Anesthesia for

abdominal surgery
Preanesthetic considerations
• Assessment of preoperative fluid status.
• Metabolic and hematologic
derangements.
• Length of surgery.
• All patients for emergency abdominal
procedures are considered to have full
stomachs.
 Assessment of preoperative
fluid status
• Surgical pathology may cause severe derangement in
volume homeostasis, producing both hypovolemia and
anemia. The main sources of fluid deficits are
inadequate intake, sequestration of water and
electrolytes into abdominal structures, and fluid loss.
 Mechanisms of fluid loss
• Patients may have reduced or no oral intake for varying periods
of time before surgery. Gastrointestinal tract obstruction may prevent
adequate oral intake. Anorexia in chronically ill patients may reduce
oral intake for a prolonged period.
• Emesis or gastric drainage may produce significant fluid losses,
particularly in patients with bowel obstruction. Quantity, quality
(bloody), duration, and frequency of emesis should be assessed.
• Sequestration of fluid may occur either into bowel lumen from ileus
or into interstitium from peritonitis.
• Bleeding from gastrointestinal sources includes ulcers, neoplasms,
esophageal varices, diverticula, angiodysplasia, and hemorrhoids. All
may result in normovolemic or hypovolemic anemia; hematocrit may
be falsely elevated due to haemoconcentration.
• Diarrhea from intestinal disease, infection, or cathartic bowel
preparation can cause significant extracellular fluid loss.
• Fever increases insensible fluid loss.
Physical signs of hypovolemia
• Postural changes in vital signs (increased
heart rate and decreased blood pressure) may
reveal mild-to-moderate hypovolemia.
• Severe hypovolemia will produce tachycardia
and hypotension.
• Dry mucous membranes, decreased skin
turgor and temperature, and skin mottling
indicate decreased peripheral perfusion
secondary to hypovolemia.
• Haematocrit, serum osmolality, blood urea
nitrogen–creatinine ratio, serum and urine
electrolyte concentrations, and urine output is
sometimes helpful in estimating volume
deficits. 
• No definitive laboratory test indicates
intravascular volume status.
• If the intravascular volume status of a patient
cannot be determined by clinical assessment
alone, then invasive monitoring such as
central venous pressure and pulmonary artery
pressure measurements may be necessary.
Metabolic and hematologic
derangements
• Metabolic and hematologic
derangements occur frequently in patients
requiring emergency abdominal surgery.
• Hypokalemic metabolic alkalosis is common in
patients with large gastric losses (emesis or
nasogastric tube drainage);
• Large losses from diarrhea or septicemia can
cause metabolic acidosis.
• Sepsis can produce disseminated intravascular
coagulopathy.
• Length of Surgery is influenced by the history of
previous abdominal surgery, intra-abdominal infection,
radiation therapy, steroid use, surgical technique, and
surgeon experience.
• All Patients for Emergency Abdominal Procedures
are Considered to Have Full Stomachs. A rapid-
sequence induction using cricoid pressure or an awake
intubation technique is indicated with the goal of
minimizing aspiration risk. Premedication with histamine
(H2) antagonist and oral nonparticulate antacid can
decrease gastric acidity. Metoclopramide decreases
gastric volume but should not be used in cases of bowel
obstruction.
Anesthetic techniques
General anesthesia
• General anesthesia is the most commonly employed
technique.
• Advantages include protection of the airway,
assurance of adequate ventilation, and rapid induction
of anesthesia with controlled depth and duration.
• Disadvantages include loss of airway reflexes, which
increases the risk of aspiration during routine or
emergency surgery, and potential adverse hemodynamic
consequences of general anesthetics.
Anesthetic techniques
Regional anesthetic techniques
Lower abdominal procedures (e.g., inguinal hernia repair) can be
performed with regional anesthesia techniques that produce a sensory level to
T4–6.
• Epidural anesthesia usually is performed with a continuous catheter technique.
A “single-dose” technique is applicable for surgery of less than 3 hours.
• Spinal anesthesia usually is performed with a single-dose technique, although
spinal catheters can be placed. The duration of block is determined by the choice
of local anesthetic and adjuvants.
• Nerve blocks can also provide adequate anesthesia for abdominal surgery.
