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Principles I* > E3- General / Gynecologic Surgery > Flashcards

E3- General / Gynecologic Surgery Flashcards

1
Q

When was laparoscopy first used? What for?

A
  • 1970’s for gynecologic conditions
  • Cholecystectomy – Late 1980’s
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2
Q

What is the purpose of gastric insufflation?

A
  • Allows for room to work + equipment
  • identification of intraperitoneal space
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3
Q

What occurs with the onset of pneumoperitoneum insufflation of the abdomen?

A
  • Release of catecholamines & vasopressin&raquo_space; increase SVR
  • Arterial vasculature is compressed
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4
Q

What is the goal pressure in mmHg for gastric insufflation?

A

≤ 20 mmHg

12 - 15 mmHg is most common.

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5
Q

%%%

What causes increased CO₂ during laparoscopic surgeries?

A
  1. Positioning (frequently Trendelenburg)
  2. CO₂ insufflation (absorbed by peritoneum into the blood stream).
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6
Q

What are the pulmonary effects of insufflation?

A
  • ↑ PaCO₂
  • ↓ compliance
  • ↑ PIP
  • ↓ FRC&raquo_space; dec Vt
  • Atelectasis
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7
Q

%%%

In what laparoscopic position is atelectasis development most common?

A

Trendelenburg

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8
Q

How much change in pulmonary compliance occurs with gastric insufflation?

A

30 - 50% decrease in compliance

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9
Q

%%%

Is increased PaCO₂ in laparoscopic cases primary from diaphragm displacement or CO₂ absorption?

A

Primarily from diaphragm displacement.

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10
Q

When does the increase in PaCO₂ from gastric insufflation plateau?

A

after 10 - 15 min

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11
Q

How does the CRNA typically treat hypercarbia secondary to gastric insufflation?

A
  • increase Vm
  • ↑ VT or RR
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12
Q

When would the CRNA be hesitant to treat a hypercarbic patient?

A

Towards the end of the case.

↑ CO₂ necessary to stimulate pt’s respiratory drive and facilitate extubation.

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13
Q

%%%

What typically causes pulmonary complications in laparoscopic cases?

A

Improper trocar placement

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14
Q

What are the pulmonary complications associated with improper trocar placement?

A
  • SubQ emphysema, pneumothorax - into chest
  • Gas embolism - into vessel
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15
Q

When does Subq emphysema usually resolve?

A

In 30-60 min

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16
Q

What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?

A

endobronchial intubation

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17
Q

What’s the hemodynamic result of a gas embolism into the vena cava?

A

Massive CO drop
obstruction to venous return

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18
Q

What are the s/s of gas embolism?

A
  • ↓ EtCO₂ (best early sign)
  • tachycardia
  • Dysrhythmias
  • hypotension w/ ↑ CVP
  • Millwheel murmur
  • Hypoxemia
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19
Q

What is the treatment for CO₂ gas embolism?

A
  • Cessation of insufflation
  • Trendelenburg w/ L lateral tilt
  • Fluid bolus
  • 100% O₂
  • Aspiration of air
  • Vasopressor support
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20
Q

How is endobronchial intubation detected?

A
  • Loss of bilateral breath sounds
  • ↓ pulse oximetry
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21
Q

At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?

A

> 10 mmHg IAP

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22
Q

What hemodynamic changes are seen with insufflation?

A
  • ↓ CO
  • Reflexive ↑ BP
  • Reflexive ↑ SVR/PVR
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23
Q

What drugs would be best for the hemodynamic effects from CO₂ insufflation?

A

Vasodilting agents
- Voltailes
- Nitroglycerin
- Cardene
- Remifentanil
- Esmolol

short acting

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24
Q

%%%

How much do cardiac arrhythmias increase with increased PaCO₂?

A

Trick question. Arrhythmias arise from hypoxia not from hypercarbia.

