E3- General / Gynecologic Surgery Flashcards
When was laparoscopy first used? What for?
- 1970’s for gynecologic conditions
- Cholecystectomy – Late 1980’s
What is the purpose of gastric insufflation?
- Allows for room to work + equipment
- identification of intraperitoneal space
What occurs with the onset of pneumoperitoneum insufflation of the abdomen?
- Release of catecholamines & vasopressin»_space; increase SVR
- Arterial vasculature is compressed
What is the goal pressure in mmHg for gastric insufflation?
≤ 20 mmHg
12 - 15 mmHg is most common.
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What causes increased CO₂ during laparoscopic surgeries?
- Positioning (frequently Trendelenburg)
- CO₂ insufflation (absorbed by peritoneum into the blood stream).
What are the pulmonary effects of insufflation?
- ↑ PaCO₂
- ↓ compliance
- ↑ PIP
- ↓ FRC»_space; dec Vt
- Atelectasis
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In what laparoscopic position is atelectasis development most common?
Trendelenburg
How much change in pulmonary compliance occurs with gastric insufflation?
30 - 50% decrease in compliance
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Is increased PaCO₂ in laparoscopic cases primary from diaphragm displacement or CO₂ absorption?
Primarily from diaphragm displacement.
When does the increase in PaCO₂ from gastric insufflation plateau?
after 10 - 15 min
How does the CRNA typically treat hypercarbia secondary to gastric insufflation?
- increase Vm
- ↑ VT or RR
When would the CRNA be hesitant to treat a hypercarbic patient?
Towards the end of the case.
↑ CO₂ necessary to stimulate pt’s respiratory drive and facilitate extubation.
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What typically causes pulmonary complications in laparoscopic cases?
Improper trocar placement
What are the pulmonary complications associated with improper trocar placement?
- SubQ emphysema, pneumothorax - into chest
- Gas embolism - into vessel
When does Subq emphysema usually resolve?
In 30-60 min
What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?
endobronchial intubation
What’s the hemodynamic result of a gas embolism into the vena cava?
Massive CO drop
obstruction to venous return
What are the s/s of gas embolism?
- ↓ EtCO₂ (best early sign)
- tachycardia
- Dysrhythmias
- hypotension w/ ↑ CVP
- Millwheel murmur
- Hypoxemia
What is the treatment for CO₂ gas embolism?
- Cessation of insufflation
- Trendelenburg w/ L lateral tilt
- Fluid bolus
- 100% O₂
- Aspiration of air
- Vasopressor support
How is endobronchial intubation detected?
- Loss of bilateral breath sounds
- ↓ pulse oximetry
At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?
> 10 mmHg IAP
What hemodynamic changes are seen with insufflation?
- ↓ CO
- Reflexive ↑ BP
- Reflexive ↑ SVR/PVR
What drugs would be best for the hemodynamic effects from CO₂ insufflation?
Vasodilting agents
- Voltailes
- Nitroglycerin
- Cardene
- Remifentanil
- Esmolol
short acting
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How much do cardiac arrhythmias increase with increased PaCO₂?
Trick question. Arrhythmias arise from hypoxia not from hypercarbia.
What do cardiac arrythmias correlate with?
Not correlate with? 3
- young females
- PaCo2 , length surgery, bp
What are the cardiac arrythmias seen d/t insufflation?
severe bradycardia to asystole
What often causes cardiac arrythmias in laparoscopic cases?
Increases in vagal tone
- Peritoneal/cervical stretch
- Pulling on cervix
- electrocautery/stretch fallopian tubes
How would the bradycardia from vagal stimulation be treated?
- Limit insufflation pressure
- Glycopyrrolate
Position effects of Reverse Tburg + Tburg?
- venous stasis, dec CO … good ventilation
- edema , increase CO/CVP , increase IOP , decrease FRC/TLC/compliance
In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?
Lithotomy
What is the most common surgical complication of laparoscopy?
Whats the occurence?
- Intestinal injury :: perforation, CBD injury
- 30-50%
- May remain undiagnosed
What are the possible surgical complications of laparoscopy?
- Intestinal injuries :: 30-50%
- Vascular injuries
- Burns :: 15-20%
- Infection :: very small
When is laparoscopy contraindicated?
Patient with ↑ ICP (tumor, trauma, hydrocephalus)
Is LMA a good option for Laparoscopic procedures?
