Local and regional anesthesia (spinal and epidural) can be used for shorter laparoscopic procedures, such as diagnostic laparoscopy, that require lower IAP and minimal head-down tilt. Nevertheless, patient discomfort associated with creation of pneumoperitoneum and extreme position changes during the procedure can be significant. Therefore, balanced general anesthesia with tracheal intubation and mechanical ventilation with acceptance of higher end-tidal carbon dioxide levels remains the best practice for minimally invasive surgical procedures.

1. Induction of Anesthesia and Airway Management
   1. Because of its unique recovery profile, propofol is considered the sedative–hypnotic drug of choice for induction of anesthesia. Propofol also offers an advantage over other intravenous anesthetics because of its antiemetic properties and associated euphoria on emergence.
   2. Tracheal intubation and controlled mechanical ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO₂ and avoid ventilatory compromise from pneumoperitoneum and position changes.
   3. Although the laryngeal mask airway has been used during short pelvic laparoscopic procedures, this evidence cannot be extrapolated to procedures requiring high IAP, steep head-down positions, and upper abdominal laparoscopy as well as in patients at increased risk of regurgitation.
2. Maintenance of anesthesia with the newer inhaled anesthetics (desflurane or sevoflurane) remains the mainstay of modern anesthesia practice probably because of the ease of titratibility.
   1. N2O use during laparoscopic procedures has been controversial as a result of concerns regarding its ability to diffuse into bowel lumen, causing distention and impaired surgical access as well as increased postoperative nausea and vomiting (PONV) (not clinically significant).
   2. Intraoperative Opioids. Opioids remain an important component of a balanced general anesthetic technique and are typically titrated to achieve hemodynamic stability.
      1. It may be prudent to use a ultra short-acting opioid (remifentanil) or sympatholytic drugs (esmolol and nicardipine) to treat pneumoperitoneum-induced hypertension.
      2. Remifentanil is a novel opioid with a short duration of action independent of the duration of infusion.
   3. Muscle Relaxants and Reversal of Residual Neuromuscular Blockade
      1. Muscle paralysis reduces the IAP needed for the same degree of abdominal distention.
      2. Patient movement during robotic surgery can result in displacement of the robotic arms, which has a potential for patient harm.
   4. Mechanical Ventilation. The changes in pulmonary function (reduction in lung volumes, increase in peak inspiratory pressures, and decrease in pulmonary compliance) during laparoscopy may require intraoperative modification in mechanical ventilation. Typically, the minute ventilation needs to be increased by 20% to 30%, which could be achieved by increasing the respiratory rate while maintaining a constant tidal volume.
   5. Monitoring. In addition to standard intraoperative monitoring, minimally invasive hemodynamic monitoring (arterial waveform analysis) may be appropriate in patients with significant cardiopulmonary disease to monitor the cardiovascular response to pneumoperitoneum and position changes and to institute therapy. Cerebral oximetry monitoring could be useful in high-risk patients undergoing prolonged endoscopic procedures in steep head-up or head-down procedures.
   6. Fluid Management. In patients undergoing robotic prostatectomy fluid minimization is recommended because steep head-down positioning for prolonged period may in result in facial, pharyngeal, and laryngeal edema.
3. Nausea and Vomiting Prevention
   1. Patients undergoing laparoscopic surgery are at a greater risk for PONV probably because of intraperitoneal insufflation and bowel manipulation.
   2. A multimodal approach to PONV prophylaxis could include use of combinations of 4 to 8 mg dexamethasone administered after induction of anesthesia and 5-HT₃ antagonists (4 mg of ondansetron) at the end of surgery as well as aggressive hydration, minimal opioid use, and aggressive pain control.

Anesthesia for Laparoscopic and Robotic Surgeries

1. Surgical Techniques
2. Physiologic Effects
3. Anesthetic Management
4. Pain Prevention
5. Intraoperative Complications
6. Postoperative Considerations
7. Ambulatory Laparoscopic Procedures
8. Summary