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25
Q

What do cardiac arrythmias correlate with?
Not correlate with? 3

A
  • young females
  • PaCo2 , length surgery, bp
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26
Q

What are the cardiac arrythmias seen d/t insufflation?

A

severe bradycardia to asystole

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27
Q

What often causes cardiac arrythmias in laparoscopic cases?

A

Increases in vagal tone

  • Peritoneal/cervical stretch
  • Pulling on cervix
  • electrocautery/stretch fallopian tubes
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28
Q

How would the bradycardia from vagal stimulation be treated?

A
  • Limit insufflation pressure
  • Glycopyrrolate
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29
Q

Position effects of Reverse Tburg + Tburg?

A
  • venous stasis, dec CO … good ventilation
  • edema , increase CO/CVP , increase IOP , decrease FRC/TLC/compliance
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30
Q

In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?

A

Lithotomy

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31
Q

What is the most common surgical complication of laparoscopy?
Whats the occurence?

A
  • Intestinal injury :: perforation, CBD injury
  • 30-50%
  • May remain undiagnosed
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32
Q

What are the possible surgical complications of laparoscopy?

A
  • Intestinal injuries :: 30-50%
  • Vascular injuries
  • Burns :: 15-20%
  • Infection :: very small
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33
Q

When is laparoscopy contraindicated?

A

Patient with ↑ ICP (tumor, trauma, hydrocephalus)

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34
Q

Is LMA a good option for Laparoscopic procedures?

A

Not really, insufflation can displace the LMA.

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35
Q

What are the reasons for OGT/NGT insertion in laparoscopies?

A

Aspiration of stomach air so surgeon has better visualization.
Decompression
NGT = if needed postop or convert to laporotmy

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36
Q

Why is it important to discuss referred pain?

A

Belly surgery + have bad shoulder pain
gastric insufflation after case - CO2 rise + irritate diaphragm = shoulder pain

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37
Q

What important part of the SCIP protocol is anesthesia in charge of now?

A

Antibiotics within 1 hr of cut time

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38
Q

What are the two most common firstline antibiotics indicated by the SCIP protocol?

A
  • Cefazolin 1-2 grams
  • Cefoxitin
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39
Q

What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?

A

Vancomycin : 1-1.5 grams

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40
Q

What are the other factors important to the SCIP protocol besides antibiotics?

A
  • β-blockers : within 24 hrs
  • Temperature : >36 C
  • Time Out : prior to incision
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41
Q

5 Indications for breast surgery

A

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

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42
Q

Breast Preop: Why evaluate cardiac/pulm?
Pregnancy test!

A

chemo/radiation given prior

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43
Q

Breast

Wire localizarion

A

of area of concerns
Wire put in under radiology guidance
Do not pull out ,, just don’t touch it

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44
Q

Breast

Local vs. LMA
Positioning
Pain control

A

ALL depends on type of surgery
More serious (reconstruction) = LMA, chagne positiongs, high pain needs
biopsy, partial mastectomy = local, supine, small pain

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45
Q

What is SLN mapping + what dyes?

A

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

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46
Q

Why might a surgeon want a short acting NMBD during breast surgery

A

Long thoracic nerve + wind scapula

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47
Q

Breast

Describe tissue expander

A

o Plastic balloon inside where breast tissue was with sterile saline + blow up
o Low cost, no allergies, quick

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48
Q

Describe the LAT FLAP

A
  • Latissimus Dorsi Myocutaneous (LDM)
  • Below scapula
  • Muscle + skin – still attached
  • Cut away as pedicle graft and tunneled through axilla
  • Quicker, less SE’s
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49
Q

Describ the TRAM FLAP

A
  • Transverse Rectus Abdominus Myocutaneous (TRAM)
  • From :: abdominal muscle, sub-q, skin
  • Remains attached to native blood supply
  • Mesh prosthesis for abdomen
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50
Q

Describe DIEP

A
  • 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
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51
Q
  • Indications for Nissen Fundiplocation?
  • What severe complications of GERD are avoided by a Niessen fundiplocation?
  • Other indication?
A

increase lower esophageal sphincter pressure
- Stricture
- Aspiration PNA
- Esophageal Ulcerations
- Barret’s Esophagus

Failure/unwilling to commit to meds

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52
Q

Nissen Fundiplocation

How do prokinetic drugs work?
Which ones are commonly given?

