|Year : 2019 | Volume
| Issue : 1 | Page : 57-59
Laparoscopic cholecystectomy in a case of previously treated coarctation of aorta: A major concern for an anaesthesiologist
Shreya Lahiri1, Udayan Kundu2, Sanjoy Seth3
1 Department of Anaesthesiology, Malda Medical College, Malda, West Bengal, India
2 Department of Gynaecology and Obstetrics, Nivedita Seva Sadan, West Bengal, India
3 Department of General Surgery, Raiganj Government Medical College, Raiganj, Uttar Dinajpur, West Bengal, India
|Date of Submission||05-Apr-2019|
|Date of Acceptance||10-Apr-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Udayan Kundu
“Satish Bhabanh”, Arabindo Road, Ukilpara, RaiganUttar Dinajpur - 733 134, West Bengal
Source of Support: None, Conflict of Interest: None
Coarctation of the aorta (CoA) is a congenital disability which poses a real challenge to the life of an individual. We successfully managed a case of CoA, previously corrected by Cheatham platinum stent, planned for laparoscopic cholecystectomy in a small town with a limited-resource setup.
Keywords: Anesthesiologist's challenge, coarctation of the aorta, laparoscopic cholecystectomy
|How to cite this article:|
Lahiri S, Kundu U, Seth S. Laparoscopic cholecystectomy in a case of previously treated coarctation of aorta: A major concern for an anaesthesiologist. Saudi J Laparosc 2019;4:57-9
|How to cite this URL:|
Lahiri S, Kundu U, Seth S. Laparoscopic cholecystectomy in a case of previously treated coarctation of aorta: A major concern for an anaesthesiologist. Saudi J Laparosc [serial online] 2019 [cited 2020 Apr 8];4:57-9. Available from: http://www.saudijl.org/text.asp?2019/4/1/57/267859
| Introduction|| |
Congenital heart disease (CHD) is the most common (incidence is about 8/1000 live births) group of congenital disabilities. Among them, coarctation of the aorta (CoA) accounts for 8% of all CHDs.
Several cardiovascular and neurological sequelae and risks of CoA depending on the age at correction and intervention performed create real challenge for anesthesiologists. Even, repaired CoA is never a benign condition.
There is very few literature addressing the perioperative anesthetic management in laparoscopic procedures in patients with CoA.
We present successful anesthetic management of a case of stented CoA, scheduled for laparoscopic cholecystectomy.
| Case Report|| |
A 32-year-old, 65-kg male was scheduled for laparoscopic cholecystectomy in January 2019. He was diagnosed with postductal stenosis and undergone stenting for CoA with covered Cheaththam Platinum stent in November, 2015. Apparently, he was asymptomatic with no history of chest pain, palpitation, syncopal attack, or headache. He was of average built and his pulse rate was 70 beats/min. Blood pressure (BP) was 140/82 mmHg in the right upper limb, 142/78 mmHg in the left upper limb, 130/74 mmHg in the right lower limb, and 128/76 mmHg in the left lower limb. Cardiac auscultation as well as chest auscultation was normal.
On investigation, his routine blood and biochemical tests were found normal. His electrocardiogram (ECG) was normal. Recent echocardiography (January 2019) revealed dilated left ventricle and left ventricular ejection fraction was found to be 62%. Trace mitral regurgitation and trace aortic regurgitation were also noted [Figure 1]. His chest X-ray clearly revealed the stent in situ [Figure 2]. The patient was kept fasting overnight and was premedicated with oral ranitidine tablet 150 mg, tablet bisacodyl 5 mg, and tablet clonazepam 0.5 mg at night before the operation.
Combined spinal-epidural (CSE) anesthesia was planned for this case.
In the operation theatre, routine monitors (ECG, pulse oximeter, and automated noninvasive BP [NIBP]) were attached to the patient's body. Nasogastric tube and Urinary catheter were inserted. Preoperative heart rate was 76 beats/min, and NIBP was 136/84 mmHg. Epidural anesthesia was administered at T11 – 12 inter vertebral space with 18G Tuohy needle. After administering test dose of injection lignocaine (2% with adrenaline), a 19G epidural catheter was placed in situ. Spinal anesthesia was given (injection hyperbaric bupivacaine 4 ml + injection tramadol 50 mg) with 25G Quincke needle at L2 – 3 inter vertebral space. Intravenous (IV) midazolam 1 mg and fentanyl 50 μg were administered. After around 5 min of administration of CSE anesthesia, an episode of hypotension (BP 66/50 mmHg) was recorded. Hypotension was managed with IV injection mephentermine (total 12 mg). The pneumoperitoneum pressure was maintained at 10–12 mmHg. The surgery was performed in reverse Trendelenburg position and took 35 min. At the end of surgery, BP was 110/70 mmHg and heart rate was 68 beats/min. ECG tracing was also normal. The patient was shifted to the recovery for monitoring. In the recovery, heart rate fluctuated from 60 beats/min to 72 beats/min. BP remained around 98/60 during the first 6 h. No active intervention was performed. Epidural top-up dose was given at 6th h with 15 ml 0.0625% bupivacaine after BP was recorded as 112/70 mmHg. Second day onward, he maintained heart rate around 72 beats/min and BP around 130/80 mmHg. Epidural catheter was removed on the 2nd day of operation. Further duration of stay was uneventful, and the patient was shifted to the ward on the 2nd day and discharged home on the 3rd postoperative day. Follow-up visit on the 7th day and after 30 days were absolutely normal, and the patient was satisfied with overall management.
| Discussion|| |
CoA is a localized narrowing of the aortic arch, just distal or proximal to the ductus arteriosus. CoA after surgical repair is associated with excess long-term morbidity and mortality, due to congestive heart failure, aortic rupture, myocardial infarction, or subarachnoid hemorrhage. Aneurysm formation is associated with a significant risk of aortic rupture.
