12: SPECIAL CONSIDERATIONS

Question 1

Reproductive health issues with obesity

Answer 1

Annovulation and menstrual disorders
Endometrial hyperplasia
Endometrial carcinoma

Question 2

How does obesity contribute to reproductive disorders

Answer 2

Peripheral aromatization of androgens to estradiol

Question 3

Benefits of laparoscopy to laparotomy in obese

Answer 3

Quicker recovery
Better wound healing, less recovery
Less blood loss

Question 4

Physiologic CV changes in obesity

Answer 4

Strain on body frame because of more tissue, as well as more tissue to perfuse > more work for heart via increased CO > HTN, CHF > arrhythmias

Question 5

Physiologic pulmonary changes with obesity

Answer 5

Reduced TLV, VC, FRC
Restrictive lung disease
Even worse with Trendelenberg

Question 6

Physiologic GI changes with obesity

Answer 6

GERD
Increased intra-abdominal pressure
Increased risk for aspiration

Question 7

Is opening pressure higher or lower in obese patients

Answer 7

Usually higher

Question 8

Recommendation for insufflation pressure in obese

Answer 8

Start with 12mmHg instead of 15mmHg

Question 9

When to perform LSC in pregnancy

Answer 9

Can perform in any trimester

Question 10

Incidence of pregnant women who need surgery

Answer 10

~1/500

Question 11

Most common GYN indication for surgery in pregnancy patient

Answer 11

Adnexal mass (1-4% incidence in pregnancy)
Adnexal torsion

Question 12

Incidence of adnexal mass in pregnancy

Answer 12

~1-4%

Question 13

Majority of adnexal cysts in pregnancy

Answer 13

Functional cysts that resolve in 2nd trimester

Question 14

___% of adnexal masses <6cm in pregnant patients will spontaneously resolve, therefore non-operative management is recommended

Answer 14

80-95%

Question 15

__% risk of acute complication for adnexal mass in pregnancy

Answer 15

<2%

Question 16

Respiratory changes in pregnancy:
Minute ventilation
FRC
Residual lung volume
O2 consumption
% in O2 pulmonary system
Oropharyngeal edema

Answer 16

Increased minute ventilation
Decreased FRC
Decreased RLV
Increased O2 consumption
Decrease in % O2 in pulmonary system
Increase in oropharyngeal edema

Question 17

CV changes in pregnancy:
CO
Plasma volume
HR
Aortocaval compression
SVR
Colloid oncotic pressure
BP
Risk of pulmonary edema

Answer 17

Increased CO
Increased plasma volume
Increased HR
Increased aortocaval compression
Decreased SVR
Decreased colloid oncotic pressure
Decreased BP
Higher risk of pulmonary edema

Question 18

Physiology of IVC compression

Answer 18

IVC compression > decreased venous return > decreased CO > maternal hypotension > decreased placental perfusion

Question 19

When is surgical tilt recommended and to what degree?

Answer 19

After 16w
L lateral decubitus with 15deg tilt

Question 20

Recommended intraabdominal pressure pregnant patient

Answer 20

</=15mmHg

Question 21

How to correct maternal acidosis

Answer 21

Hyperventilation and decreased intraabdominal pressure

Question 22

Tocolysis for surgery?

Answer 22

Not indicated

Question 23

Fetal monitoring recommendation for surgery

Answer 23

Before and after

Question 24

Corpus luteum supports pregnancy up to?

Answer 24

7-9w

Question 25

Fascial closure in pregnant patient

Answer 25

All >/=10mm

Question 26

Elderly patient considerations

Answer 26

Reduction in brain size/# NT receptors
Sensitivity to anesthetics
Ventilatory response diminished to hypercapnia/hypoxemia
Increased pain threshold
Pain perception usually isn’t as obvious

Question 27

Pulm changes associated with pneumoperitoneum

Answer 27

Hypercarbia, decreased FRC, hypoxemia

Question 28

Renal changes associated with pneumoperitoneum

Answer 28

Decreases renal blood flow, therefore decreased GFR/urine output/Na excretions/Cr clearance

Question 29

GI changes with pneumoperitoneum

Answer 29

Decreased gastric pH (possibly 2/2 decreased splanchnic perfusion from increased intrabdominal pressure)
>/=14mmHg associated with significant reduction in portal venous flow