A
  • Strengthen LES & increase gastric emptying
  • Metoclopramide & domperidone
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53
Q

Nissen Fundiplocation

How do PPI’s work?
Examples?

A

Blockade of ATPase in parietal cells - decrease acid production
“prazoles” = nexium, prilosec, protonix, prevacid

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54
Q

With Nissen Fundiplocation, pt should have documented ___________________

A

esophageal hyperacidity

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55
Q

What intubation technique is indicated for Niessen patients?

A

RSI

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56
Q

What position is indicated for Niessen Fundiplocations?

A

Supine, Low lithotomy, reverse Tburg

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57
Q

What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?

A

Esophageal Dilator - 60 Fr
Maloney = pointy

58
Q

What size is the esophageal dilator used for Niessen’s?

A

60 fr

59
Q

In what surgery is the Triangle of Calot relevant?

A

Cholecystectomy

60
Q

What structures are isolated and stapled during a cholecystectomy?

A
  • Cystic artery and hepatic duct
61
Q

What are the indications for Cholecystectomy?

A

Symptomatic cholelithiasis
Symptomatic cholecystitis

62
Q

Who is most at risk for gallbladder disease?

A

5 F’s

  • Female
  • Forty
  • Fair (caucasian)
  • Flatulent
  • Fat
63
Q

What drugs should be considered for an emergent gallbladder?

A
  • Prokinetics
  • Bicitra
64
Q

What position is a gallbladder placed in for surgery?

A

Reverse Tburg + L tilt

65
Q

How is a sphincter of Oddi spasm treated?

A

Glucagon

66
Q

When would an ERCP be indicated?

A

Choledocholithiasis

67
Q

What are 4 indications for Spleenectomy?

A
  • ITP (Immune thrombocytopenic purpura)
  • Lymphoma
  • Hemolytic anemia
  • Trauma
68
Q

What vaccines should have been received prior to spleenectomy?
When should they be given?

A
  • Pneumococcal
  • Meningococcal
  • H. Influenza

1 week prior

69
Q

With what pathology would one expect left lower lobe atelectasis?

A

Spleen problems (inflammation → swollen → pushes on LLL)

70
Q

In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?

A

Spleenectomy

71
Q

Differentiate a type and screen and a type and cross. (very superficially)

A
  • Type & Screen = blood type identified
  • Type and Cross = blood type identified and bags are ready down in blood bank.
72
Q

What position would one place a spleenectomy patient in?

A
  • 45° right lateral decubitus
  • kidney rest + table flexed
73
Q

What are 5 indications for bowel resection?

A
  • Ulcerative colitis
  • Crohn’s
  • Diverticular disease
  • Cancer
  • Ischemic bowel
74
Q

What is necessary pre-operatively for bowel resection patients?

A
  • Bowel prep
  • μ-opioid antagonists
  • ERAS protocol
75
Q

What would be the purpose of a μ-opioid antagonist prior to bowel surgery?
Name? When given? Why

A

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

76
Q

What is the ERAS protocol?

A

Enhanced Recovery After Surgery.

Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia - GABAPENTIN, ACETA, SCOP
- Proper hydration preoperatively - GATORADE

77
Q

With which surgery might the CRNA more readily consider albumin vs crystalloids?

A

Bowel resection

78
Q

What positions are used commonly for bowel resections?

A

Supine & low lithotomy

(can range all the way to very high lithotomy)

79
Q

What is the indication for appendectomy?

A

Suspected appendicitis

80
Q

Why might appendectomy patients be dehydrated?

What are the most commonly used labs to note this dehydration?