Stent repair is associated with lesser rate of recurrence of recoarctation compared to repair in infancy,, subclavian flap aortoplasty,,, and balloon angioplasty., There is a lesser chance of aortic aneurysm and rupture of aneurysm comparing to other surgical methods such as patch aortoplasty, and balloon angioplasty.
Our patient was an example of late presentation of CoA being corrected by synthetic stent angioplasty.
In laparoscopy, the main concerns include insufflations of peritoneal cavity with carbon dioxide, patient positioning, and increased intra-abdominal pressures. Pneumoperitoneum should be started with slow gas flow, and intra-abdominal pressures should be kept as low as possible to minimize hemodynamic changes. The pressure threshold during pneumoperitoneum, associated with minimal changes in the hemodynamics, is 12 mmHg. An increase in intra-abdominal pressure results in a fall in the preload and an increase in the afterload, along with an increase in the systemic vascular resistance. Creation of the pneumoperitoneum causes an increase in total peripheral resistance along with a decrease in stroke volume and cardiac and ejection velocity indices., These changes can lead to further decrease in blood flow distal to the coarctation. We took measures to obtund hemodynamic responses so as to avoid the adverse effects of hypertension and tachycardia. Our patient had an episode of hypotension soon after administration of CSE. During his stay at recovery, he had excellent hemodynamic stability as well as postoperative analgesia. It has been well established that regional anesthesia reduces cardiovascular stress and release of catecholamines.
To summarize, patients with CoA need thorough evaluation for associated lesions. The intra-abdominal pressures for laparoscopic procedures should be kept just enough to allow adequate visibility for conduct of surgery. The anesthetic management we opted was CSE anesthesia. Epidural analgesia can ensure postoperative analgesia and avoid pain-associated adverse effects. Our plan of anesthesia can become a role model for anesthetic management In low resource setups.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Riou B. Anaesthesia for noncardiac surgery in adults with congenital heart disease. Anaesthesiology 2009;111:432-40.
Zwiers WJ, Blodgett TM, Vallejo MC, Finegold H. Successful vaginal delivery for a parturient with complete aortic coarctation. J Clin Anesth 2006;18:300-3.
Uǧuz E, Ozkan S, Akay HT, Gűltekin B, Aslamaci S. Surgical repair of coarctation of aorta in neonates and infants: A 10 years experience. Turk J Thoracic Cardiovasc Surg 2010;18:94-9.
Maron BJ, Humphries JO, Rowe RD, Mellits ED. Prognosis of surgically corrected coarctation of the aorta. A 20-year postoperative appraisal. Circulation 1973;47:119-26.
Koller M, Rothlin M, Senning A. Coarctation of the aorta: Review of 362 operated patients. Long-term follow-up and assessment of prognostic variables. Eur Heart J 1987;8:670-9.
Brouwer MH, Kuntze EE, Ebels T, Talsma MD, Eijgellar A. Repair of aortic coarctation in infants. J Thorac Cardiovasc Surg 1991;101:1093-8.
Clarkson PM, Nicholson MR, Barratt-Boyes BG, Neutze JM, Whitlock RM. Results after repair of coarctation of the aorta beyond infancy: A 10 to 28 year follow-up with particular reference to late systemic hypertension. Am J Cardiol 1983;51:1481-8.
Presbitero P, Demarie D, Villani M, Perinetto EA, Riva G, Orzan F, et al.
Long term results (15-30 years) of surgical repair of aortic coarctation. Br Heart J 1987;57:462-7.
Dietl CA, Torres AR, Favaloro RG, Fessler CL, Grunkemeier GL. Risk of recoarctation in neonates and infants after repair with patch aortoplasty, subclavian flap, and the combined resection-flap procedure. J Thorac Cardiovasc Surg 1992;103:724-31.
Johnson MC, Canter CE, Strauss AW, Spray TL. Repair of coarctation of the aorta in infancy: Comparison of surgical and balloon angioplasty. Am Heart J 1993;125:464-8.
Shaddy RE, Boucek MM, Sturtevant JE, Ruttenberg HD, Jaffe RB, Tani LY, et al.
Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation 1993;87:793-9.
Bergdahl L, Ljungqvist A. Long-term results after repair of coarctation of the aorta by patch grafting. J Thorac Cardiovasc Surg 1980;80:177-81.
Knyshov GV, Sitar LL, Glagola MD, Atamanyuk MY. Aortic aneurysms at the site of the repair of coarctation of the aorta: A review of 48 patients. Ann Thorac Surg 1996;61:935-9.
Rao PS, Galal O, Smith PA, Wilson AD. Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol 1996;27:462-70.
Koivusalo AM, Pere P, Valjus M, Scheinin T. Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum is safe even for high-risk patients. Surg Endosc 2008;22:61-7.
Kamolpornwijit W, Iamtrirat P, Phupong V. Cardiac and hemodynamic changes during carbon dioxide pneumoperitoneum for laparoscopic gynecologic surgery in Rajavithi hospital. J Med Assoc Thai 2008;91:603-7.
Reuter DA, Felbinger TW, Schmidt C, Moerstedt K, Kilger E, Lamm P, et al.
Trendelenburg positioning after cardiac surgery: Effects on intrathoracic blood volume index and cardiac performance. Eur J Anaesthesiol 2003;20:17-20.
[Figure 1], [Figure 2]