Advertisement

Surgical Endoscopy

, Volume 8, Issue 11, pp 1272–1284 | Cite as

Laparoscopic surgery—anesthetic implications

  • A. J. Cunningham
Review

Abstract

Laparoscopic cholecystectomy is a relatively new surgical procedure which is enjoying everincreasing popularity and presenting new anesthetic challenges. The advantages of shorter hospital stay and more rapid return to normal activities are combined with less pain associated with the small limited incisions and less postoperative ileus compared with the traditional open cholecystectomy. The efficacy of laparoscopic appendectomy and hemicolectomy has been recently evaluated. However, there have been no prospective randomized studies to date comparing laparoscopic with traditional laparotomy techniques. The physiological effects of prolonged pneumoperitoneum and the longer duration of surgery with the laparoscopic techniques are of concern. The application of laparoscopic inguinal hernia repair may be limited because, unlike traditional surgical hepair, general anesthesia is required and concerns have been expressed about the duration of surgery and the possibility of hernia recurrence. Notwithstanding case reports and series describing successful diaphragmatic and hiatus hernia repair using a laparoscopic surgical technique, the frequently encountered complications of cervical surgical emphysema, pneumothorax, and pneumomediastinum, attributed to passage of insufflating gas through weak points or defects in the diaphragm, must be of major concern. Anesthesiologists must maintain a high index of suspicion for these potential complication and must undertake appropriate monitoring. If there is clinical evidence of a tension pneumothorax, immediate chest tube decompression is indicated.

Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiological changes associated with patient positioning and pneumoperitoneum creation. The choice of anesthetic technique for upper abdominal laparoscopic procedures is most frequently limited to general anesthesia. Controlled ventilation avoids hypercarbia, and an anesthetic technique incorporating antiemetics and nonsteroidal anti-inflammatory agents has reduced postoperative nausea and vomiting following laparoscopic cholecystectomy. The use of nitrous oxide during laparoscopic procedures remains controversial.

Laparoscopic cholecystectomy is a major advance in the management of patients with symptomatic gallbladder disease. However, in the present era of cost containment, older and sicker patients may present for this procedure on the day of surgery without adequate preoperative evaluation. Anesthesiologists should thus be prepared to recommend deflation of the pneumoperitoneum and possibly conversion to an open procedure if hemodynamic, oxygenation, or ventilation difficulties arise during the procedure.

