Exam 3 General/Gyn/Laparoscopic Surgery (7/11/24) Flashcards
When did laparoscopy first assist with diagnosis’ of gynecologic conditions?
When did it first start to be used in cholecystectomies?
1970’s
Late 1980’s
What are the responses by the body after creating a pneumoperitoneum for a laparoscopic procedure?
Release of catecholamines and vasopressin at onset of pneumoperitoneum = Huge increase in SVR
Compression of arterial vasculature
What is the upper limit we want the IAP to be at when creating a pneumoperitoneum?
Less than or equal to 20 mmHg
(Ideally we want 12-15 mmHg)
What are some pulmonary effects seen while creating a pneumoperitoneum for laparoscopic cases?
- Increased PaCO2
- Decreased compliance by 30-50%
- Increased PIP
- Decreased VT, FRC
- Development of Atelectasis
What can we do to treat some of the pulmonary effects seen with a pneumoperitoneum?
Increase Minute ventilation = blow off more CO2 to avoid acidosis
At which point in the case might it be a good idea to allow for a slight increase in PaCO2?
Why?
At the end of the case!
Leaving a slightly elevated CO2 level will help stimulate the patient to initiate their own breath and wake up easier (per Kane)
What are some specific pulmonary complications that may be seen that are caused by the trocars?
Sub-q Emphysema
Pneumothorax
Pneumomediastinum
Others include Gas embolism and Endobronchial intubation
What is the usual time it takes for the Subq-emphysema/pneumothorax to resolve?
30-60 minutes
How can a gas embolism develop while creating a pneumoperitoneum?
Is this usually from the 1st, 2nd, 3rd trocar site..?
Gas can be infused directly into the vessel because the 1st trocar site is put in blind!
In the worst cases you can see a gas lock in the vena cava = obstructing venous return.
Which of the following can be seen in the diagnosis of a gas embolism caused by insufflation of CO2 while creating a pneumoperitoneum? (Select 3)
A. Hypoxemia
B. Bradycardia
C. Decreased ETCO2
D. Increased ETCO2
E. Millwheel murmur
F. Hypertension with decreased CVP
A. Hypoxemia
C. Decreased ETCO2
E. Millwheel murmur
Which of the following are the correct positioning treatments for a venous gas embolism caused by insufflation of CO2 while creating a pneumoperitoneum? (Select 2)
A. Lithotomy
B. Right Lateral Decubitus
C. Trendelenburg
D. Reverse Trendelenburg
E. Prone
F. Left Lateral
C. Trendelenburg
F. Left Lateral
Rationale: We want to keep the bubble in the right heart (away from Left side and mitral valve)
When are hemodynamic effects seen during laparoscopic surgeries?
What are some of these effects?
Occur when IAP is > 10 mmHg
Decreased CO, Increased arterial pressure, increased SVR/PVR
Usually these effects resolve in several minutes
Pharmacologic treatments for the hemodynamic effects seen when IAP reaches pressures > 10 mmHg:
- Vapor
- Nitroglycerin
- Cardene
- Remifentanil
- Esmolol
We want very short acting vasodilating agents!!
In which patient population specifically are Cardiac arrhythmias more common?
What is a pre-treatment that can be used?
Young Females
Glycopyrrolate
Peritoneal Stretching and electrocautery/stretching of the fallopian tubes can cause ___.
Reflex increases in vagal tone
Glycopyrrolate to pre-treat
Per lecture, this is the BEST patient position for anesthesia.
Why?
Head Up/ Reverse Trendelenburg
Favorable Ventilation
What are some effects seen in the Trendelenburg position?
- Facial/pharyngeal/laryngeal airway edema
- Increased CVP/CO
- Increased intraocular pressure, ICP can worsen
- Altered pulmonary mechanics… FRC, TLV, compliance
Most common nerve injuries when the patient is NOT in stirrups, and when they ARE in stirrups (Lithotomy):
No Stirrups: Brachial Plexus
In Stirrups: Common Peroneal Nerve
What are some surgical complications of Laparoscopy?
- Intestinal Injuries (Perforations, CBD injury)
- Vascular Injuries
- Burns
- Infection
What percent of “Serious Complications” from laproscopic surgeries are intestinal injury related?
30-50%
How are “burns” caused from laparoscopic surgeries?
What percent of complications does this account for?
From the camera.
15-20%
Relative Contraindications of laparoscopic surgeries:
Increased ICP
Tumor
Trauma
Hydrocephalus
Anesthesia Plan for Laparoscopic surgeries:
Preop Meds (Versed, PPI, H2 Antag.)