A
  • Dehydration d/t fever & N/V
  • Hemoconcentration (H/H), ↑ BUN
81
Q

What positioning is utilized for appendectomy patients?

A

Supine, left arm tucked, trendelenburg (head down)

82
Q

Which two gastric surgeries result in rapid initial weight loss?

A

Sleeve Gastrectomy & Gastric Bypass

83
Q

In what gastric surgery would one expect protein and nutrient absorption to be the most affected?

A

Gastric Bypass

84
Q

What is the primary adverse event associated with lap banding surgery?

A

Band erosion

85
Q

Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?

A

Lap Banding

86
Q

What are some possible indications for Bariatric surgery?

A

Morbid Obesity associated with:

  • HTN
  • DM
  • OSA
  • Asthma
87
Q

What parameters (generally) result in approval from insurance companies for bariatric surgery?

A
  • BMI > 35 w/ comorbidities
  • BMI > 40
88
Q

What possible homeopathic remedies for appetite suppression should be considered for patients receiving bariatric surgery?

A

G - Supplements (gingko, green tea, etc.)

89
Q

Prophylaxis for ____ is important for bariatric surgeries.

A

VTE

90
Q

Bariatric surgery patients commonly have undiagnosed ____.

A

OSA

91
Q

What position is typically used for bariatric surgeries?

A
  • Reverse Tburg ++ Head up at 30°
92
Q

What positioning do obese patients generally not tolerate?

A

Supine (or also head down)

93
Q

What s/s is more common post lap banding surgery?

A

Dysphagia

94
Q

What are some concerns for patients post-operative bariatric surgery?

A
  • Diarrhea
  • Dysphagia
  • Protein malabsorption - less contact time + bile/pancreatic enzymes
  • Vitamin malabsorption - A,D,E,K,B12,Ca
95
Q

What are 6 indications for conversion of laparoscopy to laparotomy?

A
  • Obesity
  • Adhesions
  • Bleeding
  • Unclear anatomy
  • Staple misfire
  • Inability to ventilate
96
Q

What are some indications for exploratory laparotomy?

A
  • Trauma
  • Abdominal catastrophes (ex. ischemic bowel)
  • Cancer staging
97
Q

With what surgeries would the CRNA consider an epidural placement?

A

Laparotomies

98
Q

____ are necessary for the inevitable ileus in post-operative laparotomies.

A

NGT’s

99
Q

What surgeries are often at risk for PONV?

A

Gynecologic surgeries

100
Q

What risk factors for PONV exist with gynecologic surgeries?

A
  • Female
  • Opioids
  • Volatiles
  • Laparoscopy/Laparotomy
101
Q

Describe the D+C procedure

A

removes endometrial lining of uterues to treat bleeding from uterus or cervix
Young or old people

102
Q

What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?

A

Cervix manipulation via the tenaculum

103
Q

What complications would occur with retained products of conception?

A
  • Sepsis
  • Hemorrhage
104
Q

What positioning is utilized for both a D&C and a D&E ?

A
  • Lithotomy
105
Q

Which surgeries are SCIP protocol not indicated on?

A

D&C and D&E

106
Q

What IV med may be needed in D+C and D+E ? Why?

A

pitocin IV
to clamp down uterus + lessen bleeding

107
Q

What is D+E for?
Weeks preformed during?

A

abortion or incomplete miscarriage
20-24 wks

108
Q

Where is oxytocin secreted from?

A

Neurohypophysis - posterior pituitary

109
Q

What does oxytocin do?

A
  • Stimulate uterine contraction
  • ↑ H₂O reabsorption from glomerular filtrate
110
Q

What is the name for synthetic oxytocin?
What is the dose?
Similar to what substance?

A

Pitocin
20 u/Liter
vasopressin - increase water reabs.

111
Q

What procedure allows for examination of the endometrial cavity?
What does it investigate?

A

Hysteroscopy
IUB - intrauterine bleeding

112
Q

What two fluids are used for hysteroscopy? Why?

