20 General surgery

Analgesia 540

Temperature control 542

Fluid management 544

Summary of general surgical procedures 545

Oncological considerations* 546

The sick laparotomy 548

Laparoscopic surgery 554

Laparoscopic cholecystectomy 558

Laparoscopic hemicolectomy/anterior resection 560

Appendicectomy 562

Inguinal hernia repair 563

Haemorrhoidectomy 564

Testicular surgery 565

Breast surgery 566

See also:

Detailed preoperative patient education, information, and risk assessment.

Avoidance of preoperative dehydration. Clear fluids up to 2hr before surgery should be routine and carbohydrate drinks before surgery may be beneficial.

No sedative premedication.

No bowel preparation—may cause dehydration and difficulty in perioperative fluid management.

Avoid routine use of NG tubes and surgical drains.

Prophylactic antibiotics administered within 30min before surgical incision to reduce the risk of surgical site infection.

Minimally invasive surgical approaches (small incisions or laparoscopic techniques) may reduce pain and length of hospital stay.

Avoidance of perioperative hypothermia (see p. 542).

Appropriate fluid management using a goal-directed approach, e.g. oesophageal Doppler management.

Close attention to the prevention of nausea and vomiting.

Multimodal analgesia including simple analgesics (paracetamol, NSAIDS) and local anaesthetic techniques (thoracic epidural, rectus sheath block, transversus abdominis plane (TAP) block), or intrathecal opiods, which reduce parenteral opioid use and opioid complications. Close involvement of the Acute Pain Team postoperatively.

Early removal of urinary catheter.

Early enteral feeding—may reduce muscle loss, length of stay, and possibly infection.

Early mobilisation and input from physiotherapy.

Assessment of exercise function (e.g. CPET)—see p. 1053.

Optimise nutrition and cardiac and respiratory function.

Discuss analgesia strategies.

Discuss invasive monitoring if planned.

Consider premedication with H₂ antagonist or proton pump inhibitor if risk of regurgitation and discuss rapid sequence induction.

Consider whether postoperative HDU/ICU care is indicated (e.g. poor preoperative respiratory and/or cardiac function, anticipated prolonged and complex procedure) and ensure bed is booked before surgery.

Ensure clear fluids (including clear carbohydrate drinks) are taken up to 2hr prior to surgery to reduce dehydration.

Site low thoracic epidural if planned and administer test dose (see pp. 540–541).

Rapid sequence induction if evidence of abdominal obstruction or risk of regurgitation.

Prophylactic antibiotics before skin incision (see p. 1254).

Avoid prolonged exposure during preparation for surgery and establish active patient warming (fluid warmer, hot air blanket, warming mattress/blanket) as soon as possible. Monitor central temperature and aim for normothermia (see p. 542).

Urinary catheter with urimeter.

Appropriate (goal-directed) fluid management (see p. 544).

Postoperative nausea and vomiting are common after gastrointestinal surgery. Reduce risk through adequate hydration, multimodal analgesia to avoid or limit opioids, avoidance of nitrous oxide, and administration of different classes of antiemetic.

Procedures may be prolonged; pay special attention to pressure areas. Be prepared for lithotomy or Lloyd-Davies position with steep head-down tilt. Prolonged surgery in this position may require higher FiO₂ and PEEP to maintain oxygenation due to reduction in FRC.

If no epidural, consider insertion of a wound catheter or rectus sheath catheters to provide postoperative local anaesthetic.

Administration of 80% oxygen during surgery and for 2hr afterwards has been suggested to reduce the risk of surgical site infection;² however, this effect has not been consistently found.³ Nitrous oxide-free anaesthesia with 80% oxygen has been shown to result in fewer wound infections compared with a mix of 30% oxygen and 70% nitrous oxide, but it is unclear whether this effect was due to nitrous oxide or the higher oxygen concentration.⁴

Prescribe overnight oxygen and continue as required to maintain SpO₂ >95%. Supplemental oxygen should be prescribed if using an opioid-based analgesic technique (e.g. PCA, opioid infusion).

