Laparoscopic Cholecystectomy with Previous Pneumonectomy

We present a case of an eighty year old female who presented with history of upper abdominal pain, fever and vomiting. Ultrasonographic scan revealed acute calculous Cholecystitis.

The patient had a past history of pneumonectomy being done thirty years back. Though the blood gases were normal, special care was taken for proper anaesthetic management. We have described our technique of anaesthesia as well as precautions and special measures to be adopted for optimizing outcome in such cases. This is the first such case reported in literature.

Introduction

Laparoscopic cholecystectomy has become the gold standard in operative management of gall bladder diseases. We present a case report of laparoscopic cholecystectomy in a patient with previous pneumonectomy. From the point of view of anaesthesia, the decreased lung functioning is compounded by the respiratory effects of pneumoperitoneum and patient postion. Special care has to maintained for optimizing the arterial oxygenation.

Case Report

An eighty year old female weighing forty kg. ( BMI < 25 kg/m2 ) presented to the out-patient department with history of repeated upper abdominal pain, fever and vomiting since 5 days. She had undergone left pneumonectomy thirty years ago for bronchiectasis. On general examination, there was no cyanosis, respiratory rate was twenty two per minute. On abdominal examination, right hypochondriac tenderness was noted. Respiratory examination did not reveal any abnormality on the right side and no air entry was noted on the left side.

Her preoperative arterial blood gases values were within normal limits. She underwent Laparoscopic Cholecystectomy under general anesthesia with endotracheal tube with controlled ventillation. Intraoperatively she was ventilated with Tidal volume 5 ml / kg, airway pressure 15 – 20 cm of water, 33 % Oxygen and without any PEEP. There was no change in the intraoperative anesthetic or surgical management. Procedure was uneventful. Postoperatively she was kept in a high dependency unit with two litres of oxygen for six hours. She was discharged on third postoperative day. Her postoperative stay was uneventful.

Discussion

Laparoscopic cholecystectomy (LC) differs from open cholecystectomy mainly in its effect on the cardiorespiratory mechanics. Induction of pneumoperitoneum in the supine position results in the peak airway and plateau airway pressures increasing by 50% and 81% respectively1. The compliance of the respiratory system decreases by 47% during the period of increased intra-abdominal pressure1. Following the release of pneumoperitoneum, peak and plateau pressures remain elevated by 37% and 27% respectively, and the compliance is 86% of the pre-insufflation value1. During LC, there is a significant increase in the linear elastance and resistance and a significant decrease of flow and volume dependence of resistance2. Adopting the head-up and right lateral tilt position, balanced anaesthesia (N2O/O2) and CO2 pneumoperitoneum at a constant pressure of 12-14 mm.Hg, it was found that the peak and pause airway pressures increases by 6 cmH2O and mean pressure by 3 cmH2O. End-inspiratory airway pressue increases by 40%. The compliance is reduced by 30-48%. After release of the pneumoperitoneum, inspiratory airway pressure and compliance return to control levels3,4. In our case, this respiratory compromise was compounded by the fact that the patient had only one lung. However, patient’s position would have assisted her respiratory mechanics5.

Moreover, the fact that the patient had a low body mass (BMI < 25 kg/m2) also helped our case as it has been established that with increasing BMI, Functional Residual Capacity decreases, the compliance of the lungs decreases, the resistance of the respiratory system and the lung increases, the oxygenation index (PaO2/PAO2) decreases and the work of breathing increases6. In such a situation, “alveolar recruitment strategy” (ARS) would be helpful in improving the arterial oxygenation7,8.

Conclusions

Though laparoscopic surgery is known to have a compromising effect on the respiratory mechanics, the head up with right lateral position and a low BMI would have a beneficial effect. Adopting ARS would be beneficial in improving the arterial oxygenation. We have shown that even in a patient with a single lung, LC can be safely performed. This is the first such case reported in literature.

References

1. Bardoczky GI, Engelman E, Levarlet M, Simon P. Ventilatory effects of pneumoperitoneum monitored with continuous spirometry. Anaesthesia. 1993 Apr;48(4):309-11.
2. Vassiliou MP, Rizzoti L, Laopodis V etal. Non-linear evaluation of respiratory mechanics during laparoscopic cholecystectomy. Hepatogastroenterology. 2003 Jul-Aug;50(52):934-8.
3. Di Sebastiano N, Bonetti L, Boninsegni P etal. Respiratory mechanics and gas exchange in anesthesia for laparoscopic cholecystectomy. Minerva Anestesiol. 1993 Oct;59(10):487-92.
4. Makinen MT, Yli-Hankala A. The effect of laparoscopic cholecystectomy on respiratory compliance as determined by continuous spirometry. J Clin Anesth. 1996 Mar;8(2):119-22.
5. Salihoglu Z, Demiroluk S, Cakmakkaya S etal. Influence of the patient positioning on respiratory mechanics during pneumoperitoneum. Middle East J Anesthesiol. 2002 Jun;16(5):521-8.
6. Pelosi P, Croci M, Ravagnan I etal. The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesth Analg. 1998 Sep;87(3):654-60.
7. Pang CK, Yap J, Chen PP. The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy. Anaesth Intensive Care. 2003 Apr;31(2):176-80.
8. Tusman G, Bohm SH, Melkun F etal. Alveolar recruitment strategy increases arterial oxygenation during one-lung ventilation. Ann Thorac Surg. 2002 Apr;73(4):1204-9.

Author Details:

Corresponding author:
Dr. Vijaykumar Malladi
Gem Hospital,
45A, Pankaja Mill Road,
Ramanathapuram,
Coimbatore – 641045.
Tamilnadu, India.
Email: mvk_doc@yahoo.com.
Tel.: (0422) 2324100.
Fax: (0422) 2320879
Co-authors :
1. Dr. C. Palanivelu, Gem Hospital, Coimbatore, India.
2. Dr. Kalpesh V. Jani, Gem Hospital, Coimbatore, India.
3. Dr. S. Venkatachalam, Gem Hospital, Coimbatore, India.
4. K. Sendhilkumar, Gem Hospital, Coimbatore, India.
5. Dr. R. Parthasarathi, Gem Hospital, Coimbatore, India.
6. Dr. G. S. Maheshkumar, Gem Hospital, Coimbatore, India.
7. Dr. A. Roshan Shetty, Gem Hospital, Coimbatore, India.
8. Dr. R.Senthilkumar, Gem Hospital, Coimbatore, India.
9. Dr. Anand Prakash, Gem Hospital, Coimbatore, India.

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