GETA (LMA may lose seal w/ position changes)
Controlled Ventilation
OGT > NGT (Unless they need gastric tube post-op)
IVF (Maybe Albumin = elderly, protein deficiency)
Narcotics
NMBD (Succs vs Roc, depending on length)
Positioning
What type of referred pain may be present after a laproscopic surgery?
Is this an emergency?
Referred pain to the shoulder
Not an emergency. The nerves that supply the shoulders originated embryonically from the same area as the diaphragm.
SCIP protocol for laparoscopic procedures:
ABX within 1 hr of cut
Beta Blockers within 24 hrs (If already taking one)
Temperature maintained at > or = to 36 C
Time out prior to cut
Another term for a “Partial Mastectomy”
Lumpectomy (Lesion of 2.5-5cm)
Definition of a simple mastectomy:
Removal of breast and nipple.
No lymph node involvement or poor surgical risk
Excision of breast lesion with margins:
Biopsy
What all is removed for a radical mastectomy?
Entire breast, nodes, pectoralis muscle
What is removed in a modified radical?
breast, nipple, axillary lymph nodes
(Possible reconstruction)
For SLN mapping, what are the 3 common injections that can be used?
What are the contraindications with 2 of them and which one is most commonly used?
Methylene Blue: CI with renal insuff.
Indigo Carmine: CI in sulfa allergy
Lymphazurin: Most commonly used
What is the nerve innervating the breast that, if injured, can cause lots of pain and altered shoulder movement?
The Long Thoracic Nerve
Can cause “Wing Scapula”
Which type of reconstruction is below the scapula and is cut away as a pedicle graft and tunneled through the axilla?
Latissimus dorsi myocutaneous (LDM)
Which type of reconstruction removes the skin and fat from the abdomen but not the muscle?
Deep inferior epigastric perforators (DIEP)
This type of procedure is done to increase lower esophageal sphincter pressure:
Nissen Fundoplication
What are some of the complications of GERD, that support the indication of performing a Nissen fundoplication?
Stricture
Aspiration pneumonia
Esophageal ulcerations
Barrett’s esophagus
What are a couple of drug classes that are beneficial to give pre-op to a patient undergoing a Nissen fundoplication?
PPI’s
Prokinetics (Reglan, Domperidone)
True or False:
Nissen Fundoplications should be treated as an RSI?
TRUE
Positioning intra-op for Nissen Fundoplication
Supine, Low lithotomy, Reverse trendelenburg
What size esophageal dilator should be used for a Nissen fundoplication?
60 French
What is the important landmark we need to know in regard to a cholecystectomy?
What is this landmark bordered by?
Triangle of Calot
Bordered by the:
* Cystic Duct
* Hepatic Duct
* Liver Border
What are the 5 F’s that relate to indications of a Cholecystectomy?
Fair
Fat
Female
Forty
Flatulent
What is one important anesthesia consideration pre-op for cholecystectomy cases?
Many of them are emergent, so think of them as full-stomachs
Intra-op positioning for cholecystectomy cases?
Supine, Reverse T, Left tilt
If we are performing an intra-op cholangiogram, the dye may not disperse very well due to…?
What can we do to help with this issue?
Sphincter of Oddi spasms (caused by opioids)
Glucagon will help stop the spasms and spread the dye out more
Indications for Spleenectomy:
- Immune Thrombocytopenic Purpura (ITP)
- Lymphoma
- Hemolytic Anemia
- Trauma
Pre-op Evaluations for Spleenectomy:
Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop
Evaluate LLL atelectasis = may indicated a larger spleen, hence a more difficult surgery (bleeding)
Intra-op positioning for spleenectomy:
45 Degree Right lateral decubitus
Kidney rest, table flexed
Indications for a Bowel resection:
- Ulcerative colitis
- Crohn’s disease
- Diverticular disease
- Cancers
- Ischemic bowel
Pre-op considerations for a bowel resection:
Bowel Prep
Mu-opioid antagonist (Alvimopan)
Pre-op warming
Multi-modal approach (Gabapentin, ACET, Scopolamine)
Gatorade (up until about 2 hrs prior to surgery)
Intra-op positioning for bowel resections:
Low lithotomy or supine.
Depending on whether or not the entire case is laparoscopic or more involved. You may start supine and then have to move to a low lithotomy and even back to supine again to end the case.
What is a cardinal lab finding of dehydration rather than renal failure?