Treat nausea and vomiting aggressively.

Close monitoring of fluid balance. Consider on-going losses from abdominal drains, ileostomy, and NG aspirate. Following major surgery, measure urine output hourly for at least 48hr.

Arrange a chest radiograph if CVP line sited.

If epidural sited, continue for 48hr.

Prescribe regular paracetamol (IV or oral) or NSAIDs if not contraindicated. Other agents, including clonidine, gabapentin, and ketamine, may further reduce postoperative opioid use and opioid side effects.

Referral to Acute Pain Team for postoperative review.

Worsening postoperative pain may indicate a complication of surgery.

Consider daily FBC/U&Es until return of normal bowel function.

Oesophageal Doppler provides a minimally invasive means of real-time continuous cardiac output monitoring as well as indicating preload, afterload, and myocardial contractility. Studies have demonstrated reduced morbidity and length of hospital stay if fluid therapy for colorectal surgery is guided by a protocol-based algorithm using data provided from oesophageal Doppler monitoring⁵(See p. 1046.)

Intraperitoneal infiltration in laparoscopic surgery.

Transversus abdominis plane (TAP) block—see p. 1155.

Rectus sheath infiltration—see p. 1156.

Insertion of wound catheter.

Spinal (± intrathecal opioid) injection.

Epidural analgesia.

Simple IM/SC opioids for less invasive procedures, e.g. appendicectomy, reversal of colostomy.

Parenteral opioids by PCA, e.g. lower abdominal procedures, open cholecystectomy following failed laparoscopy, and for any laparotomy when an epidural is contraindicated or refused. Continuous infusion techniques may be preferable in the elderly population who may become confused postoperatively and unable to use a PCA effectively. Ensure additional oxygen therapy and hourly sedation/pain scoring.

Epidural analgesia provides effective analgesia, although there is a 30% failure rate over 3d of infusion.

Improved postoperative respiratory function, resulting in reduced incidence of respiratory failure.

Improved postoperative gastrointestinal motility.

Improved myocardial function. By providing superior analgesia, stress-induced increases in heart rate, coronary vasoconstriction, and myocardial workload are reduced.

Potentially improved postoperative patient mobilisation.

Reduction in thromboembolism.

Reduced sedation and postoperative nausea and vomiting.

Risk related to misplaced catheter, e.g. intrathecal, intravascular.

Perioperative hypotension which may lead to excessive administration of postoperative fluids.

Epidural failure.

Postoperative motor blockade delaying patient mobilisation.

Itch associated with epidural opioids. Urinary retention.

Placement whilst awake or anaesthetised is controversial. Inserting the epidural awake is probably safer in adults (especially if thoracic) since it enables patient feedback during insertion and test dosing.

Epidural test dose, e.g. 3ml 0.5% bupivavciane.

Give an intraoperative epidural loading dose of 8–10ml 0.25–0.5% bupivacaine /Levobupivacaine with 50–100µg fentanyl (divide into 3–4ml boluses) and assess response.

Bupivacaine/Levobupivacaine takes 15–20min to achieve its maximum effect and top-ups should be performed cautiously. An extensive sympathetic block may develop with relatively low volumes of local anaesthetic in thoracic epidurals.

If extensive bleeding is expected, or in cardiovascularly unstable patients, it is often wise to avoid epidural local anaesthetic until bleeding is controlled and the patient has stabilised.

Epidural block for AP resection (which requires analgesia and anaesthesia across thoracic, lumbar, and sacral dermatomes) can be difficult. Effectiveness of the epidural may be improved by the addition of epidural opioid and larger volumes of weak anaesthetic solution, e.g. 0.125% bupivacaine. The epidural is usually effective for postoperative (mainly incisional) pain.

An appropriate regime for postoperative analgesia consists of a mix of LA and opioid, e.g. bupivacaine 0.125% + fentanyl 4µg/ml (2–10ml/hr) or bupivacaine 0.167% + diamorphine 0.1mg/ml (2–10ml/hr).

Increased perioperative blood loss.