Not really, insufflation can displace the LMA.
What are the reasons for OGT/NGT insertion in laparoscopies?
Aspiration of stomach air so surgeon has better visualization.
Decompression
NGT = if needed postop or convert to laporotmy
Why is it important to discuss referred pain?
Belly surgery + have bad shoulder pain
gastric insufflation after case - CO2 rise + irritate diaphragm = shoulder pain
What important part of the SCIP protocol is anesthesia in charge of now?
Antibiotics within 1 hr of cut time
What are the two most common firstline antibiotics indicated by the SCIP protocol?
- Cefazolin 1-2 grams
- Cefoxitin
What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?
Vancomycin : 1-1.5 grams
What are the other factors important to the SCIP protocol besides antibiotics?
- β-blockers : within 24 hrs
- Temperature : >36 C
- Time Out : prior to incision
5 Indications for breast surgery
biopsy - excision of lesion w/ margins
lumpectomy - partial mastectomy - 2.5-5cm lesion
simple mastectomy - breast + nipple
Modified radical - breast, nipple, axillary lymphnodes
Radical mastectomy - breast, nodes, pectoralis muscle
Breast Preop: Why evaluate cardiac/pulm?
Pregnancy test!
chemo/radiation given prior
Breast
Wire localizarion
of area of concerns
Wire put in under radiology guidance
Do not pull out ,, just don’t touch it
Breast
Local vs. LMA
Positioning
Pain control
ALL depends on type of surgery
More serious (reconstruction) = LMA, chagne positiongs, high pain needs
biopsy, partial mastectomy = local, supine, small pain
What is SLN mapping + what dyes?
Sentinel Lymph Node mapping - dye to know where cancer is
o Methylene blue = cx renal insufficiency
o Indigo carmine = cx in sulfa allergies
o Lymphazurin = rare anaphylaxis – most commonly used
Why might a surgeon want a short acting NMBD during breast surgery
Long thoracic nerve + wind scapula
Breast
Describe tissue expander
o Plastic balloon inside where breast tissue was with sterile saline + blow up
o Low cost, no allergies, quick
Describe the LAT FLAP
- Latissimus Dorsi Myocutaneous (LDM)
- Below scapula
- Muscle + skin – still attached
- Cut away as pedicle graft and tunneled through axilla
- Quicker, less SE’s
Describ the TRAM FLAP
- Transverse Rectus Abdominus Myocutaneous (TRAM)
- From :: abdominal muscle, sub-q, skin
- Remains attached to native blood supply
- Mesh prosthesis for abdomen
Describe DIEP
- Deep Inferior Epigastric Perforators (DIEP)
o Skin and fat removed from abdomen (without muscle)
Very vascular, heals well, not much volume
No hernia concern
o Denervates abdomen
- Indications for Nissen Fundiplocation?
- What severe complications of GERD are avoided by a Niessen fundiplocation?
- Other indication?
increase lower esophageal sphincter pressure
- Stricture
- Aspiration PNA
- Esophageal Ulcerations
- Barret’s Esophagus
Failure/unwilling to commit to meds
Nissen Fundiplocation
How do prokinetic drugs work?
Which ones are commonly given?
- Strengthen LES & increase gastric emptying
- Metoclopramide & domperidone
Nissen Fundiplocation
How do PPI’s work?
Examples?
Blockade of ATPase in parietal cells - decrease acid production
“prazoles” = nexium, prilosec, protonix, prevacid
With Nissen Fundiplocation, pt should have documented ___________________
esophageal hyperacidity
What intubation technique is indicated for Niessen patients?
RSI
What position is indicated for Niessen Fundiplocations?
Supine, Low lithotomy, reverse Tburg
What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
Esophageal Dilator - 60 Fr
Maloney = pointy
What size is the esophageal dilator used for Niessen’s?
60 fr
In what surgery is the Triangle of Calot relevant?
Cholecystectomy
What structures are isolated and stapled during a cholecystectomy?
- Cystic artery and hepatic duct
What are the indications for Cholecystectomy?
Symptomatic cholelithiasis
Symptomatic cholecystitis
Who is most at risk for gallbladder disease?
5 F’s
- Female
- Forty
- Fair (caucasian)
- Flatulent
- Fat
What drugs should be considered for an emergent gallbladder?