– Blockade of the ilioinguinal, iliohypogastric, and genitofemoral nerves
produces a satisfactory field block for herniorrhaphy. These nerve blocks are
easily performed by the anesthesiologist but may require direct
supplementation of spermatic cord structures by the surgeon.
– Bilateral blockade of T8–12 intercostal nerves provides somatic sensory
anesthesia, whereas celiac plexus block provides visceral anesthesia.
Anesthetic techniques
Regional anesthetic techniques
Upper abdominal procedures (above the umbilicus, T10) are
not well tolerated under regional anesthesia alone.
• Spinal or epidural anesthesia for upper abdominal procedures may
require a sensory level to T2–4. Paralysis of intercostal muscles from a
high thoracic level impairs deep breathing; although minute ventilation
is maintained, patients often complain of dyspnea. Intraperitoneal air
or upper abdominal exploration produces a dull pain referred to a
C5 distribution (usually over the shoulders) that is not prevented by
regional anesthesia and may require supplementation with intravenous
analgesics.
• Celiac plexus blockade alone does not completely block upper
abdominal sensation; visceral traction is poorly tolerated.
Anesthetic techniques
Regional anesthetic techniques
• Advantages:
 Patients maintain the ability to communicate symptoms
(e.g., chest pain).
 Airway reflexes are maintained.
 Profound muscle relaxation and bowel contraction
optimize surgical exposure.
 Sympathectomy increases blood flow to bowel.
 Continuous catheter techniques provide a ready means
for postoperative analgesia.
Anesthetic techniques
Regional anesthetic techniques
• Disadvantages:
 Local anesthetic toxicity from inadvertent IV injection or rapid absorption.
 Patient cooperation is necessary for the institution of block and positioning during surgery.
 Failure necessitates intraoperative conversion to GA.
 Regional nerve blockade may be contraindicated in patients with abnormal bleeding profile
or localized infection at the site of injection.
 Sympathectomy may lead to venodilation and bradycardia that can precipitate profound
hypotension. Unopposed parasympathetic activity causes the bowel to contract and may
make construction of bowel anastomoses more difficult; this can be reversed with
glycopyrrolate, 0.2 to 0.4 mg IV.
 Blockade of upper thoracic nerves may compromise pulmonary function.
 It is not appropriate to delay emergent surgical intervention to perform regional anesthetic
techniques.
 Awake patients often require frequent communication and reassurance; this may distract
the anesthesiologist during complicated cases.
Anesthetic techniques
A combined technique
• A combined technique makes use of an epidural anesthetic along with a general
anesthetic. This technique is commonly used for extensive upper abdominal surgeries.
• Advantages:
 Epidural anesthesia reduces the anesthetic requirement during GA, thereby
minimizing myocardial depression and potentially decreasing emergence time and
nausea.
 Combined techniques may reduce postoperative ventilatory depression and improve
pulmonary function early after upper abdominal surgery, especially in patients at high
risk for postoperative pulmonary complications (e.g., obese patients).
• Disadvantages:
 Sympathectomy produced by regional anesthesia can complicate the differential
diagnosis of intraoperative hypotension.
 Epidural catheter placement and testing add to preparation time.
Management of anesthesia
Induction in anesthesia
• Restoration of volume deficits before induction and careful titration
of sedative premedications provide increased hemodynamic
stability.
• Rapid-sequence induction or awake intubation is required for
all patients considered “full stomachs.” Indications include
conditions in which gastric emptying is delayed, intra-abdominal
pressure is increased, or lower esophageal tone is compromised.
Examples include trauma, bowel obstruction or ileus, hiatal hernia,
gastroesophageal reflux disease, pregnancy beyond the first
trimester, significant obesity, ascites, and diabetes with
gastroparesis and autonomic dysfunction.
Management of anesthesia
Rapid sequence induction
• Indications. Patients at risk for aspiration include those who have recently eaten (full stomach),
pregnant patients, and those with bowel obstruction, morbid obesity, or symptomatic reflux.
• Equipment necessary for a rapid sequence induction should include the following:
 Functioning tonsil-tip (Yankauer) suction.
 Several different laryngoscope blades (Macintosh and Miller).
 Several styletted ETTs, including one that is of size smaller than normal.