Increased surgical wound infection.

Prolonged duration of action of neuromuscular antagonists.

Increased duration of recovery and possible increased hospital stay.

Assessment of risk of perioperative hypothermia.

Maintaining ambient temperature in wards and theatre suites.

Recording core temperature immediately prior to leaving the ward, every 30min intraoperatively and every 15min in recovery until a temperature of 36°C is recorded.

Only commencing induction of anaesthesia if the patient's core temperature is above 36°C.

Active warming of all patients having anaesthesia for longer than 30min and warming of intravenous fluids if more than 500ml used.

Phase 2: more gradual reduction in core temperature of a further 1°C over the next 2–3hr due to heat loss by radiation, convection, and evaporation exceeding heat gain determined by metabolic rate. Evaporative heat loss is exacerbated during major abdominal surgery.

Phase 3: a plateau phase where heat loss is matched by metabolic heat production. Occurs when anaesthetised patients become sufficiently hypothermic that vasoconstriction is triggered. If a thoracic epidural is used, compensatory vasoconstriction is lost.

Active warming. Forced air warming devices are more effective than passive insulation. They reduce heat loss through radiation and may increase heat gain if forced air is warmer than the skin. Active warming by a circulating water mattress, or electric mattress, pad, or blankets can also be used, though evidence for their superiority over forced air warming devices is limited.

Fluid warming. Prevents conductive heat loss associated with the administration of cold fluids. Intravenous fluids should be warmed to 37°C by an active warming device and irrigation fluids should be prewarmed in a thermostatically controlled cabinet.

Invasive internal warming techniques. Cardiopulmonary bypass and peritoneal dialysis are very effective at transferring significant heat but are not relevant for management of mild perioperative hypothermia. The use of irrigation fluids in the bladder or abdomen which have not been warmed to body temperature may induce significant heat loss.

Intra-operative: large evaporative losses from an open abdomen, sequestration of fluid into the omentum and bowel lumen (third space loss), blood loss, and nasogastric loss.

Postoperative: ongoing sequestration of fluid into the omentum and bowel (paralytic ileus), ongoing blood and nasogastric loss.

Pulmonary toxicity occurs in 10% of patients exposed to bleomycin, consisting of acute followed by chronic fibrosing alveolitis. Inspired oxygen fraction should be limited as oxygen free radicals may be mediators.

Hepatic veno-occlusive disease (HVOD) is a progressive obliteration of venous channels in the liver.

Tumour lysis syndrome can follow initial chemotherapy (typically for lymphoma and high count leukaemias). Mass cell death leads to acute renal impairment, with hyperkalaemia, hyperuricaemia, hyperphosphataemia and hypocalcaemia.

Mediastinal masses (particularly in leukaemia or lymphoma patients), can cause complete airway collapse under anaesthesia, even in the asymptomatic. Warning signs include stridor, wheeze, orthopnoea and SVC obstruction.

Superior vena cava obstruction can arise from compression by tumour or lymph nodes (usually bronchogenic carcinoma) or direct vessel invasion. Pleural effusions and ascites are common in ovarian cancer, metastatic disease and mesothelioma.

Paraneoplastic syndromes occur in 10% of cancer patients (esp. lung, lymphoma, breast, prostate, ovarian, and pancreatic tumours). Anaesthetic considerations:

Radiotherapy may cause fever, nausea/vomiting and patients may be dehydrated. Previous radiotherapy causes ongoing localised fibrosis, which may impede laryngoscopy and airway management.

Chemotherapy commonly causes immunosuppression and myelosuppression.

Venous Thromboembolism (VTE) affects at least 15% of cancer patients.

Do Not Attempt Resuscitation (DNAR) orders may be present in cancer patients. Where these conflict with safe anaesthetic principals it is reasonable to modify or suspend the order perioperatively.

Inspired oxygen concentration should be considered during patients who have been treated with bleomycin.

