Anesthetic Considerations for Abdominal Wall Reconstructive Surgery

Abstract

Anesthesia considerations for abdominal wall reconstruction (AWR) are numerous and depend upon the medical status of the patient and the projected procedure. Obesity, sleep apnea, hypertension, and cardiovascular disease are not uncommon in patients with abdominal wall defects; pulmonary functions and cardiac output can be affected by the surgical procedure. Patients with chronic obstructive pulmonary disease are also at a higher risk of coughing during the postoperative awakening process, which can compromise the reconstruction of the fascia. Given the increased complexity of the patients presenting for AWR, and the importance of the anesthesia for these specific procedures, it is important that surgeons are aware of the challenges that anesthesiologists face when treating these patients. Some of these challenges and their resolution are reviewed here.

Keywords

abdominal wall reconstruction - regional anesthesia - intraoperative monitoring - postoperative management

• References

• 1 ASAPS Press Center – Cosmetic Procedures in 2010. American Society for Aesthetic Plastic Surgery. Available at: http://www.surgery.org/media/statistics . Accessed February 12, 2012
• 2 Ogunnaike BO, Whitten CW. Anesthesia and obesity. In Barash PG, Cullen BF, Stoelting RK, Cahalan M, eds. Clinical Anesthesia. 6th ed. Philadelphia: Lippincott Williams &Wilkins; 2009: 1230-1246
• 3 Passannante AN, Tielborg M. Anesthetic management of patients with obesity with and without sleep apnea. Clin Chest Med 2009; 30 (3) 569-579 , x
• 4 Nabili S, Verneuil A. Sleep Apnea. 2011. Available at: http://www.medicinenet.com/sleep_apnea/article.htm
• 5 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328 (17) 1230-1235
• 6 Sinha AC. Some anesthetic aspects of morbid obesity. Curr Opin Anaesthesiol 2009; 22 (3) 442-446
• 7 Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94 (3) 732-736
• 8 Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology 2009; 110 (2) 266-274
• 9 Dixon BJ, Dixon JB, Carden JR , et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 2005; 102 (6) 1110-1115 , discussion 5A
• 10 Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg 2004; 14 (9) 1171-1175
• 11 Ndoko SK, Amathieu R, Tual L , et al. Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes. Br J Anaesth 2008; 100 (2) 263-268
• 12 Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008; 106 (2) 674-675 , author reply 675
• 13 McDonnell JG, O’Donnell B, Curley G , et al. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Anal 2007; 104: 193-197
• 14 Brandstrup B, Tønnesen H, Beier-Holgersen R , et al; Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238 (5) 641-648
• 15 Hiltebrand LB, Koepfli E, Kimberger O, Sigurdsson GH, Brandt S. Hypotension during fluid-restricted abdominal surgery: effects of norepinephrine treatment on regional and microcirculatory blood flow in the intestinal tract. Anesthesiology 2011; 114 (3) 557-564
• 16 Futier E, Constantin JM, Petit A , et al. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg 2010; 145 (12) 1193-1200
• 17 Bostanjian D, Anthone GJ, Hamoui N, Crookes PF. Rhabdomyolysis of gluteal muscles leading to renal failure: a potentially fatal complication of surgery in the morbidly obese. Obes Surg 2003; 13 (2) 302-305
• 18 Don H. The mechanical properties of the respiratory system during anesthesia. Int Anesthesiol Clin 1977; 15 (2) 113-136
• 19 Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth 2000; 85 (1) 91-108
• 20 Pelosi P, Ravagnan I, Giurati G , et al. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiology 1999; 91 (5) 1221-1231
• 21 Eichenberger A, Proietti S, Wicky S , et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg 2002; 95 (6) 1788-1792
• 22 Joris JL, Sottiaux TM, Chiche JD, Desaive CJ, Lamy ML. Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest 1997; 111 (3) 665-670
• 23 Neligan PJ, Malhotra G, Fraser MW , et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology 2009; 110 (4) 878-884
• 24 Gross JB, Bachenberg KL, Benumof JL , et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104 (5) 1081-1093, quiz 1117–1118