- Prokinetics
- Bicitra
What position is a gallbladder placed in for surgery?
Reverse Tburg + L tilt
How is a sphincter of Oddi spasm treated?
Glucagon
When would an ERCP be indicated?
Choledocholithiasis
What are 4 indications for Spleenectomy?
- ITP (Immune thrombocytopenic purpura)
- Lymphoma
- Hemolytic anemia
- Trauma
What vaccines should have been received prior to spleenectomy?
When should they be given?
- Pneumococcal
- Meningococcal
- H. Influenza
1 week prior
With what pathology would one expect left lower lobe atelectasis?
Spleen problems (inflammation → swollen → pushes on LLL)
In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?
Spleenectomy
Differentiate a type and screen and a type and cross. (very superficially)
- Type & Screen = blood type identified
- Type and Cross = blood type identified and bags are ready down in blood bank.
What position would one place a spleenectomy patient in?
- 45° right lateral decubitus
- kidney rest + table flexed
What are 5 indications for bowel resection?
- Ulcerative colitis
- Crohn’s
- Diverticular disease
- Cancer
- Ischemic bowel
What is necessary pre-operatively for bowel resection patients?
- Bowel prep
- μ-opioid antagonists
- ERAS protocol
What would be the purpose of a μ-opioid antagonist prior to bowel surgery?
Name? When given? Why
Counteracts constipatory effects of narcotic and results in a faster resolving ileus.
ENTEREG (ALVIMOPAN) … prior to narcotics given … decrease ileus postop stay by 1 day
What is the ERAS protocol?
Enhanced Recovery After Surgery.
Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia - GABAPENTIN, ACETA, SCOP
- Proper hydration preoperatively - GATORADE
With which surgery might the CRNA more readily consider albumin vs crystalloids?
Bowel resection
What positions are used commonly for bowel resections?
Supine & low lithotomy
(can range all the way to very high lithotomy)
What is the indication for appendectomy?
Suspected appendicitis
Why might appendectomy patients be dehydrated?
What are the most commonly used labs to note this dehydration?
- Dehydration d/t fever & N/V
- Hemoconcentration (H/H), ↑ BUN
What positioning is utilized for appendectomy patients?
Supine, left arm tucked, trendelenburg (head down)
Which two gastric surgeries result in rapid initial weight loss?
Sleeve Gastrectomy & Gastric Bypass
In what gastric surgery would one expect protein and nutrient absorption to be the most affected?
Gastric Bypass
What is the primary adverse event associated with lap banding surgery?
Band erosion
Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?
Lap Banding
What are some possible indications for Bariatric surgery?
Morbid Obesity associated with:
- HTN
- DM
- OSA
- Asthma
What parameters (generally) result in approval from insurance companies for bariatric surgery?
- BMI > 35 w/ comorbidities
- BMI > 40
What possible homeopathic remedies for appetite suppression should be considered for patients receiving bariatric surgery?
G - Supplements (gingko, green tea, etc.)
Prophylaxis for ____ is important for bariatric surgeries.
VTE
Bariatric surgery patients commonly have undiagnosed ____.
OSA
What position is typically used for bariatric surgeries?
- Reverse Tburg ++ Head up at 30°
What positioning do obese patients generally not tolerate?
Supine (or also head down)
What s/s is more common post lap banding surgery?
Dysphagia
What are some concerns for patients post-operative bariatric surgery?
- Diarrhea
- Dysphagia
- Protein malabsorption - less contact time + bile/pancreatic enzymes
- Vitamin malabsorption - A,D,E,K,B12,Ca
What are 6 indications for conversion of laparoscopy to laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
What are some indications for exploratory laparotomy?
- Trauma
- Abdominal catastrophes (ex. ischemic bowel)
- Cancer staging
With what surgeries would the CRNA consider an epidural placement?
Laparotomies
____ are necessary for the inevitable ileus in post-operative laparotomies.
NGT’s
What surgeries are often at risk for PONV?
Gynecologic surgeries
What risk factors for PONV exist with gynecologic surgeries?
- Female
- Opioids
- Volatiles
- Laparoscopy/Laparotomy
Describe the D+C procedure
removes endometrial lining of uterues to treat bleeding from uterus or cervix
Young or old people
What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?
Cervix manipulation via the tenaculum
What complications would occur with retained products of conception?