 An assistant who can apply cricoid pressure effectively.
– The patient is preoxygenated using high flow rates of 100% oxygen for 3 to 5 minutes
(denitrogenation). Four vital capacity breaths of 100% oxygen achieve nearly the similar
results when time is of the essence.
– The neck is extended so the trachea is directly anterior to the esophagus. After IV
administration of an induction agent (e.g., thiopental, propofol, or ketamine), followed
immediately by succinylcholine (1 to 1.5 mg/kg IV) or rocuronium (1.2 mg/kg), an assistant
places firm downward digital pressure on the cricoid cartilage, effectively compressing and
occluding the esophagus (Sellick maneuver). This maneuver reduces the risk of passive
regurgitation of gastric contents into the pharynx and may bring the vocal cords into better
view by displacing them posteriorly. It should not be used if the patient is actively vomiting,
because high pressures could injure the esophagus.
– There should be no attempt to ventilate the patient by mask. Intubation can usually be
performed within 30 to 60 seconds. Cricoid pressure is maintained until successful
endotracheal intubation is verified.
– If intubation attempts are unsuccessful, cricoid pressure should be maintained continuously
during subsequent intubation maneuvers and while mask ventilation is in progress.
Maintenance of anesthesia
Fluid management
• Fluid management requires appropriate administration of maintenance fluids and
replacement of both deficits and ongoing losses.
• Bleeding should be estimated both by direct observation of the surgical field and suction
traps and by weighing sponges. Blood loss may be concealed (e.g., beneath drapes or within
the patient).
• Bowel and mesenteric edema can result from surgical manipulation or intestinal pathology.
• Evaporative losses from peritoneal surfaces are proportional to the area exposed. Fluid
replacement is guided by clinical judgment and/or invasive monitoring. Traditionally, very long
cases with significant bowel exposure and preoperative hypovolemia required fluid
replacement of up to 10 to 15 mL/kg/hour. New evidence, however, suggests that a more
restrictive approach with as little as 4 mL/kg/hour plus bolus fluid supplementation for
hypotension may be associated with faster recovery and fewer complications.
• Abrupt drainage of ascitic fluid with surgical entry into the peritoneum can produce acute
hypotension from sudden decreases of intra-abdominal pressure and pooling of blood in
mesenteric vessels, thus reducing venous return to the right heart. Postoperative
reaccumulation of ascitic fluid can produce significant intravascular fluid losses.
• Naso-gastral and other enteric drainage should be quantified and replaced appropriately.
 Maintenance of anesthesia
• Fluid losses should be replaced with crystalloids, colloids, or blood products. Initially, fluid
should be replaced by administration of an isotonic salt solution. There is no formula to
calculate the volume required to correct extracellular fluid depletion. Adequate repletion
must be assessed clinically; blood pressure, pulse, urine output, and haematocrit are
guides. Further management of electrolyte and acid–base abnormalities should be based on
laboratory studies. When an isotonic crystalloid solution is used to replace blood loss, about
two thirds of administered volume will pass into the interstitial space and one third will
remain in the intravascular space; thus, a ratio of at least 3 mL of replacement per 1 mL
lost is usually needed.
• Colloids are fluids containing particles large enough to exert oncotic pressure. They remain
in the intravascular space longer than crystalloids. Multiple studies comparing fluid
resuscitation with crystalloids to colloids have reported no benefit (and perhaps even poorer
outcome) with colloids. Colloid solutions are more expensive than crystalloids; thus, routine
use is not justified. Albumin may be superior to crystalloid in patients with significant burns,
hepatorenal disease, or acute lung injury. Hydroxyethyl starch solutions are non–blood-
derived colloids that may also be used as methods of volume expansion. It is important to
note that at volumes above 1 L/day, these solutions may impair coagulation, although
newer preparations, not currently available in the United States, do appear to have less
effect on coagulation.
• Use of blood products should be guided by laboratory measurements of hematocrit,
platelet count, and coagulation parameters.
Maintenance of anesthesia
• Muscle relaxation is required for all but the
most superficial intra-abdominal procedures;
sufficient relaxation is critical during
abdominal closure because bowel distention,
edema, and organ transplantation can
increase the volume of abdominal content.