Brachytherapy places a radioactive source close to the tumour via an applicator. It is often used in patients unfit for surgery, and may involve single or multiple treatments. Procedures usually last 1.5–3 hours but may be longer. Blood loss is usually minimal, but postoperative pain may be an issue. Postoperative radioactivity can require patients to be recovered in an isolated environment. Anaesthetic options are:

Pulmonary—acute lung injury or ARDS, fluid extravasation into pulmonary interstitium, alveolar collapse, hypoxaemia, shunting, reduced compliance and FRC, and increased work of breathing.

Haematological—DIC with low platelets, hypofibrinogenaemia, prolonged clotting times.

Renal—hypoperfusion due to relative hypovolaemia and systemic vasodilatation may result in renal failure and altered drug clearance.

Metabolic—impaired glucose tolerance, altered drug metabolism.

Hepatic—impaired hepatic oxygen delivery at a time of increased hepatic oxygen consumption resulting in liver dysfunction.

ABGs and lactate are useful to assess the degree of metabolic derangement and may indicate the severity of illness, impact of resuscitation, and the appropriate environment for perioperative care. An unresponsive metabolic acidosis is a poor predictor of outcome.

Ideally, perioperative hypovolaemia should be diagnosed by flow-based measurements. When direct flow measurements are not possible, hypovolaemia can be diagnosed clinically on the basis of pulse, peripheral perfusion and capillary refill, venous (JVP/CVP) pressure, and Glasgow Coma Scale, together with acid–base and lactate measurements.

Excessive losses from gastric aspiration/vomiting should be treated preoperatively with an appropriate crystalloid solution which includes an appropriate potassium supplement. Hypochloraemia is an indicator for the use of 0.9% sodium chloride; otherwise a balanced crystalloid solution (e.g. Hartmann's solution) should be used.

In high-risk surgical patients, preoperative IV fluids and inotropes to achieve predetermined goals for cardiac output and oxygen delivery may improve survival.

Hypovolaemia due to blood loss should be treated with either a balanced crystalloid (e.g. Hartmann's solution) or colloid, until blood is available.

Oxygen should be administered preoperatively to all sick patients.

A nasogastric tube should be inserted in patients presenting with intestinal obstruction.

Electrolytes will often be deranged and should be corrected as far as possible prior to surgery.

Monitor blood sugar; control will likely deteriorate in diabetic patients and non-diabetics may develop impaired glucose tolerance.

Metabolic acidosis should improve with aggressive fluid and cardiovascular manipulation. If the pH does not respond and remains low (<7.2) the patient is at high risk. Tissue hypoxia is the likely cause of acidosis if blood lactate is high. If acidotic with normal lactate, exclude renal failure and underlying metabolic disorders, e.g. diabetic ketoacidosis. If surgery is indicated and the pH is unresponsive, 1mmol/kg (1ml/kg) of 8.4% sodium bicarbonate IV should be considered.

Thrombocytopenia and coagulopathy should be anticipated and treated appropriately, especially in the septic patient and following transfusion of large volumes of stored blood. Liaise with haematologists to optimally manage transfusion of blood products. Increased INR may require administration of vitamin K (5–10mg slow IV).

Haemoglobin should be maintained above 8g/dl.

Use IV morphine for pain control prior to surgery and avoid NSAIDs due to risk of renal damage, decreased platelet function, and gastroduodenal ulceration.

Check that appropriate antibiotics have been given if indicated.

Oesophageal Doppler monitoring allows real-time estimation of stroke volume and cardiac output and can help guide fluid therapy, vasopressor, and inotrope use. See p. 1046.

A number of new devices which derive stroke volume and cardiac output from the arterial waveform characteristics without the need for calibration or thermodilution are now in clinical use (e.g. LIDCOrapid, Vigilio/Flotrac). While data on accuracy and reliability are limited, these less invasive and simple to use devices may help assess fluid responsiveness and guide fluid and vasopressor management in patients having major surgery.

Aspirate nasogastric tube prior to induction.

Have a large-bore IV infusion running connected to pressurised fluids.

Anticipate hypotension following induction. Have vasopressors (ephedrine and metaraminol/phenylephrine) and vagolytics (atropine, glycopyrronium) drawn up and to hand.