Key words

Anesthesia Laparoscopy Intraabdominal 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Adamthwaite DN (1984) Traumatic diaphragmatic hernia: a new indication for laparoscopy. Br J Surg 71: 315Google Scholar
  2. 2.
    Alexander GD, Noe FE, Brown EM (1969) Anesthesia for pelvic laparoscopy. Anesth Analg 48: 14–18Google Scholar
  3. 3.
    Anteby SO, Schenker JG, Polishuk WZ (1975) The value of laparoscopy in acute pelvic pain. Ann Surg 181: 484–486Google Scholar
  4. 4.
    Bovill JG, Sebel PS, Stanley TH (1984) Opioid analgesics in anesthesia: with special reference to their use in cardiovascular anesthesia. Anesthesiology 61: 731–755Google Scholar
  5. 5.
    Brown DR, Fishburne JI, Roberson VO, Hulka JF (1977) Ventilatory and blood gas changes during laparoscopy with local anesthesia. Am J Obstet Gynecol 124: 741–745Google Scholar
  6. 6.
    Burton A, Steinbrook RA (1993) Precipitous decrease in oxygen saturation during laparoscopic surgery. Anesth Analg 76: 1177–1178Google Scholar
  7. 7.
    Busman DC, Munting JD (1982) Results of highly selective vagotomy in a non university teaching hospital. Br J Surg 69: 620–624Google Scholar
  8. 8.
    Calhoun B, Viani B, LaRue D (1992) The effect of ketorolac on patients undergoing laparoscopic cholecystectomy. Anesthesiology 77: A48Google Scholar
  9. 9.
    Calverley RK, Jenkins LC (1973) The anaesthetic management of pelvic laparoscopy. Can Anaesth Soc J 20: 679–686Google Scholar
  10. 10.
    Cameron JL, Gadacz TR (1991) Laparoscopic cholecystectomy. Ann Surg 213: 1–2Google Scholar
  11. 11.
    Campos LI, Sipes EK (1991) Laparoscopic repair of diaphragmatic hernia. J Laparoendosc Surg 1: 369–373Google Scholar
  12. 12.
    Case EH, Stiles JA (1946) The effect of various surgical positions on vital capacity. Anesthesiology 7: 29–31Google Scholar
  13. 13.
    Clarke CC, Weeks DB, Gusdon JP (1977) Venous carbon dioxide embolism during laparoscopy. Anesth Analg 56: 650–652Google Scholar
  14. 14.
    Collet D, Edye M, Magne E, Perissat J (1992) Laparoscopic cholecystectomy in the obese patient. Surg Endosc 6: 186–188Google Scholar
  15. 15.
    Craig DB (1981) Postoperative recovery of pulmonary function. Anesth Analg 60: 46–52Google Scholar
  16. 16.
    Cunningham AJ, Brull SJ (1993) Laparoscopic cholecystectomy—anesthetic implications. Anesth Analg 76: 1120–1133Google Scholar
  17. 17.
    Cunningham AJ, Schlanger M (1992) Intraoperative haemoglobinopathy complicating laparoscopic cholecystectomy in a patient with sickle hemoglobinopathy. Anesth Analg 75: 838–843Google Scholar
  18. 18.
    Cunningham AJ, Turner J, Rosenbaum S, Rafferty T (1993) Transesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br J Anaesth 70: 621–625Google Scholar
  19. 19.
    Cunningham AJ (1987) Acid aspiration: Mendelson's syndrome. Ann R Coll Phys Surg Can 20: 335–340Google Scholar
  20. 20.
    Cuschieri A, Dubois F, Mouiel J, Mouret P, Becker H, Buess G, Trede M, Troidl H (1991) The European experience with laparoscopic cholecystectomy. Am J Surg 61: 385–387Google Scholar
  21. 21.
    Cuschieri A, Nathanson LK, Shimi S (1991) Laparoscopic ligamentum teres cardiopexy. Br J Surg 78: 947–951Google Scholar
  22. 22.
    Cuschieri A, Shimi S, Nathanson KL (1992) Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg 163: 425–430Google Scholar
  23. 23.
    Daly CJ (1991) Laparoscopic cholecystectomy. JAMA 266: 269Google Scholar
  24. 24.
    Deutch AA, Zelikovsky A, Reiss R (1982) Laparoscopies in the prevention of unnecessary appendicectomies: a prospective study. Br J Surg 69: 336–337Google Scholar
  25. 25.
    Drews JA, Mercer EC, Benfield JR (1973) Acute diaphragmatic injuries. Ann Thoracic Surg 16: 67Google Scholar
  26. 26.
    Dubois F, Berthelot G, Levard H (1991) Laparoscopic cholecystectomy: historical perspective and personal experience. Surg Laparosc Endosc 1: 52–57Google Scholar
