Intraoperative desaturation and unilateral breath sounds during Nissen fundoplication

Haemodynamic compromise during thoracoscopic/laparoscopic oesophagectomy

Minimally invasive oesophagectomy is a relatively new procedure that is performed by means of thoracoscopy and laparoscopy. One stage of the procedure involves creation of a peritoneo-pleural communication in the presence of a pneumoperitoneum. In the case presented, severe hypotension occurred at this point. We believe this was caused by the escape of carbon dioxide from the peritoneal cavity into the right hemithorax, resulting in tension pneumothorax and cardiac tamponade. We believe this to be a predictable complication of this procedure but one that if expected, recognised and correctly managed, should not result in adverse outcomes.

Complications of laparoscopy

The frontiers of laparoscopic surgery have extended from gynecologic procedures to general surgical techniques. As new applications for laparoscopy emerge, anesthesiologists must be familiar with the possible complications associated with the various laparoscopic procedures. Only by an appreciation of the potential complications of a procedure can their overall incidence be minimized. A systematic approach must consider all potential complications during laparoscopy. In addition to routine evaluation (i.e., depth of anesthesia and volume status), anesthesiologists must confirm that intra-abdominal pressure is less than 15 mm Hg, and that inadvertent endobronchial intubation, pneumothorax, and gas embolism have not occurred. In the case of precipitous changes in vital signs not responding to routine management, it is imperative to release the pneumoperitoneum and place the patient in the supine (or Trendelenburg) position. After cardiopulmonary stabilization, cautious slow reinsufflation then can be attempted. With persistent signs of significant cardiopulmonary impairment, however, it is sometimes necessary to convert to an open procedure.

Anesthesia for laparoscopy in the pediatric patient

Pediatric laparoscopy is a novelty that has yet to be critically assessed in large, randomized controlled trials. Just because an operation can be performed laparoscopically does not mean it must be done that way. Many procedures can now be performed more quickly and cheaply through small incisions without the added cardiorespiratory risks seen in laparoscopy. Reports of serious complications are beginning to appear in publications. It will become important to compare laparoscopic techniques with both open surgery and the minimally invasive approach for the same procedure. Many published studies suggest laparoscopy offers significant advantages for some operations and for sicker patients. Practitioners must have a thorough understanding of the physiologic changes that follow pneumoperitoneum and extremes of positioning. As enthusiasm builds, it is essential to maintain safety standards. Endoscopists must be appropriately trained and peer reviewed. The use of virtual reality models now allows surgeons to develop and perfect their laparoscopic skills. When the laparoscopic approach is difficult, surgeons must be willing to convert to open surgery rather than persevere and risk iatrogenic damage. The role of pediatric laparoscopy has yet to be defined, although current trends suggest that it will assume an important position in pediatric surgery.