Preoxygenate and perform rapid sequence induction.

Choice of induction agent and dose depends on cardiovascular stability. Thiopental is commonly used for rapid sequence induction. Etomidate causes less hypotension on induction; however, it may temporarily interfere with steroid synthesis so its use in critically ill patients (already at risk of adrenocortical insufficiency) is controversial.⁴ If etomidate is used, administer steroid cover with 50–100mg hydrocortisone. Ketamine (1–2mg/kg IV) may be useful in the severely compromised patient, but avoid in those with pre-existing cardiovascular disease.⁵

Relaxants. Suxamethonium for rapid sequence, then use drugs metabolised independently of liver and renal function, e.g. atracurium.

Analgesia. Centroneuraxial blockade should be used cautiously in this group of patients due to risks of infective complications, excessive hypotension, and potential coagulopathy. If an epidural is used, local anaesthetic agents should be restricted until cardiovascular stability is achieved. In some patients this may be postoperatively on the ICU.

Fentanyl/morphine for intraoperative analgesia. Give with induction and supplement as needed. Caution with remifentanil; may cause significant hypotension if hypovolaemic.

Active warming should be strenuously undertaken with the aim of maintaining normothermia (see p. 544).

Patients who require repeated bolus doses of vasopressors, despite an adequately restored circulating volume, should be commenced on an infusion of vasopressor/inotrope early. In the emergency situation an infusion of adrenaline (make up 1:10 000 and start at 5ml/hr) can be commenced and continued until the most appropriate agent is determined. Noradrenaline is the first choice for the vasodilated septic patient. Dopamine may be useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic. Dobutamine may be useful in patients with measured or suspected low cardiac output in the presence of adequate fluid resuscitation but may worsen hypotension if fluid resuscitation is inadequate. The influence of dopexamine on the mortality of patients undergoing major abdominal surgery has been widely examined, but results are conflicting^{,  6} Dopexamine stimulates dopamine receptors and is a potent beta 2 agonist. It inhibits noradrenaline reuptake but has no direct alpha activity. These actions result in positive inotropism, afterload reduction, and renal and splanchic dilatation. A low-dose dopexamine infusion has been recommended to supplement goal-directed fluid therapy in emergency major surgery,⁷but a large randomised clinical trial is required to resolve the controversies regarding its effect on survival in such patients.

Urine output should be measured hourly throughout the perioperative period, maintaining an output >0.5ml/kg/hr. In patients with persistently low urine output, assess whether ATN is developing and reconsider fluid balance.

Postoperative CXR to check CVP line position.

Administer oxygen for a minimum of 72hr postoperatively.

Regular chest physiotherapy.

Improved postoperative respiratory function, reduced postoperative ileus.

Earlier mobilisation, shorter hospital stays.

Improved cosmetic results.

Carbon dioxide, being non-combustible, allows the use of diathermy or laser.

Carbon dioxide is insufflated at a rate of 4–6l/min to a pressure of 10–15mmHg.

The capnoperitoneum is maintained by a constant gas flow of 200–400ml/min.

Patients placed head down are at greater risk of reduction in FRC, V/Q mismatch, and atelectasis. Cephalad movement of the lungs and carina in relation to a fixed endotracheal tube increases the risk of endobronchial intubation.

Patients placed head up are at increased risk of reduced blood pressure and cardiac output due to decreased venous return. Those most at risk include the hypovolaemic patient, the elderly, and patients with pre-existing cardiovascular disease.

Stretching of the peritoneum may cause vagal stimulation resulting in sinus bradycardia, nodal rhythm, and occasional asystole. Anticipate and treat with vagolytics, e.g. atropine, glycopyrronium.

Gas insufflation may result in sympathetic response leading to hypertension and tachycardia.

CO₂ is readily absorbed from the peritoneum and may cause hypercarbia and acidosis.