 Naso-gastral tubes
• Preoperative placement is indicated for decompression of the stomach, especially in trauma
victims and patients with obstructed bowel; many patients arrive in the operating suite with an NG
tube already in place. Although suction via a large-bore NG tube can reduce the volume of gastric
contents, it does not completely evacuate the stomach and may facilitate aspiration by stenting
open the lower esophageal sphincter. NG tubes may also compromise mask fit. Before induction,
suction should be applied to NG tubes. During induction, tubes should be allowed to drain. Cricoid
pressure may help to prevent passive reflux when an NG tube is present.
• Intraoperative placement is required to drain gastric fluid and air during abdominal surgery.
Nasogastric and orogastric tubes should never be placed with excessive force; lubrication and head
flexion facilitate insertion. Tubes can be directed into the esophagus by using a finger within the
oropharynx or using Magill forceps under direct visualization with a laryngoscope. If these methods
fail, a large endotracheal tube (9.5 mm or larger), split lengthwise, can be used as an introducer.
The split endotracheal tube is introduced orally into the esophagus and the NG tube is passed
through the lubricated lumen of the tube into the stomach; the split tube is then removed while
stabilizing the NG tube.
• Complications of NG tube insertion include bleeding, submucosal dissection of the retropharynx,
and placement in the trachea. Intracranial placement has been described in patients with basilar
skull fracture. The NG tube should be secured carefully to avoid excessive pressure on the nasal
septum or nares, as this may cause ischemic necrosis.
Common intraoperative
problems 
• Pulmonary compromise can be caused by surgical
retraction of abdominal viscera to improve exposure
(insertion of soft packs or rigid retractors), insufflation
of gas during laparoscopy, or Trendelenburg
positioning. These maneuvers may elevate the
diaphragm, decrease functional residual capacity (FRC),
and produce hypoxemia. Application of positive end-
expiratory pressure (PEEP) may counter these effects.
• Temperature control. Heat loss in open abdominal
procedures is common.
Common intraoperative
problems
• Hemodynamic changes as a result of bowel
manipulation (i.e., hypotension, tachycardia, and facial
flushing). Prostanoid, prostaglandin F1α, found in vascular
endothelial cells and luminal cells of the bowel has been
implicated as a humoral element.
• Opioids may aggravate biliary tract spasm. Although
uncommon, opioids may produce painful biliary spasm in some
patients when administered as a premedication or into the
epidural space. Spasm rarely complicates surgical repair or
interpretation of a cholangiogram and can be reversed with
naloxone. Nitroglycerin and glucagon also relieve spasm by
nonspecific smooth muscle relaxation.
Common intraoperative
problems
• Fecal contamination from perforation of the gastrointestinal
tract can cause infection and sepsis.
• Hiccups are episodic diaphragmatic spasms that may occur
spontaneously or in response to stimulation of the diaphragm or
abdominal viscera. Potential therapies include the following:
– Increasing depth of anesthesia to ameliorate reaction to
endotracheal, visceral, or diaphragmatic stimulation.
– Removal of source of diaphragmatic irritation, such as gastric
distention.
– Increasing depth of neuromuscular blockade; this may
decrease the strength of spasms. Complete diaphragmatic
paralysis is difficult to achieve and may be possible only with
doses of relaxants in excess of those required for relaxation of
abdominal musculature.
– Chlorpromazine titrated in 5-mg IV increments.
Anesthetic considerations for
specific abdominal
procedures
Laparoscopic surgery
• Due to advances in instrumentation and surgical techniques,
laparoscopic approaches are applied to an increasing number of
surgical procedures, including appendectomy, cholecystectomy, hernia
repair, fundoplication, nephrectomy, weight loss surgery, and colon
resection. Benefits of laparoscopic surgery include smaller incision,
reduced postoperative pain, decreased postoperative ileus, early
ambulation, shorter hospital stay, and earlier return to normal
activities.
• Operative technique involves intraperitoneal insufflation of
CO2 through a needle inserted into the abdomen via a small
infraumbilical incision until intra-abdominal pressure reaches 12 to 15
mm Hg. Patient positioning is used to facilitate operative exposure:
steep reverse Trendelenburg improves visualization of upper
abdominal structures; Trendelenburg helps to visualize lower
abdominal structures.