  27. 27.
    Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 211: 60–62Google Scholar
  28. 28.
    Duffy BL (1979) Regurgitation during pelvic laparoscopy. Br J Anaesth 51: 1089–1090Google Scholar
  29. 29.
    Edelman DS (1991) Laparoscopic cholecystectomy under continuous epidural anesthesia in patients with cystic fibrosis (letter). Am J Dis Child 145: 723–724Google Scholar
  30. 30.
    Editorial (1969) Friedrich Trendelenburg (1844–1924). Trendelenburg's position. JAMA 207: 1143–1144Google Scholar
  31. 31.
    Eger EI II, Saidman LJ (1965) Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology 26: 61–66Google Scholar
  32. 32.
    Falcone RE, Barnes FE, Hoogeboom JE (1991) Blunt diaphragmatic rupture diagnosed by laparoscopy: report of a case. J Laparendosc Surg 1: 299–302Google Scholar
  33. 33.
    Filipi CJ, Fitzgibbons RJ, Salerno GM, Hart RO (1992) Laparoscopic herniorrhaphy. Surg Clin N Am 75: 1109–1124Google Scholar
  34. 34.
    Flowers JL, Bailey RW, Scovill WA, Zucker KA (1991) The Baltimore experience with laparoscopic management of acute cholecystitis. Am J Surg 161: 388–392Google Scholar
  35. 35.
    Frazee RC, Roberts JW, Okeson GC, Symmonds RE, Snyder SK, Hendricks JC, Smith RW (1991) Open versus laparoscopic cholecystectomy: a comparison of postoperative pulmonary function. Ann Surg 213: 651–653Google Scholar
  36. 36.
    Gadacz TR, Talamini MA (1991) Traditional versus laparoscopic cholecystectomy. Am J Surg 161: 336–338Google Scholar
  37. 37.
    National Institute of Health (1993) Gallstones and laparoscopic cholecystectomy: NIH consensus development panel on gallstones and laparoscopic cholecystectomy. JAMA 269: 1018–1024Google Scholar
  38. 38.
    Gaskin TA, Isobe JH, Mathews JL, Winchester SB, Smith RJ (1991) Laparoscopy and the general surgeon. Surg Clin North Am 71: 1085–1097Google Scholar
  39. 39.
    Gilchrist BF, Lobe TE, Schropp KP, Kay GA, Hixson SD, Wrenn EL, Philippe PG, Hollabaugh RS (1992) Is there a role for laparoscopic appendectomy in pediatric surgery? J Ped Surg 27: 209–214Google Scholar
  40. 40.
    Grace PA, Quereshi A, Coleman J, Keane R, McEntee G, Broe P, Osborne H, Bouchier-Hayes D (1991) Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 78: 160–162Google Scholar
  41. 41.
    Graves HA, Ballinger JF, Anderson WJ (1991) Appraisal of laparoscopic cholecystectomy. Ann Surg 213: 655–663Google Scholar
  42. 42.
    Greville AC, Clements EAF (1991) Anaesthesia for laparoscopic cholecystectomy using the Nd:YAG laser. The implications for a district general hospital. Anaesthesia 45: 944–945Google Scholar
  43. 43.
    Hall D, Goldstein A, Tynan E, Braunstein L (1993) Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry. Anesthesiology 79: 173–174Google Scholar
  44. 44.
    Hanley ES (1992) Anesthesia for laparoscopic surgery. Surg Clin North Am 72: 1014–1018Google Scholar
  45. 45.
    Hasel R, Arora SK, Hickey DR (1993) Intraoperative complications of laparoscopic cholecystectomy. Can J Anaesthiol 40: 459–464Google Scholar
  46. 46.
    Heinonen J, Takki S, Tammisto T (1969) Effect of the Trendelenburg tilt and other procedures on the position of endotracheal tubes. Lancet 1: 850–853Google Scholar
  47. 47.
    Holohan TV (1991) Laparoscopic cholecystectomy. Lancet 338: 801–803Google Scholar
  48. 48.
    Johnson WC (1975) Postoperative ventilation performance: dependence upon surgical incision. Am Surg 41: 615–619Google Scholar
  49. 49.
    Jones RM, Detmer M, Hill AB, Bjoraker DG, Pandit U (1981) Incidence of choledochoduodenal sphincter spasm during fentanyl-supplemented anesthesia. Anesth Analg 60: 638–640Google Scholar
  50. 50.
    Jones RM, Fletcher DR, MacLellan DG, Lowe AW, Hardy KJ (1991) Laparoscopic cholecystectomy: initial experience. Aust N Z J Surg 61: 261–266Google Scholar