A
  • NS/LR
  • Sorbitol

To inflate uterus with irrigating fluid

113
Q

What equipment should be used if NS is used in a hysteroscopy?

A

Bipolar Cautery

Monopolar cautery + NS = burns

114
Q

When should sorbitol be avoided?

A

With diabetic patients
causes excess fructose + sz

115
Q

When should glycine irrigation be avoided?
Why is this?

A

Avoided in liver patients due to the buildup of ammonia

116
Q

What are the two typical anesthetic options for hysteroscopy?

A
  • Paracervical block
  • General w/ LMA
117
Q

What would most likely cause bradycardia during a hysteroscopy?

A

Vagal response of cervix manipulation w/ tenaculum

118
Q

Position for Hysteroscopy? Does it require SCIP?

A

Lithotomy
YES SCIP abx

119
Q

What are urethral slings used to treat?

A

Incontinence
Loss of support to the bladder neck + pelvic floor

120
Q

Who is at risk of incontinence requiring a urethral sling?

A
  • 15-60% of women
  • Multiparous women (older)
  • 1/4 Nulliparous young athletes - jumping sports
121
Q

What type of anesthesia is typically performed for urethral sling patients?
What position?

A

General w/ LMA
Lithotomy

122
Q

What is the sling material made of in urethral sling procedures?

A

Prolene mesh

123
Q

Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.

A

bladder neck ; pelvic floor

124
Q

What special equipment is necessary for Condyloma removals?

A
  • Laser masks
  • Smoke evacuation system - for the “plume” - surgeon can develop condyloma
125
Q

What is condyloma? Where do they occur?
Anesthesia? Position?

A

STD from HPV - oral, throat, rectal, vaginal
General (LMA) - Lithotomy

126
Q

What causes pelvic organ (bladder, vagina, etc) prolapse?

A

Weakened pelvic floor
- Delivery + repair postponed
- aging
- previous pelvic surgery

127
Q

What are the three types of prolapse?

A
  • Cystocele (bladder) - Anterior prolapse
  • Rectocele (rectum) - Posterior prolapse
  • Enterocele (intestine)
128
Q

What medical device do patients typically go home with post prolapse repair?

A

Foley catheter (ensures urethra won’t be obstructed)

129
Q

Anesthesia for repair procedures? Position? SCIP?

A
  • general - ETT vs LMA
  • Lithotomy
  • SCIP !
  • Foley catheter
130
Q

What are the three types of hysterectomy?

A
  • Partial hysterectomy = uterus
  • Total = uterus + cervix
  • BSO – Bilateral salpingo-oophorectomy = tubes + ovaries + cervix
131
Q

What two types of cut are used in hysterectomies if an abdominal approach is indicated?

A
  • Pfannenstiel (bikini cut)
  • Midline
132
Q

What is the most common surgical approach for hysterectomies?

A

LAVH - combination bw vaginal + belly incisions

Laparoscopic assisted vaginal hysterectomy

133
Q

Hysterectomy :: anesthesia? position? abx? Special?

A
  • GETA
  • pfanneistel = supine , vaginal = lithotomy , LAVH = both
  • SCIP
  • foley ,, bowel prep ,, bradycardia ,, PONV
134
Q

What was Robitics first used for?
What benefits does robotic surgery provide?

A
  • gyn - fallopian tubal anastamoses (1999)
  • 3-Dimensional Views

Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies

135
Q

What are the pros and cons of robotic surgery?

A
  • Improved dexterity
  • Increased cost
  • More OR time
136
Q

What positioning is typically used with robotic surgery?

A

Extreme Trendelenburg + STAYING THERE !

137
Q

Robotic surgeries necessitate less fluid administration. Why?

A

Positioning (severe trendelenburg) results in extreme facial and airway edema.

138
Q

Robotic surgery - anesthesia? abx? special?

A

GETA
SCIP
good muscle relaxation! fluid restriction

139
Q
A
140
Q
A

Principles I* (20 decks)

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