Laparoscopic surgery
Anesthetic considerations
• Hemodynamic changes associated with laparoscopy are influenced by
the intra-abdominal pressure needed for the creation of pneumoperitoneum,
volume of CO2 absorbed, patient's intravascular volume status, positioning,
and anesthetic agents used. Generally, intra-abdominal pressures of 12 to
15 mm Hg are well tolerated in healthy patients. Mean arterial pressure and
systemic vascular resistance usually increase with the creation of
pneumoperitoneum in healthy patients; cardiac output is unaffected.
Patients with coexisting cardiac disease may develop decreased cardiac
output and hypotension associated with pneumoperitoneum. Absorption of
CO2 across the peritoneal surface can cause hypercarbia, resulting in
sympathetic nervous system stimulation and increased blood pressure,
heart rate, and cardiac output.
Laparoscopic surgery
Anesthetic considerations
• The reduction in FRC associated with general anesthesia is compounded
by the creation of pneumoperitoneum. FRC may be further compromised
by the Trendelenburg position because of increased pressure from
abdominal viscera on the diaphragm. PEEP may be necessary to treat
alveolar collapse. Pneumoperitoneum increases peak airway pressures.
However, transalveolar pressure may not be increased because of
decreased abdominal and chest wall compliance, leading to decreased
respiratory system compliance. Because CO2 is absorbed across the
peritoneal surface, an increase in minute ventilation is necessary to
maintain normocarbia.
• Because patients may be positioned in steep Trendelenburg or reverse
Trendelenburg, changes in venous return must be anticipated and
monitored. Also, frequent attention must be given to patients' arms to
prevent brachial plexus injury.
Laparoscopic surgery
Anesthesia considerations
• Temperature control. Heat loss may occur from intraperitoneal
insufflation of cold gas.
• Embryonic channels between the peritoneal and
pleural/pericardial cavities may open with increased
intraperitoneal pressure, resulting in pneumomediastinum,
pneumopericardium, and pneumothorax. Diffusion of gas
cephalad from the mediastinum can lead to subcutaneous
emphysema of the face and neck.
• Vascular injuries secondary to the introduction of the needle or
trocar can produce sudden blood loss and necessitate conversion
to an open procedure to control bleeding.
Laparoscopic surgery
Anesthesia considerations
• Venous gas embolism is rare but may occur on induction of pneumoperitoneum if
the needle or trocar is placed into a vessel or an abdominal organ or if gas is trapped
in the portal circulation. The high capacity of blood to absorb CO 2 and its rapid
elimination in the lungs increases the margin of safety in case of accidental IV
injection of CO2. Insufflation of gas under high pressure can lead to a “gas lock” in the
vena cava and right atrium; this will decrease venous return and cardiac output and
produce circulatory collapse. Embolization of gas into the pulmonary circulation leads
to increased dead space, ventilation/perfusion mismatch, and hypoxemia. Systemic
gas embolization (with occasionally devastating effects on cerebral and coronary
circulation) can occur with massive gas entrainment or via a patent foramen ovale.
Treatment consists of stopping gas insufflation, placing the patient on 100% O 2 to
relieve hypoxemia, and positioning the patient in steep head-down left lateral
decubitus to displace gas from the right ventricular outflow tract.
Laparoscopic surgery
Anesthetic management
• General anesthesia is usually required for
laparoscopy. Creation of pneumoperitoneum and
steep Trendelenburg positioning can compromise
ventilatory function.
• Controlled ventilation is necessary to prevent
hypercarbia.
• A urinary bladder catheter and an NG tube are
inserted (usually after induction of general
anesthesia) to improve visualization and reduce the
risk of trauma to bladder and stomach with trocar
insertion.
 Gastric surgery
• Gastric surgery is usually performed with GA or combined GA–
epidural. The high likelihood of aspiration in these patients necessitates
rapid-sequence or awake intubation. Large third-space losses and
potential for hemorrhage should be anticipated.
• Gastrectomy or hemigastrectomy with
gastroduodenostomy (Billroth I) or gastrojejunostomy(Billroth II)
is usually performed for gastric adenocarcinoma or intractable bleeding
from gastric or duodenal ulcers; rarely, it is necessary in Zollinger-
Ellison syndrome.
