Miller Anestesia

cardiorrespiratorios intraoperatorios. La Paco

aumenta a causa de

la absorción de CO

desde la cavidad peritoneal. Este aumento de

la Paco

es aún mayor en los pacientes con alteraciones cardiorres-

piratorias, y en los pacientes cardíacos de alto riesgo las alteracio-

nes hemodinámicas se acentúan. El mejor conocimiento de los

trastornos hemodinámicos fisiopatológicos que se producen en las

personas sanas permite establecer técnicas anestésicas satisfacto-

rias a los enfermos cardíacos, optimizando la precarga antes de

iniciar el neumoperitoneo y utilizando con prudencia fármacos

vasodilatadores. No parece que el empleo de gases alternativos para

la insuflación (p. ej., He, Ar, N

O) reduzca los cambios hemodiná-

micos. La laparoscopia sin gas puede ser más útil, pero por desgra-

cia su dificultad técnica es mayor. En varias revisiones a gran escala

se ha establecido una incidencia de complicaciones que pueden

compararse favorablemente con las de la cirugía abierta. La mor-

talidad durante la intervención laparoscópica oscila en torno de

0,1-1 por 1.000 casos y la incidencia de complicaciones hemorrá-

gicas y lesiones viscerales es de 2-5 por 1.000 casos. Aunque no se

ha demostrado que ninguna técnica anestésica sea clínicamente

superior a las demás, parece que la anestesia general con ventila-

ción controlada es la más segura para la laparoscopia quirúrgica.

Un mejor conocimiento de las repercusiones intraoperatorias de la

laparoscopia permitirá un tratamiento más seguro de los pacientes

con enfermedades cardiorrespiratorias cada vez más graves, que

pueden beneficiarse de las múltiples ventajas postoperatorias de

esta técnica.

Bibliografía

1. Dubois F, Icard P, Berthelot G, et al: Coelioscopic

cholecystectomy: Preliminary report of 36 cases.

Ann Surg 211:60, 1990.

2. Grace PA, Quereshi A, Coleman J, et al: Reduced

postoperative hospitalization after laparoscopic

cholecystectomy. Br J Surg 78:160, 1991.

3. Joris J, Cigarini I, Legrand M, et al: Metabolic and

respiratory changes after cholecystectomy perfor-

med via laparotomy or laparoscopy. Br J Anaesth

69:341, 1992.

4. Wahba RW, Tessler MJ, Kleiman SJ: Acute ventila-

tory complications during laparoscopic upper

abdominal surgery. Can J Anaesth 43:77, 1996.

5. Bardoczky GI, Engelman E, Levarlet M, et al: Venti-

latory effects of pneumoperitoneum monitored with

continuous spirometry. Anaesthesia 48:309, 1993.

6. Fahy BG, Barnas GM, Flowers JL, et al: The effects

of increased abdominal pressure on lung and chest

wall mechanics during laparoscopic surgery. Anesth

Analg 81:744, 1995.

7. Fahy BG, Barnas GM, Nagle SE, et al: Changes in

lung and chest wall properties with abdominal

insufflation of carbon dioxide are immediately

reversible. Anesth Analg 82:501, 1996.

8. Dumont L, Mattys M, Mardirosoff C, et al: Changes

in pulmonary mechanics during laparoscopic gas-

troplasty in morbidly obese patients. Acta Anaes-

thesiol Scand 41:408, 1997.

9. Sprung J, Whalley DG, Falcone T, et al: The impact

of morbid obesity, pneumoperitoneum, and posture

on respiratory system mechanics and oxygenation

during laparoscopy. Anesth Analg 94:1345, 2002.

10. Mutoh T, LammWJ, Embree LJ, et al: Volume infu-

sion produces abdominal distension, lung compres-

sion, and chest wall stiffening in pigs. J Appl Physiol

72:575, 1992.

11. Andersson LE, Baath M, Thorne A, et al: Effect of

carbon dioxide pneumoperitoneum on develop-

ment of atelectasis during anesthesia, examined by

spiral computed tomography. Anesthesiology

102:293, 2005.

12. Odeberg-Wernerman S: Laparoscopic surgery—

effects on circulatory and respiratory physiology: an

overview. Eur J Surg (Suppl) 585:4, 2000.

13. Andersson L, Lagerstrand L, Thorne A, et al: Effect

of CO(2) pneumoperitoneum on ventilation-perfu-

sion relationships during laparoscopic cholecystec-

tomy. Acta Anaesthesiol Scand 46:552, 2002.

14. Mullet C, Viale J, Sagnard P, et al: Pulmonary CO

elimination during surgical procedures using intra-

or extraperitoneal CO

insufflation. Anesth Analg

76:622, 1993.

15. Nyarwaya J, Mazoit J, Samii K: Are pulse oximetry

and end-tidal carbon dioxide tension monitoring

reliable during laparoscopic surgery? Anaesthesia

49:775, 1994.

16. Baraka A, Jabbour S, Hammoud R, et al: End-tidal

carbon dioxide tension during laparoscopic chole-

cystectomy: Correlation with the baseline value

prior to carbon dioxide insufflation. Anaesthesia

49:304, 1994.

17. Lister DR, Rudston-Brown B, Warriner CB, et al:

Carbon dioxide absorption is not linearly related to

intraperitoneal carbon dioxide insufflation pressure

in pigs. Anesthesiology 80:129, 1994.

18. Ciofolo MJ, Clergue F, Seebacher J, et al: Ventilatory

effects of laparoscopy under epidural anesthesia.