Extraperitoneal gas insufflation may occur through a misplaced trocar or insufflation needle, via an anatomical defect (e.g. between pleura and peritoneum), or when gas under pressure within the abdomen dissects through tissue planes. This may result in subcutaneous emphysema, capnomediastinum, capnopericardium, or capnothorax.

Passage of CO₂ from the abdomen can be anticipated in laparoscopic procedures around the diaphragm (e.g. see ‘Hiatal hernia repair’, p. 401) where a communication is made between the abdomen and chest. Capnomediastinum and capnothorax may occur and suggestive signs include a rapidly rising ETCO_2, rising airway pressures, and falling O₂ saturations. Evacuating the CO₂ from the abdomen will often rapidly resolve the problem and recommencing surgery under reduced insufflation of CO₂ will usually enable completion of surgery. If there is significant cardiac or respiratory compromise, manage like a tension pneumothorax by needle decompression.

During prolonged procedures with a rising ETCO₂ a ‘CO₂ break’ may be required (see p. 556).

Venous gas embolism may rarely occur when gas is inadvertently insufflated directly into a blood vessel. Physiological effects are less with CO₂ than air due to its greater plasma solubility; however, a significant embolism may be fatal. Signs of venous gas embolism include reduced ETCO₂, desaturation, arrhythmias, myocardial ischaemia, hypotension, and elevated CVP (see p. 432).

CVS depression with a fall in cardiac output. Treat with fluids, vasodilators, and inotropes.

Damage to blood vessels may result in massive haemorrhage, necessitating rapid conversion to an open procedure.

All patients scheduled must be considered at risk of conversion to an open procedure and a plan for analgesia discussed.

Laparoscopic procedures are increasingly performed in obese patients due to improved postoperative recovery when compared to an open procedure.

Premedication with H₂-antagonists or proton pump inhibitors if at risk of aspiration (e.g. obesity, hiatus hernia). Simple analgesics (paracetamol, NSAIDs) may be beneficial.

Avoid gastric distension during bag-mask ventilation which may increase the risk of gastric injury during trocar insertion.

For lower abdominal procedures a urinary catheter may be required to decompress the bladder and reduce risk of injury.

Systemic absorption of CO₂ and raised intra-abdominal pressure will require increased minute volume and result in higher intrathoracic pressure.

Aim for normocarbia, but beware of adverse effects of high intrathoracic pressure. Controlling ETCO₂ during prolonged procedures, especially in the obese and head down position, can be difficult and may occasionally necessitate intermittent release of intraperitoneal gas or tolerance of a degree of hypercarbia. With high peak inspiratory pressures, check position of the ETT and try a change to pressure-controlled ventilation, I:E ratio of 1:1, and 5cm H₂O PEEP. When the patient is levelled out, remember to check tidal volume or alter ventilation mode/pressures.

Nitrous oxide is controversial due to possible associations with bowel distension and increased postoperative nausea and vomiting.

Analgesia: dictated by the procedure. Pain may be intense but short-lived and short-acting opioids, e.g. fentanyl and alfentanil, may be effective for short procedures. Remifentanil infusion can be useful for longer procedures and may help counter the haemodynamic changes due to the capnopertioneum. Longer-acting opioids may be required for extensive laparoscopic operations.

Fluids: avoid hypovolaemia as this exaggerates the deleterious CVS effects of laparoscopy.

Antiemetics: high incidence of nausea and vomiting following laparoscopic surgery. Give prophylactic antiemetic and prescribe postoperatively.

Monitoring: pay close attention to ETCO₂ and airway pressure. Invasive arterial blood pressure and CVP monitoring may be required for extensive procedures, or for patients with CVS or respiratory compromise.

Reduced cardiac output—IVC compression, arrhythmias, haemorrhage, myocardial depression, venous gas embolism, extraperitoneal gas.

V/Q mismatch—reduced FRC, atelectasis, endobronchial intubation, venous gas embolism, pulmonary aspiration, and rarely pneumothorax.

Subcutaneous emphysema during the procedure should arouse suspicion—stop gas insufflation immediately and check for the source of the problem.