- Sepsis
- Hemorrhage
What positioning is utilized for both a D&C and a D&E ?
- Lithotomy
Which surgeries are SCIP protocol not indicated on?
D&C and D&E
What IV med may be needed in D+C and D+E ? Why?
pitocin IV
to clamp down uterus + lessen bleeding
What is D+E for?
Weeks preformed during?
abortion or incomplete miscarriage
20-24 wks
Where is oxytocin secreted from?
Neurohypophysis - posterior pituitary
What does oxytocin do?
- Stimulate uterine contraction
- ↑ H₂O reabsorption from glomerular filtrate
What is the name for synthetic oxytocin?
What is the dose?
Similar to what substance?
Pitocin
20 u/Liter
vasopressin - increase water reabs.
What procedure allows for examination of the endometrial cavity?
What does it investigate?
Hysteroscopy
IUB - intrauterine bleeding
What two fluids are used for hysteroscopy? Why?
- NS/LR
- Sorbitol
To inflate uterus with irrigating fluid
What equipment should be used if NS is used in a hysteroscopy?
Bipolar Cautery
Monopolar cautery + NS = burns
When should sorbitol be avoided?
With diabetic patients
causes excess fructose + sz
When should glycine irrigation be avoided?
Why is this?
Avoided in liver patients due to the buildup of ammonia
What are the two typical anesthetic options for hysteroscopy?
- Paracervical block
- General w/ LMA
What would most likely cause bradycardia during a hysteroscopy?
Vagal response of cervix manipulation w/ tenaculum
Position for Hysteroscopy? Does it require SCIP?
Lithotomy
YES SCIP abx
What are urethral slings used to treat?
Incontinence
Loss of support to the bladder neck + pelvic floor
Who is at risk of incontinence requiring a urethral sling?
- 15-60% of women
- Multiparous women (older)
- 1/4 Nulliparous young athletes - jumping sports
What type of anesthesia is typically performed for urethral sling patients?
What position?
General w/ LMA
Lithotomy
What is the sling material made of in urethral sling procedures?
Prolene mesh
Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.
bladder neck ; pelvic floor
What special equipment is necessary for Condyloma removals?
- Laser masks
- Smoke evacuation system - for the “plume” - surgeon can develop condyloma
What is condyloma? Where do they occur?
Anesthesia? Position?
STD from HPV - oral, throat, rectal, vaginal
General (LMA) - Lithotomy
What causes pelvic organ (bladder, vagina, etc) prolapse?
Weakened pelvic floor
- Delivery + repair postponed
- aging
- previous pelvic surgery
What are the three types of prolapse?
- Cystocele (bladder) - Anterior prolapse
- Rectocele (rectum) - Posterior prolapse
- Enterocele (intestine)
What medical device do patients typically go home with post prolapse repair?
Foley catheter (ensures urethra won’t be obstructed)
Anesthesia for repair procedures? Position? SCIP?
- general - ETT vs LMA
- Lithotomy
- SCIP !
- Foley catheter
What are the three types of hysterectomy?
- Partial hysterectomy = uterus
- Total = uterus + cervix
- BSO – Bilateral salpingo-oophorectomy = tubes + ovaries + cervix
What two types of cut are used in hysterectomies if an abdominal approach is indicated?
- Pfannenstiel (bikini cut)
- Midline
What is the most common surgical approach for hysterectomies?
LAVH - combination bw vaginal + belly incisions
Laparoscopic assisted vaginal hysterectomy
Hysterectomy :: anesthesia? position? abx? Special?
- GETA
- pfanneistel = supine , vaginal = lithotomy , LAVH = both
- SCIP
- foley ,, bowel prep ,, bradycardia ,, PONV
What was Robitics first used for?
What benefits does robotic surgery provide?
- gyn - fallopian tubal anastamoses (1999)
- 3-Dimensional Views
Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies
What are the pros and cons of robotic surgery?
- Improved dexterity
- Increased cost
- More OR time
What positioning is typically used with robotic surgery?
Extreme Trendelenburg + STAYING THERE !
Robotic surgeries necessitate less fluid administration. Why?
Positioning (severe trendelenburg) results in extreme facial and airway edema.
Robotic surgery - anesthesia? abx? special?
GETA
SCIP
good muscle relaxation! fluid restriction