  51. 51.
    Joris J, Lamy M (1993) Neuroendocrine changes during pneumoperitoneum for laparoscopic cholecystectomy. Anesthesiology 79: A33Google Scholar
  52. 52.
    Joris J, Noirot DP, Legrang MJ, Jacquet NJ, Lamy ML. (1993) Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg 76: 1067–1071Google Scholar
  53. 53.
    Kabukoba JJ, Skillern LH (1992) Coping with extraperitoneal insufflation during laparoscopy: a new technique. Obstet Gynecol 80: 144–145Google Scholar
  54. 54.
    Kalhan SB, Reaney JA, Collins RL (1990) Pneumomediastinum and subcutaneous emphysema during laparoscopy. Cleve Clin J Med 57: 639–642Google Scholar
  55. 55.
    Lennon F (1991) Laparoscopic cholecystectomy: a cautionary note (letter). Br J Surg 78: 1400Google Scholar
  56. 56.
    Lew JKL, Gin T, Oh TE (1992) Anaesthetic problems during laparoscopic cholecystectomy. Anaesth Intensive Care 20: 91–92Google Scholar
  57. 57.
    Liu J, Ding Y, White PF, Feinstein R, Shear J (1992) Laparoscopic cholecystectomy: effect of ketorolac on postoperative pain and ventilatory function. Anesthesiology 77: A1255Google Scholar
  58. 58.
    Liu SY, Leighton T, Davis I, et al. (1991) Prospective analysis of cardiopulmonary responses to laparoscopic cholecystectomy. J Laparendosc Surg 1: 241–246Google Scholar
  59. 59.
    Loh A, Taylor RS (1992) Laparoscopic appendicectomy. Br J Surg 79: 289–290Google Scholar
  60. 60.
    Lonie DS, Harper NJN (1986) Nitrous oxide, anaesthesia and vomiting: the effect of nitrous oxide anaesthesia on the incidence of vomiting following gynaecological laparoscopy. Anaesthesia 41: 703–707Google Scholar
  61. 61.
    Luna GK, Heimbach DM, Olson H, Hanson J (1986) Hospital stay following biliary tract surgery. A comparison of two community hospitals. Arch Surg 21: 693–696Google Scholar
  62. 62.
    Marco AP, Yeo CJ, Rock P (1990) Anesthesia for a patient undergoing laparoscopic cholecystectomy. Anesthesiology 73: 1268–1270Google Scholar
  63. 63.
    Martin IG, Holdsworth PJ, Asker J, Baltas B, Glinatsis MT, Ling SH, Gibson J, Johnson D, McMahon MJ (1992) Laparoscopic cholecystectomy as a routine procedure for gallstones: results of an “all-comers” policy. Br J Surg 79: 807–810Google Scholar
  64. 64.
    McAnena OJ, Austin O, O'Connell PR, Hederman WP, Gorey TF, Fitzpatrick J (1992) Laparoscopic versus open appendicectomy: a prospective evaluation. Br J Surg 79: 818–820Google Scholar
  65. 65.
    McKiernan J, Saye W (1990) Laparoscopic general surgery. J Med Assoc Ga 79: 148Google Scholar
  66. 66.
    Semm K (1983) Endoscopic appendectomy. Endoscopy 15: 59–64Google Scholar
  67. 67.
    McKinstry LJ, Perverseff RA, Yin RW (1992) Arterial and end-tidal carbon dioxide in patients undergoing laparoscopic cholecystectomy. Anesthesiology 77: A108Google Scholar
  68. 68.
    Miller AH (1940) Surgical posture with symbols for its record on the anesthetist's chart. Anesthesiology 1: 241–245Google Scholar
  69. 69.
    Monson JRT, Darzi A, Carey PD, Guillou PJ (1992) Prospective evaluation of laparoscopic-assisted colectomy in an unselected group of patients. Lancet 340: 831–833Google Scholar
  70. 70.
    Muir JJ, Warner MA, Offord KP, Buck CF, Harper JV, Kunkel SE (1987) Role of nitrous oxide and other factors in postoperative nausea and vomiting: a randomized and blinded prospective study. Anesthesiology 66: 513–518Google Scholar
  71. 71.
    Muller NL, Nelems B (1986) Postcoital catamenial pneumothorax: report of a case not associated with endometriosis and successfully treated with tubal ligation. Am Rev Respir Dis 134: 803–804Google Scholar
  72. 72.
    Mullet CE, Viale JP, Sagard PE (1993) Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg 76: 622–626Google Scholar
  73. 73.
    Myers J (1992) Laparoscopic repair of inguinal hernia. Med J Aust 1156: 508Google Scholar