Intraperitoneal local anaesthetic infiltration of port sites may reduce postoperative analgesia requirements. 20–30ml 0.25% bupivacaine on the gallbladder bed may reduce postoperative analgesic requirements for laparoscopic cholecystectomy.

Pain varies and is often worst in the first few hours. Shoulder tip pain due to diaphragmatic irritation may be troublesome but is usually short-lived. Significant pain extending beyond the first day raises the possibility of intra-abdominal complications.

Prescribe regular paracetamol and NSAIDs with opioid PRN for more extensive procedures. Consider postoperative antiemetic.

Regional anaesthesia is not generally used as the sole anaesthetic technique because of the high level of block required to cover the capnoperitoneum.

Laparoscopic appendicectomy: may aid diagnosis of patients with right lower quadrant pain and prevent unnecessary laparotomy. Less useful if perforated appendix is suspected.

Complications of gall stone disease (e.g. pancreatitis) may make surgery more difficult and increase the risk of conversion to open procedure.

With appropriate planning, facilities, and patient information the procedure can be performed as a day case. Experienced units may be able to manage 70% or more laparoscopic cholecystectomy cases as day patients. Procedures for managing unanticipated admissions must be in place.

If planned as a day case, list early in the day.

Consider NSAID and paracetamol premedication.

Ensure adequate IV access—haemodynamic changes may be profound and potential for sudden blood loss.

Combination of capnoperitoneum and obesity may make ventilation difficult.

Paracetamol and NSAIDs IV if not administered preoperatively.

High risk for PONV. Consider prophylactic antiemetics (e.g. dexamethasone and ondansetron).

IV fluids improve speed of recovery.

Short-acting opioids (remifentanil, fentanyl) may counter the haemodynamic fluctuations and limit postoperative opiod-related side effects.

Ask the surgeon to infiltrate port sites with local anaesthetic at the end.

Conversion to open procedure is typically about 5%. This is usually due to difficulty identifying the cystic duct, suspected common bile duct injury, uncontrolled bleeding from the cystic artery, stones present in the common bile duct, or acute inflammatory changes.

Local anaesthetic applied to the gall bladder bed may reduce postoperative analgesic requirements (20ml 0.25% bupivacaine).

If conversion to open cholecystectomy, pain can be significant and a morphine PCA may be required. Local anaesthetic should be infiltrated by surgeons and a wound catheter for postoperative local anaesthetic may be beneficial.

Open surgery provokes less cardiovascular stress during surgery, but this is increased postoperatively; the reverse is true of laparoscopic surgery. Caution has been suggested for patients with significant cardiac failure from extensive laparoscopic surgery, but the postoperative advantages would mitigate against this approach.

Patients may be anaemic due to malignancy—check Hb and group and save.

Many patients are elderly and have significant comorbidity.

Surgery will involve prolonged steep head down tilt—beware of patients at risk from raised ICP (recent head injury) or intracranial haemorrhage (venous malformations, aneurysms).

Some surgeons will request a naso-/orogastric tube during surgery. Check as it is easier to place before surgery starts.

An arterial line is useful with the transducer fixed in position to ensure it does not become dislodged during patient positioning.

Endotracheal intubation and adequate muscle relaxation throughout the case—always use a PNS. Remifentanil infusion is useful to moderate the stimulating effects of the capnoperitoneum.

Multimodal analgesia. Rectus sheath catheters, TAP block, or wound catheters with PCA usually work well.

Monitor temperature and warm actively.

Ensure all fixings are firmly tightened down and the shoulders padded.

Antibiotic prophylaxis.

CVP or Doppler for high-risk patients—both have disadvantages in terms of position and diathermy interference.

Avoid letting surgeon persist for too long in the steep head down position if progress is not being made—time passes quickly for them!

Restrict IV crystalloid during surgery as fluid losses are small and the head down positioning causes venous engorgement. Ensure the head is in a neutral position and that ETT fixation does not restrict venous blood flow.

Ventilation is described on p. 556.

Careful eye protection is advised as gastric secretions may reflux in the steep head-down position.

