Perioperative management and outcomes of laparoscopy in adolescents and adults with Fontan physiology

Abstract Purpose To evaluate our institutional experience regarding the management and complication profile of laparoscopic procedures in patients with Fontan physiology. Methods Observational historical chart review at a single academic medical center of patients > 12 years of age who had undergone a complete Fontan palliation and referred for a laparoscopic abdominal or pelvic procedure between 2008 and 2023. Data collection included pre-operative clinical characteristics, perioperative anesthetic management including fluids, vasoactives, and ventilator strategy, and peri- and post-operative complications. Results A total of 22 laparoscopic procedures in 21 patients were included, with cholecystectomy being the most common procedure ( n = 10/22). We performed descriptive analyses of cases, anesthetic approach, and major and minor intra- and post-operative complications. Insufflation pressure was maintained at 15 mmHg or less, and average PEEP of 3.8 ± 1.9 cm H20. Three cases required intraoperative vasoactive support. There were no major peri- or post-operative complications. Minor post-operative complications were observed in 5/22 procedures, including pulmonary/peripheral edema, increased oxygen requirement, and one case requiring naloxone for oversedation. Conclusion Our study describes our institutional experience with laparoscopic procedures in patients with Fontan circulation. The most commonly observed complications were postoperative pulmonary and peripheral edema, as well as increased oxygen requirement from baseline. Based on our experience, we propose a comprehensive care plan for laparoscopy in this unique population, including perioperative congenital cardiology consultation, preinduction preload augmentation, insufflation pressure management, low PEEP respiratory strategy, and judicious fluid management.