A for laparoscopic surgery (linda's PPT) Flashcards
advantages of minimally invasive surgery
- smaller incision: less surgical stress
- less postop pain: fewer opioids, earlier ambulation, shorter hospital stay, rapid return of ADLs
- same surgical outcomes: good for obese population and older/sicker populations
complications
- vascular injury
- sub-Q emphysema
- gas embolism
- capnothorax
implications
pneumoperitoneum
- hemodynamics
- pulmonary
- neurohormonal
patient positioning
- upper abd → reverse trend
- lower abd → trend
surgical procedure
- use insufflation of CO2 to create pneumoperitoneum that allows surgical exposure and manipulation
- insufflator that stops gas flow at a determined inra-abd pressure: < 15 mm Hg
why CO2?
noncombustible
soluble
increased safety margin
closed technique
blunt needle
check for placement
trocar
open technique (Hassan)
mini-laparotomy
trocar
direct visualization
cardiovascular effects d/t pneumoperitoneum: hemodynamics
- increase in MAP, SVR, and HR-increase
- Cardiac filling volumes- increase or no ▲ (compression of the liver & spleen)
- cardiac index- decrease or no ▲ (increase afterload, decrease filling pressures)
cardiovascular effects d/t pneumoperitoneum: cardiac arrhythmias
brady or tachyarrhythmias
vasovagal response
can increase QT interval
respiratory effects
reduction in lung volumes and pulmonary compliance
diaphragm has cephalad displacement and is even worse in trendelenburg position
cardiovascular effects d/t pneumoperitoneum: sick patients
exaggerated response - sick patients
elderly - decreased MAP
Obese? no difference
absorption of CO₂
- hypercarbia: acidosis & increased SNS activity
- most in the first parts of insufflation, will stabilize eventually
- if acidosis is more severe you have more hydrogen ions which will switch for K in cells and cause hyperkalemia and the potential for serious arrhythmias
- myocardial depressant effect but the increase in SNS activity overrides this
- increase cerebral blood flow, ICP, IOP→ dilated pupils with sluggish response
mechanical effects pneumoperitoneum
cephalad diaphragm
position effects severity
endobronchial intubation
impair AA gradient
shunt can be a big deal in sicker patients
increase peak airway pressures & increase in CO₂, as you increase patietns MV to compensate for increase CO₂ will increase there peak pressures
Sub-Q CO₂
RAPID rise in CO₂
risk factors: BMI < 25, long surgical time, operative approach
renal effects
transient increase in creatinine clearance
decrease RBF, GFR, and UO
hepatic effects
inconclusive results
decreased hepatic blood flow
cerebral
increased CBF & ICP
increased CO₂→ increased CBF
A management: if done without general, need to have pneumo with low pressures
local: usually for minor GYN surgeries & sterilization procedures
regional: need high sensory level, shoulder pain
general: most common, new IA- quick on/off, LMA?
induction: intubation with mechanical ventilation
ventilation
- increase RR or TV (usually RR)
- PCV > VCV
- increase MV by 15-35%
- ARMS, PEEP (improve compliance) PEEP @ 10 increase PIP to 20 slowly, improve arterial saturations
- NO₂: shouldn’t necessarily avoid it
anesthesia managment
opioids: beware of treating HTN with opioids, maybe Remi good choice
fluid management: controversial, watch fluids - facial, pharyngeal, and orbital edema. if they are exchanging air around the tube you should be good
PONV - greater risk, may be as high as 72%
Post-op pain: origin - visceral not parietal, shoulder pain, non-opioids if possible
primary complicaitons
dysrhythmias
CAUSE: brady = peritoneal stretching → increased vagal
tachy: from hypercapnia
Tx: supportive
hypoxemia
CAUSE: low FiO₂, hypoventilation, endobronchial intubation, atelectasis
Tx: fix the problem, ARMS, listen for breath sounds
hypercarbia
increase CO2 absorption, capnomediastinum, CO2 embolism
how does carbon dioxide absorption happen?
inadvertent placement of veres needle or passage of CO₂ into open vessels
signs: arrhythmias (widening of QRS), hypoxemia, hypotension
diagnosis: TEE is gold standard
treatment: deflate abdomen, hyperventilate, left lateral decub/trend → this allows the embolus to get to the top of the RV and not into the pulmonary vasculature
other complications
hypothermia: no difference from open; heat loss due to convection
positioning problems: usually d/t steep trend and pneumo → POVL, facial edema, dont give too many fluids. brachial plexus injury
hemorrhage: trocar into major vessle, damage to cystic or hepatic artery, promt treatment is key!! can take patient off vent when trocar is going in. bleeding can be hard to see b/c of positioning
subcutaneous emphysema
cause: inadvertent extraperitoneal insufflation
predictors: operative time > 200 mins, 6 or more surgical ports
signs: crepitus, increased ETCO₂ hypersomnolence, increased SNS, resp acidosis