Elevated BUN with a normal creatinine
Appendectomy cases = dehydrated from fever or N/V
Intra-op positioning for Appendectomy:
Supine, Left arm tucked, trendelenburg
Which of the 3 bariatric surgeries is considered irreversible and has protein and nutrient deficiencies?
Gastric Bypass
True or False:
Initially there is rapid weight loss from all three of the bariatric surgeries discussed in lecture?
FALSE:
Lap banding is slow, the sleeve and bypass are rapid initially.
Pre-op considerations for bariatric surgeries:
Review medication list- appetite suppressors?
Assess airway- limit preoperative sedation?
Commonly have undiagnosed OSA
VTE prophylaxis!!!
Intra-op Anesthesia plan for bariatric surgeries:
- Reverse T, HOB up at least 30 degrees = pre-oxygenation
- GETA w RSI
- OGT = removed before stomach is stapled
- Calibration Tube (closed on the end, filled w/ Methylene blue)
Long term concerns with Bariatric surgeries:
- Diarrhea
- Dysphagia (Banding)
- Protein malabsorption
- Vitamin Malabsorption (A, D, E, K, B12, Calcium)
What are some reasons as to why we may switch from a laparoscopic procedure to a laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
Important intra-op considerations for an exploratory laparatomy include:
- GETA
- Profound muscle relaxation!
- NGT
- Epidural/multimodal pain control?
- Keep them WARM!
Describe the D&C procedure:
Dilation and Curettage:
Removes the endometrial lining of uterus
Can be used to diagnose and treat bleeding from the uterus or cervix
What are some intra-op considerations for a D&C?
Lithotomy position
GETA
May need pitocin IV (titrate based off bleeding/feel)
Monitor for bradycardia
This procedure is variable depending on the State you work in:
D&E
Abortions or accidental miscarriages
This is naturally secreted from the neuro-hypophysis and stimulates uterine contractions.
What is this similar to?
Pitocin
Similar to vasopressin
Dose is approximately 20u per Liter
This procedure allows for examination of endometrial cavity:
Hysteroscopy
How are we able to view the endometrial cavity better during a hysteroscopy?
- Dilate the cervix via special instrumentation
- Infuse fluid into the uterus (ensure the same amount of fluid you put in is what is coming out = uterus is easy to perf)
Depending on the fluid used when inflating the uterus, there can be adverse effects:
Normal Saline:
Sorbitol:
Normal Saline: the sodium can carry a current and leads to burns if cauterizing the area that was inflated with NaCl
Sorbitol: can cause some excesses of fructose, and even seizures
Intra-op considerations for a Hysteroscopy:
Lithotomy positioning
SCIP ABX
Possible bradycardia
Sling procedures are done in approximately ___ to ___ % of women.
15-60%
The sling procedure allows for support of these two structures:
Bladder neck
Pelvic Floor
Assists with stress urinary incontinence
Which populations specifically are sling procedures more common?
Older women that have had mulitple children
College athletes that are involved in gymnastics/other “jumping sports” (volleyball)
Intra-op considerations for the Sling procedure:
Lithotomy position
LMA’s work great
Special intra-op considerations for condylomas.
Use of Laser Masks, special suction devices.
If providers are not wearing the proper mask protection, they can inhale the smoke (plume) and develop condylomas themself.
Differentiate a Cystocele and Rectocele:
Cystocele: Anterior Prolapse, bladder through the vaginal wall.
Rectocele: Posterior Prolapse, “intestinal prolapse”
* Also can be called “enterocele”
Per Dr. Kane, if surgeries are expected to last longer than ___ hrs, then the patient will likely need a foley catheter.
2-3 hrs
Describe what is being removed in the following procedures:
Partial Hysterctomy:
Total Hysterectomy:
Partial Hysterectomy: Just uterus
Total Hysterectomy: Uterus and cervix
Positioning for Hysterectomy:
Vaginal Incision:
Pfannenstiel:
LAVH:
Vaginal Incision: Lithotomy
Pfannenstiel: Supine
LAVH: Both
Robotic assistance was first used in the late 90’s for…?
1st used in gyn for fallopian tubal anastomoses (1999)
This procedure, that is done in many older men, has reduced ocurrences of ___ due in part to the use of robot-assisted surgeries.
Prostatectomies:
Reduced post-op impotence
What is one very important intra-op consideration for robotic surgeries in regard to fluid admin.
Fluid Restriction! (< 500 mls)
* Edematous airways can occur
