LOW IMPACT SURGERY AND ANESTHESIA IN LAPAROSCOPY

Admar A. laprascopy surgery for histerctomy or cystectomy

Jan Paul M. OFA stay for opioid free anesthesia and means no opioid given before or during anesthesia till the last stitch, also not for induction and intubation. if you give an opioid after surgery it is an analgesic, not an anesthetic.. I know that this discussion is more semantic but important to know what you mean with it. Opioids given intra operative could be to block surgical stress, to stop spontaneous breathing to induce bradycardia or hypotension. Opioids given postoperative should work as analgesics and this is best achieved if tolerance did not develop yet due to the high doses given intra operative.

Jan Paul M. depending on the abdominal compliance (abd C) and the starting IAPressure at volume zero (PV0) you might be able to work with a moderate NMB when setting IAP above 12. ( ex if PV0 = 4 and abd C= 0,5L/mmHg you need 4+6=10 mmHg to get 3 liter workspace) with a deep NMB you can drop PV0 to 2 mmHg and use 8 mmHg still getting 3 liter the minimum good workspace) if the patient is obese the PV0 can start at 10 and if male with central obesity C can be only 0,1 L/mmHg meaning that even 20 mmHg is not enough and just gives 1 liter only. A deep NMB is now essential to reduce PV0 to lets assume 7 ( you have to measure as every patient is different) and this gives now at 20 mmHG 1,3 liter instead of 1 liter...
If you want to use lowest IAP possible then it helps always to go to deep NMB and drop a few mmHg lower. Next to workspace there should be no movement where you have several options: deep NMB, deep hypnosis ( 2 MAC) or high dose opioids and hyperinflation as the last three will block respiratory centers ut not relax the muscles. However today we know that deep hypnosis, high dose opioids and hyperventilation are not without any risk while deep NMB is at no risk on the condition that you measure NMT and reverse till a TOF of 100 %