates the cuff and occludes the endotracheal tube to note if the patient is able to breathe around the tube. In some situations a tube-exchange catheter may have to be used. This will allow evaluation for spontaneous breathing following extubation. If reintubation is required, the exchange catheter can serve as a guide.

c. Postoperative management

Women undergoing brief pelvic laparoscopies for common gynecological problems (tubal ligation, adnexial adhesion removal, fertility workup, for example) can be discharged on the same day and be done as outpatients. They need only small doses of opioids and can be managed with local skin infiltration and drugs like acetaminophen or ketorolac given in the surgical unit. Postoperative pain is managed using a non-narcotic regimen with opioids for back up. Patients needing longer and more complicated procedures will require hospitalization. Because laparoscopic approaches are associated with less postoperative pain when compared with open operations, these patients can be typically managed using a multi-modal plan for pain care. The short-term use of NSAIDS (ibuprofen, ketorolac), acetaminophen, local skin infiltration of trocar sites, and mesosalpinx infiltration during tubal ligation help with pain control in these patients.

The use of single-shot spinal, continuous patient-controlled low thoracic epidural analgesia, and single-shot extended release morphine are also ways to manage pain in these patients.

Many patients can be extubated safely in the post-anesthesia recovery unit and after observation for stability can be discharged to the regular ward unless there is a reason for telemonitoring, including monitoring for apnea (those on extended release morphine and with a history of obstructive sleep apnea) and need for CPAP.

Patients who have experienced significant upper airway and facial edema may need to remain intubated for several hours until this has subsided and extubation can occur safely. These patients will need to be in the intensive care unit. Similarly, those with perforated sigmoid diverticulitis, sepsis, or abscess will need to be in the SICU for continued ventilatory care and postoperative sepsis care.

Patients are at risk for DVT/PE following pelvic laparoscopy. They need to be on sequential compression devices intra- and postoperatively to reduce DVT/PE. There is also a role for fractionated heparin in some patients, particularly those undergoing longer gynecological procedures.

What's the Evidence?

Calverley, R. K, Jenkins, L. C. ""The anaesthetic management of pelvic laparoscopy"". Can Anaesth Soc J. vol. 20. 1973. pp. 679-86.

O'Malley, C, Cunningham, A. J. "Physiologic changes during laparoscopy". Anesthesiol Clin North America. vol. 19. 2001. pp. 1-19.

Olympio, M.A, Hemal, A.K, Menon, M. "Robotics in Genitourinary Surgery". Springer-Verlag London Limited. 2011. pp. 79-95.

Sayed, A.M, Al-Kandari, A.M, , I.S. "Difficult conditions in laparoscopic urologic surgery". Springer-Verlag London Limited. 2011. pp. 17-31.

Afshar, S, Kurer, M. A. "Laparoscopic Peritoneal Lavage for Perforated Sigmoid Diverticulitis". Colorectal Dis. 21-Jan-2011.

Rizzuto, M. I, Oliver, R. "Laparoscopic management of ectopic pregnancy in the presence of a significant haemoperitoneum". Arch Gynecol Obstet. vol. 277. 2008. pp. 433-6.

Tare, Daniel, Maria, Pedro, Ghavamian, Reza, Ghavamian, R. "Complications of Laparoscopic and Robotic Urologic Surgery". Springer Science+Business Media, LLC. 2010. pp. 45-58.

Joshi, G. P. "Complications of laparoscopy". Anesthesiol Clin North America. vol. 19. 2001. pp. 89-105.

Kalmar, A. F, Foubert, L. "Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy". Br J Anaesth. vol. 104. pp. 433-9.

Bowers, Steven P, Hunter, John G. "Contraindications to Laparoscopy. In: THE SAGES MANUAL". 2006. pp. 25-32.

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