Anesthesia for Laparoscopic and Robotic Surgery (Part 2) Flashcards
Cholecystectomy Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB
Positioning: Reverse Trendelenburg, L-tilt
Procedure: can be done traditionally or robotic-assisted
Appendectomy Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB
Positioning: Trendelenbrug, L-tilt, L arm tucked at side
Procedure: Traditional or robotic-assisted
Nissen Fundoplication Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB RSI
Positioning: Supine
Procedure: Traditional or robotic-assisted
Nissen Fundoplication Special Considerations
-High aspiration risk
-RSI + PONV prophylaxis!
-NOTHING IN ESOPHAGUS!
Adrenalectomy Anesthesia, Positioning, Surgery
-Usually done for pheochromocytoma
Anesthesia: GETA with NMB
Positioning: Lateral position
Procedure: Traditional or robotic-assisted
Adrenalectomy Special Considerations
-Remember alpha before beta blockade (alpha block 10-14 days preoperatively)
-Major hemodynamic changes expected –> large bore IVs, adequate hydration, ABP monitoring, take BP meds DOS
-Use of multimodal pain management and erector spinae block
Pheochromocytoma Classic Triad
-Headache
-Diaphoresis
-Tachycardia
think too much coffee even though we never have enough
Diagnosis testing for pheo:
-Plasma free and urinary fractionated metanephrines
-CT abdomen
Hysterectomy Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB
TAP block for pain management
Positioning: Steep trendelenburg, low lithotomy, arms tucked to side
Procedure: Traditional, Robotic-assisted, or Mix
Use of dye
Gastric Bypass Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB
Positioning: Steep reverse trendelenburg
Procedure: Traditional or robotic-assisted
Nothing in esophagus
Adjustable Gastric Band
Purpose and benefits?
-Reduces/limits food intake
-Avoids permanent alteration of anatomy and has low mortality + low re-operation rates
*Done laparoscopically to reduce morbidity, mortality, and hospital costs
Sleeve Gastrectomy
Purpose and risks
-Permenantly removes portion of stomach
-Risks of infection, leak at staple line, malnutrition
-Can be negated by overeating
Roux-en-Y Gastric Bypass
Purpose and risks
-Small gastric pouch connects to jejunum to change GI hormones
-Risk of vitamin deficiency, malnutrition, perforation, staple line failure, dumping syndrome
We don’t feel great about our patients breathing, they are still super somnolent after the procedure. What do we do?
Obesity Review
Leave em intubated
Benefits of minimally invasive robotic surgery
-Improved patient outcomes
-Greater precision
-Reduced blood loss and postoperative pain
-Shorter LOS
-Faster recovery
An important advantage of robotic technology is the incorporation of ___-____ imaging giving better depth perception.
Three-dimensional
-Improves ergonomics, dexterity
Anesthesia Implications for robotic-assisted surgeries
-Longer operation times
-Harder to access pt
-Physiological changes due to positioning for robot
-Physiological changes due to pneumoperitoneum use
-Risk of POVL
-New ERAS protocols
Why is adequate preparation of the pt for robotic surgery so essential?
We often cannot access the pt as we could normally due to the robot.
-Secured airway, good IVs, monitoring devices secured
____ ____ is a commonly used position for robotic procedures.
Steep trendelenburg
-This places our pt at higher risks of certain cardiac, respiratory, neurophysiological changes.
Goal of robotic-assisted surgery
The goal of minimally invasive robotic procedures is to improve surgical outcomes and allow patients to return to normal activity as quickly as possible
What 2 specific things about robotic surgeries caused increased risk of injury?
- Extreme surgical positions necessary for robot
- Prolonged surgery durations
We should assess our surgical positioning during robotic surgeries how often?
q15 mins or whenever the patient, robot, or table are moved around
What is mentioned as being one of the most common robotic surgeries worldwide?
The robotic-assisted laparoscopic prostatectomy (RALP)
-Less blood loss, shorter LOS, however more expensive
RALP Anesthesia, Positioning, Surgery
Anesthesia: GETA with NMB
Positioning: Steep trendelenburg and lithotomy
peroneal nerve damage risk in lithotomy
Surgery: Most common robotic
Trendelenburg considerations:
-Increases VR, CVP, ICP, IOP, PIP
-Decreases lung compliance, tidal volumes, oxygen sats
Lithotomy considerations:
-May see falsely high BP and hypovolemia can be masked
-Increased PIP, dead space
-Decreased pulmonary compliance, tidal volumes
Most important risk (for us) with positioning changes?
Maintain that patent airway and ETT placement
____ ____ ____ accounts for 89% of post op vision loss due to hypotension.
Ischemic optic neuropathy (ION)
___ ___ ___ ___ causes post op vision loss from decreased blood supply to the entire retina. Most often due to improper positioning of the head.
Central retinal artery occlusion (CRAO)
Repeat card on purpose
Signs and symptoms of CO2 embolism
-Decreased EtCO2, oxygen saturation
-Increased EtN2
-Tachycardia, hypotension, dysrhythmias, CV collapse
Repeat card on purpose
Most CO2 embolisms will resolve how?
Spontaneously with no treatment
Repeat card on purpose
Treatment of CO2 embolus that will not resolve on its own
- D/c insufflation, Stop N2O if using, give 100% O2
- Deflate abdomen
- Flood the field with saline
- Place in left lateral position (durant maneuver)
- Aspirate out of central line if present
- Hemodynamically support the patient
What is the purpose of enhanced recovery after surgery (ERAS) protocols?
To enhance recovery management pathways and allow return to normal activity as soon as possible
Robotic cardiothoracic surgery Anesthesia and Positioning
Anesthesia: GETA with NMB
Positioning: Modified left or right lateral position
Robotic cardiothoracic surgery Considerations
-May use prolonged one-lung ventilation
-Continuous TEE and invasive monitoring may be in place