PCA morphine or fentanyl. Other analgesics as indicated.

Occasionally present in the elderly. May be the presenting condition of caecal adenocarcinoma requiring right hemicolectomy.

Check fluid status and replace deficit prior to surgery if possible.

Obtain consent for suppositories.

If considering ilioinguinal block, warn of possible associated femoral nerve blockade.

Muscle relaxation required for surgery.

Consider NSAID and paracetamol IV.

Ask the surgeon to infiltrate locally or perform right ilioinguinal nerve block or right-sided TAP block.

Extubate awake on left side.

Can usually be performed as a day-case procedure

Iliohypogastric and ilioinguinal nerves are easily blocked 2cm caudal and medial to the anterior superior iliac spine (see p. 1153). Genitofemoral nerve is located 1–2cm above the midpoint of the inguinal ligament, deep to the aponeurosis of the external oblique. This may be left to the surgeon to block, reducing the risk of vascular or peritoneal puncture.

Repair using inguinal hernia field block is probably the technique of choice in the high-risk patient if operator is experienced in local anaesthetic techniques. Low-dose propofol infusion may be a useful adjunct in cases performed solely under local anaesthetic.

Mesh insertion usually requires administration of prophylactic antibiotics.

Caudal anaesthesia is useful for postoperative analgesia (20ml bupivacaine 0.25%), but beware risk of urinary retention. Infiltration by the surgeon during the procedure is usually as effective.

Potential for bradycardia/asystole as surgery starts. Anticipate and have vagolytics to hand.

Anal stretch is an intense stimulus. There is a risk of laryngospasm and coughing if anaesthesia is too light. Anticipate and deepen the anaesthetic, e.g. increase volatile and give a bolus of short-acting opioid, e.g. alfentanil (500µg). The anal stretch can also produce an increase in vagal tone.

A sacral-only spinal block (‘saddle block’) using heavy bupivacaine is a useful alternative with little effect on cardiovascular dynamics.

A spermatic cord block can be used as an adjunct to GA or as part of a local technique for scrotal surgery. The block covers all nerves except the pudendal and posterior scrotal branches. If used as part of a local anaesthetic technique supplemental infiltration of the scrotal skin is also required.

Spermatic cord is best blocked under direct vision by the surgeon. However, if a local technique is planned, feel for the spermatic cord as it enters the top of the scrotum and infiltrate 5–10ml local anaesthetic around it.

Patients who have recently undergone chemotherapy may be immunocompromised. Check FBC for evidence of bone marrow suppression and anticipate potentially difficult venous access.

Reconstructive procedures, mastectomy following radiotherapy, mastectomy where breasts are large, and breast reduction surgery increase the risk of blood loss. Check Hb and ensure blood is grouped and saved.

Avoid venous access on the side of surgery.

Additional invasive monitoring may be required for prolonged reconstructive procedures including free flap surgery (see p. 524).

LMA and spontaneous ventilation is often appropriate for short to medium length procedures. Use intubation and mechanical ventilation for prolonged procedures, the obese, and patients at risk of aspiration.

Give balanced analgesia including NSAID if tolerated, systemic opioid, and regional techniques if necessary (see below).

Breast surgery patients are at high risk of PONV. Avoid causative agents and administer prophylactic antiemetics.

Consider for more radical procedures, e.g. radical mastectomy/axillary clearance and breast reconstruction.

Four types of regional analgesia can be used: paravertebral block, thoracic epidural, intercostal blocks, and intrapleural block. Beware of the complications of each technique. Ultrasound may be beneficial in paravertebral block.

A retrospective study found that breast surgery supplemented by a paravertebral block may reduce the risk of cancer recurrence; however, further prospective studies are required.¹

If a paravertebral catheter or thoracic epidural is sited, continue infusion postoperatively.

Chronic pain typically presenting in the affected anterior chest wall, ipsilateral axilla, or upper arm may occur following breast surgery. Intensity of pain following extensive surgery, postoperative radiotherapy, and chemotherapy are risk factors.