Anesth Analg 70:357, 1990.

19. Wahba RW, Mamazza J: Ventilatory requirements

during laparoscopic cholecystectomy. Can J Anaesth

40:206, 1993.

20. Bures E, Fusciardi J, Lanquetot H, et al: Ventilatory

effects of laparoscopic cholecystectomy. Acta

Anaesthesiol Scand 40:566, 1996.

21. Wittgen CM, Andrus CH, Fitzgerald SD, et al:

Analysis of the hemodynamic and ventilatory

effects of laparoscopic cholecystectomy. Arch Surg

126:997, 1991.

22. Wittgen CM, NaunheimKS, Andrus CH, et al: Preo-

perative pulmonary function evaluation for lapa-

roscopic cholecystectomy. Arch Surg 12:880, 1993.

23. Fitzgerald SD, Andrus CH, Baudendistel LJ, et al:

Hypercarbia during carbon dioxide pneumoperito-

neum. Am J Surg 163:186, 1992.

24. Wulkan ML, Vasudevan SA: Is end-tidal CO

accurate measure of arterial CO

during laparosco-

pic procedures in children and neonates with cya-

notic congenital heart disease? J Pediatr Surg

36:1234, 2001.

25. Tolksdorf W, Strang CM, Schippers E, et al: [The

effects of the carbon dioxide pneumoperitoneum in

laparoscopic cholecystectomy on postoperative

spontaneous respiration]. Anaesthesist 41:199, 1992.

26. Rademaker BM, Odoom JA, de Wit LT, et al: Hae-

modynamic effects of pneumoperitoneum for lapa-

roscopic surgery: a comparison of CO

with N

insufflation. Eur J Anaesthesiol 11:301, 1994.

27. Rademaker BM, Bannenberg JJ, Kalkman CJ, et al:

Effects of pneumoperitoneum with helium on

hemodynamics and oxygen transport: A compari-

son with carbon dioxide. J Laparoendosc Surg 5:15,

1995.

28. Tan PL, Lee TL, TweedWA: Carbon dioxide absorp-

tion and gas exchange during pelvic laparoscopy.

Can J Anaesth 39:677, 1992.

29. Kazama T, Ikeda K, Kato T, et al: Carbon dioxide

output in laparoscopic cholecystectomy. Br J

Anaesth 76:530, 1996.

30. Nunn J: Applied Respiratory Physiology, 4th ed.

London, Butterworths Heinemann, 1993.

31. Hirvonen EA, Nuutinen LS, Kauko M: Ventilatory

effects, blood gas changes, and oxygen consumption

during laparoscopic hysterectomy. Anesth Analg

80:961, 1995.

32. Wilcox S, Vandam LD: Alas, poor Trendelenburg

and his position! A critique of its uses and effecti-

veness. Anesth Analg 67:574, 1988.

33. Hall D, Goldstein A, Tynan E, et al: Profound hyper-

carbia late in the course of laparoscopic cholecystec-

tomy: Detection by continuous capnometry.

Anesthesiology 79:173, 1993.

34. Wolf JS Jr, Monk TG, McDougall EM, et al: Extra-

peritoneal approach and subcutaneous emphysema

are associated with greater absorption of carbon

dioxide during laparoscopic renal surgery. J Urol

154:959, 1995.

35. Streich B, Decailliot F, Perney C, et al: Increased

carbon dioxide absorption during retroperitoneal

laparoscopy. Br J Anaesth 91:793, 2003.

36. Chien GL, Soifer BE: Pharyngeal emphysema with

airway obstruction as a consequence of laparosco-

pic inguinal herniorrhaphy. Anesth Analg 80:201,

1995.

37. Spielman FJ: Laparoscopic surgery. In Kirby DD,

Hood RR, Brown DL (eds): Problems in Anesthesia:

Anesthesia in Obstetrics and Gynecology. Philadel-

phia, JB Lippincott, 1989, pp 151.

38. Whiston RJ, Eggers KA, Morris RW, et al: Tension

pneumothorax during laparoscopic cholecystec-

tomy. Br J Surg 78:1325, 1991.

39. Knos GB, Sung YF, Toledo A: Pneumopericardium

associated with laparoscopy. J Clin Anesth 3:56, 1991.

40. McConnell MS, Finn JC, Feeley TW: Tension

hydrothorax during laparoscopy in a patient with

ascites. Anesthesiology 80:1390, 1994.

41. Joris JL, Chiche JD, Lamy ML: Pneumothorax

during laparoscopic fundoplication: diagnosis and

treatment with positive end-expiratory pressure.

Anesth Analg 81:993, 1995.

42. Batra MS, Driscoll JJ, Coburn WA, et al: Evanescent

nitrous oxide pneumothorax after laparoscopy.

Anesth Analg 62:1121, 1983.

43. Bottcher-Haberzeth S, Dullenkopf A, Gitzelmann

CA, Weiss M: Tracheal tube tip displacement during

laparoscopy in children. Anaesthesia 62:131, 2007.

44. Morimura N, Inoue K, Miwa T: Chest roentgeno-

gram demonstrates cephalad movement of the

carina during laparoscopic cholecystectomy. Anes-

thesiology 81:1301, 1994.

45. Burton A, Steinbrook RA: Precipitous decrease in

oxygen saturation during laparoscopic surgery.

Anesth Analg 76:1177, 1993.

Anestesia para la cirugía laparoscópica

1963

Sección IV

Anestesia por subespecialidades en el adulto