Exam 3 General/Gyn/Laparoscopic Surgery (7/11/24) Flashcards by Kimberly Diane Hill

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

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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

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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)

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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

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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

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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)

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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

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What is the usual time it takes for the Subq-emphysema/pneumothorax to resolve?

30-60 minutes

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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.

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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

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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)

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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

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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!!

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In which patient population specifically are Cardiac arrhythmias more common?

What is a pre-treatment that can be used?

Young Females

Glycopyrrolate

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Peritoneal Stretching and electrocautery/stretching of the fallopian tubes can cause ___.

Reflex increases in vagal tone

Glycopyrrolate to pre-treat

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Per lecture, this is the BEST patient position for anesthesia.
Why?

Head Up/ Reverse Trendelenburg

Favorable Ventilation

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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

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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

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What are some surgical complications of Laparoscopy?

Intestinal Injuries (Perforations, CBD injury)
Vascular Injuries
Burns
Infection

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What percent of “Serious Complications” from laproscopic surgeries are intestinal injury related?

30-50%

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How are “burns” caused from laparoscopic surgeries?
What percent of complications does this account for?

From the camera.
15-20%

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Relative Contraindications of laparoscopic surgeries:

Increased ICP
Tumor
Trauma
Hydrocephalus

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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

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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.

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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?

1. Dilate the cervix via special instrumentation 2. 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