  74. 74.
    Nathanson LK, Shimi S, Cuschieri A (1991) Laparoscopic cholecystectomy: the Dundee technique. Br J Surg 78: 155–159Google Scholar
  75. 75.
    Noirot D, Joris J, Legrand M, Lamy M (1992) Hemodynamic changes during pneumoperitoneum for laparoscopic cholecystectomy. Anesthesiology 77: A69Google Scholar
  76. 76.
    Nowzaradan Y, Westmoreland J, McCarver CT, Harris RJ (1991) Laparoscopic appendectomy for acute appendicitis: indications and current use. J Laparoendos Surg 1: 247–257Google Scholar
  77. 77.
    Nyhus LM (1992) Laparoscopic hernia repair: a point of view. Arch Surg 127: 137Google Scholar
  78. 78.
    Oh S, Fabrick J, Pagualayan G (1992) Evaluation of toradol for pain control after laparoscopic cholecystectomy. Anesthesiology 77: A440Google Scholar
  79. 79.
    Parris WC, Lee EM (1991) Anaesthesia for laparoscopic cholecystectomy (letter). Anaesthesia 46: 997Google Scholar
  80. 80.
    Paterson-Brown S, Garden OJ, Carter DC (1991) Laparoscopic cholecystectomy. Br J Surg 78: 131–132Google Scholar
  81. 81.
    Paterson-Brown S (1991) The acute abdomen: the role of laparoscopy. Bailliere's Clin Gastroenterol 5: 691–703Google Scholar
  82. 82.
    Pearson FC, Cooper JD, Ilves R, Todd TRJ, Jamieson WRE (1983) Massive hiatal hernia with incarceration: a report of 53 cases. Can Ann Thorac Surg 35: 45–51Google Scholar
  83. 83.
    Perissat J, Collet DR, Belliard R (1989) Gallstones: laparoscopic treatment, intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy—a personal technique. Endoscopy 21: 373–374Google Scholar
  84. 84.
    Perissat J, Vitale GC (1991) Laparoscopic cholecystectomy: gateway to the future. Am J Surg 161: 408Google Scholar
  85. 85.
    Peters JH, Ellison EC, Innes JT, Liss JL, Nichols KE, Lomano JM, Roby SR, Front ME, Carey LC (1991) Safety and efficacy of laparoscopic cholecystectomy: a prospective analysis of 100 initial patients. Ann Surg 213: 3–12Google Scholar
  86. 86.
    Piiper J (1965) Physiological equilibria of gas cavities in the body. In: Fenn WO, Rahn M (eds) Handbook of physiology. Section 3: respiration. American Physiology Society, Washington, DC pp 1205–1220Google Scholar
  87. 87.
    Ponsky JL (1991) Complications of laparoscopic cholecystectomy. Am J Surg 161: 393–395Google Scholar
  88. 88.
    Pucci RO, Seed RW (1991) Case report of laparoscopic cholecystectomy in the third trimester of pregnancy. Am J Obstet Gynecol 165: 401–402Google Scholar
  89. 89.
    Punnonen R, Viinamaki O (1982) Vasopressin release during laparoscopy: role of increased intraabdominal pressure. Lancet 1: 175–176Google Scholar
  90. 90.
    Putensen-Himmer G, Putensen C, Lammer H, Lingnau W (1992) Functional residual capacity, postoperative lung function, and gas exchange following open laparotomy or laparoscopy for cholecystectomy. Anesthesiology 77: A1253Google Scholar
  91. 91.
    Rademaker BM, Ringers J, Odoom J, de Wit LT, Kalkman CJ, Oosting J (1992) Pulmonary function and stress response after laparoscopic cholecystectomy: comparison with subcostal incision and influence of thoracic epidural anesthesia. Anesth Analg 75: 381–385Google Scholar
  92. 92.
    Rasmussen JP, Dauchot PJ, Depalma RG, Sorensen B, Regula G, Anton AH, Gravenstein JS. (1978) Cardiac function and hypercarbia. Arch Surg 113: 1196–2000Google Scholar
  93. 93.
    Rayter Z, Knight MJ (1992) Bile duct injuries following laparoscopic cholecystectomy. Br J Surg 79: 846Google Scholar
  94. 94.
    Root B, Levy MN, Pollack S, Lubert M, Pathak K (1978) Gas embolism death after laparoscopy delayed by “trapping” in the portal circulation. Anesth Analg 57: 232–237Google Scholar
  95. 95.
    Rose DK, Cohen MM, Soutter DI (1992) Laparoscopic cholecystectomy: the anaesthetist's point of view. Can J Anaesthiol 39: 809–815Google Scholar
