Heart rhythm irregularities during laparoscopy: Description of a novel technique to manage severe intra-operative bradycardia - A case report.

INTRODUCTION & IMPORTANCE: Minimally invasive abdominal surgeries need insufflation of a gas (usually carbon dioxide) into the peritoneal cavity for creating a pneumoperitoneum. Laparoscopic techniques have its own set of inherent complications. In order to maintain the operative space, constant gas flow is required to assist various surgeries. Increase in intraabdominal pressure due to high flow rate of gas during peritoneal insufflation is considered to be a probable cause of intraoperative vagal-mediated bradycardia resulting due to stretching of peritoneum. Intraoperative bradycardia during laparoscopic surgery can potentially lead to cardiac arrest and untoward outcomes. CASE PRESENTATION: We report a case of a middle-aged hypertensive, hypothyroid patient with history of angle closure glaucoma who was undergoing elective laparoscopic cholecystectomy after proper pre-operative anesthesia/ physician and Ophthalmology clearance. Patient underwent general anesthesia (GA) and developed severe sinus bradycardia after insufflation, during stretch over gall bladder. Insufflation was stopped and abdomen deflated immediately. In view of glaucoma, atropine was contraindicated. 10 mL of 1% lignocaine was infiltrated into Calot's triangle and peri-gallbladder area. Surgery was resumed after 5 min and completed laparoscopically. CLINICAL DISCUSSION: Bradycardia can occur during laparoscopic surgery mostly during rapid inflow of gas leading to peritoneal stretching with the added effect of vagotonic drugs used for general anesthesia. Use of intraperitoneal local anesthesia drugs for postoperative pain has been thoroughly studied and recommended due to statistically significant reduction in early postoperative abdominal pain. The management of intraoperative bradycardia should be prompt as it may be an early warning for cardiac arrest.

conclusionVagal response following creation of pneumoperitoneum for minimally invasive abdominal surgeries is thought to be the most common cause for bradycardia. The effect of local anesthetic infiltration into peritoneum to reduce post operative pain is probably be due to blockade of afferent nerve endings in the peritoneum. Local anesthesia infiltration into Calot's triangle can be safely administered to mitigate localised vagal reflex.