• Gastrostomy can be performed through a small upper abdominal
incision or percutaneously with an endoscope. Local anesthesia with
sedation is often adequate in the debilitated elderly patient, although
some require general anesthesia.
Intestinal and Peritoneal
surgery
• Appendectomy is performed through a small lower abdominal
incision or via laparoscopy. Fever, poor oral intake, and vomiting may
produce hypovolemia; IV hydration before induction is indicated. In
rare cases where sepsis and dehydration are absent, a regional
anesthetic may be appropriate; otherwise, GA with rapid-sequence or
awake intubation is necessary.
• Colectomy or hemicolectomy is used to treat colon cancer,
diverticular disease, Crohn's disease, ulcerative colitis, trauma,
ischemic colitis, and abscess. Emergency colectomy on unprepared
bowel carries a high risk of peritonitis from fecal contamination. Some
emergencies involving the colon are treated with an initial diverting
colostomy, followed later by bowel preparation and elective
colectomy. Patients must be evaluated for hypovolemia, anemia, and
sepsis. All emergency colectomies and colostomies should be treated
as if at risk for aspiration. Combination general/regional anesthetics
are preferable.
 Intestinal and Peritoneal
surgery
• Perirectal abscess drainage, hemorrhoidectomy, and pilonidal
cystectomy are relatively noninvasive and brief procedures. Pilonidal cysts
are excised with patients positioned prone; abscess drainage and
hemorrhoidectomy can be performed in either a prone or a lithotomy
position. If general anesthesia is used, deep planes of anesthesia or use of
muscle relaxants may be necessary to achieve adequate sphincter relaxation.
Hyperbaric spinal anesthesia is used for procedures in the lithotomy position,
whereas a hypobaric technique is useful for the flexed prone (jackknife) or
knee–chest position. A caudal block may be performed for either position.
• Inguinal, femoral, or ventral herniorrhaphies can be performed under
local anesthesia, regional anesthesia (spinal, epidural, caudal, or nerve
block), or GA. Maximum stimulation and profound vagal responses may
occur during spermatic cord or peritoneal retraction. Communication with
surgeons is important, as they may need to reduce traction if necessary. If
GA is selected, either mask technique (e.g., laryngeal mask airway) or deep
extubation should be considered to minimize coughing on emergence that
can strain the repair.
Hepatic surgery
• Partial hepatectomy is performed for hepatoma, unilobar
metastasis of a carcinoma, arteriovenous malformation, or
echinococcal cysts.
• Extensive hemorrhage should be anticipated; standard monitors are
supplemented with placement of arterial and central venous catheters
and large-bore IV access.
• Blood loss during hepatic parenchymal division can be reduced by
temporary occlusion of portal venous and arterial inflow at the level of
the hepatic pedicle (Pringle maneuver).
• Volume of replacement fluids can be guided effectively by CVP; blood
and blood product replacement can be guided by intraoperative
assessment of hemoglobin and coagulation status.
• The normal liver has considerable reserve, and extensive resection is
required before clinical impairment of drug metabolism is evident.
• Epidural catheters can be placed in patients with normal coagulation
status.
Biliary tract procedures
• Cholecystectomy is a common procedure performed via either open
laparotomy or laparoscopic techniques. General anesthesia is favored for either
technique. During laparoscopic cholecystectomy, the patient is placed in a steep
reverse Trendelenburg position and the gallbladder is dissected from the liver
bed by using either cautery or laser. Muscle relaxants are required for adequate
abdominal wall relaxation. The amount of hemorrhage is difficult to assess
because of the limited field of view and high magnification of the laparoscope;
heavy bleeding from the cystic or hepatic arteries may occur. Advantages of
laparoscopic cholecystectomy include minimal postoperative pain and faster
recovery. Most patients are discharged on the first postoperative day.
• Biliary drainage procedures include transduodenal sphincteroplasty for
extensive choledocholithiasis; cholecystojejunostomy for distal common bile
duct obstruction from pancreatic cancer; and choledochojejunostomy for
chronic pancreatitis, stone disease, and benign strictures of the distal bile duct.
Endoscopic and transhepatic techniques are increasingly common, but open
surgical drainage is occasionally required. Blood loss is usually minimal but fluid
loss may be significant.