  96. 96.
    Scheinin B, Lindgren L, Scheinin TM (1990) Peroperative nitrous oxide delays bowel function after colonic surgery. Br J Anaesthiol 64: 154–158Google Scholar
  97. 97.
    Schirmer BD, Dix J, Edge SB, Hyser MJ, Hanks JB, Aguilar M (1992) Laparoscopic cholecystectomy in the obese patient. Ann Surg 216: 146–152Google Scholar
  98. 98.
    Schlinkert RT (1991) Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum 34: 1030–1031Google Scholar
  99. 99.
    Shah P, Ramakantan R (1990) Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy. J Postgrad Med 36: 31–32Google Scholar
  100. 100.
    Shifren JL, Adlestein L, Finkler NJ (1992) Asystolic cardiac arrest: a rare complication of laparoscopy. Obstet Gynecol 79: 840–841Google Scholar
  101. 101.
    Smith R (1991) Injuries to common bile duct during laparoscopic cholecystectomy. Br Med J 303: 1475Google Scholar
  102. 102.
    Spangenberger W, Klein J, Troidl H (1990) Laparoskopische cholecystektomie—erste erfahrungen und Ergebnisse. (Laparoscopic cholecystectomy—initial experiences and results). Langenbecks Arch Chir Suppl Vehr Dtsch Ges Forsch Chir 1361–1368Google Scholar
  103. 103.
    Stanton JM (1991) Anaesthesia for laparoscopic cholecystectomy. Anaesthesia 46: 317Google Scholar
  104. 104.
    Steptoe PC (1967) Laparoscopy in gynaecology. E.S. Livingstone, London, p 104Google Scholar
  105. 105.
    Stoker ME, Vose J, O'Mara P, Maini BJ (1992) Laparoscopic cholecystectomy. A clinical and financial analysis of 280 operations. Arch Surg 127: 589–595Google Scholar
  106. 106.
    Strasberg SM, Sanabria JR, Clavien PA (1992) Complications of laparoscopic cholecystectomy. Can Surg J 35: 275–280Google Scholar
  107. 107.
    Sugerbaker PH, Bloom BS, Sanders JH, Wilson RE (1975) Preoperative laparoscopy in the diagnosis of acute abdominal pain. Lancet i: 442–444Google Scholar
  108. 108.
    Taylor E, Feinstein R, White PF, Sopor N: (1992) Anesthesia for laparoscopic cholecystectomy: is nitrous oxide contraindicated? Anesthesiology 76: 541–543Google Scholar
  109. 109.
    The Southern Surgeons Club (1991) A prospective analysis of 1,518 laparoscopic cholecystectomies. N Engl J Med 324: 1073–1078Google Scholar
  110. 110.
    Wahba RWM (1991) Perioperative functional residual capacity. Can J Anaesth 38: 384–400Google Scholar
  111. 111.
    Way LW (1990) Changing therapy for gallstone disease. N Engl J Med 323: 1273–1274Google Scholar
  112. 112.
    Whiston RJ, Eggers KA, Morris RW, Stamatakis JD (1991) Tension pneumothorax during laparoscopic cholecystectomy. Br J Surg 78: 1325Google Scholar
  113. 113.
    Whitworth CM, Whitworth PW, Sanfillipo J, Polk HC Jr (1988) Value of diagnostic laparoscopy in young women with possible appendicitis. Surg Gynecol Obstet 167: 187–190Google Scholar
  114. 114.
    Wilcox S, Vandam LD (1988) Alas, poor Trendelenburg and his position! A critique of its uses and effectiveness. Anesth Analg 67: 574–578Google Scholar
  115. 115.
    Williamson R (1988) Clinical freedom, clinical behaviour, and anesthesia for laparoscopy. Anesthesia 44: 999Google Scholar
  116. 116.
    Wilson P, Leese T, Morgan WP, Kelly JF, Brigg JK (1991) Elective laparoscopic cholecystectomy for “all-comers”. Lancet 338: 795–797Google Scholar
  117. 117.
    Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski DL (1991) Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 126: 997–1001Google Scholar
  118. 118.
    Yamanaka MK, Sue DY (1987) Comparison of arterial-end tidal PCO2 difference and dead space/tidal volume ratio in respiratory failure. Chest 92: 832–835Google Scholar

Copyright information

© Springer-Verlag New York Inc 1994

Authors and Affiliations

  • A. J. Cunningham
    • 1
  1. 1.Department of AnaesthesiaRoyal College of Surgeons in IrelandDublin 2Ireland

Personalised recommendations