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DH: Principles I > Exam 3 General/Gyn/Laparoscopic Surgery (7/11/24) > Flashcards

Exam 3 General/Gyn/Laparoscopic Surgery (7/11/24) Flashcards

1
Q

When did laparoscopy first assist with diagnosis’ of gynecologic conditions?
When did it first start to be used in cholecystectomies?

A

1970’s

Late 1980’s

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2
Q

What are the responses by the body after creating a pneumoperitoneum for a laparoscopic procedure?

A

Release of catecholamines and vasopressin at onset of pneumoperitoneum = Huge increase in SVR

Compression of arterial vasculature

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3
Q

What is the upper limit we want the IAP to be at when creating a pneumoperitoneum?

A

Less than or equal to 20 mmHg

(Ideally we want 12-15 mmHg)

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4
Q

What are some pulmonary effects seen while creating a pneumoperitoneum for laparoscopic cases?

A
  • Increased PaCO2
  • Decreased compliance by 30-50%
  • Increased PIP
  • Decreased VT, FRC
  • Development of Atelectasis
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5
Q

What can we do to treat some of the pulmonary effects seen with a pneumoperitoneum?

A

Increase Minute ventilation = blow off more CO2 to avoid acidosis

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6
Q

At which point in the case might it be a good idea to allow for a slight increase in PaCO2?
Why?

A

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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7
Q

What are some specific pulmonary complications that may be seen that are caused by the trocars?

A

Sub-q Emphysema
Pneumothorax
Pneumomediastinum

Others include Gas embolism and Endobronchial intubation

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8
Q

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

A

30-60 minutes

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9
Q

How can a gas embolism develop while creating a pneumoperitoneum?

Is this usually from the 1st, 2nd, 3rd trocar site..?

A

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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10
Q

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

A. Hypoxemia
C. Decreased ETCO2
E. Millwheel murmur

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11
Q

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

A

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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12
Q

When are hemodynamic effects seen during laparoscopic surgeries?
What are some of these effects?

A

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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13
Q

Pharmacologic treatments for the hemodynamic effects seen when IAP reaches pressures > 10 mmHg:

A
  • Vapor
  • Nitroglycerin
  • Cardene
  • Remifentanil
  • Esmolol

We want very short acting vasodilating agents!!

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14
Q

In which patient population specifically are Cardiac arrhythmias more common?

What is a pre-treatment that can be used?

A

Young Females

Glycopyrrolate

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15
Q

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

A

Reflex increases in vagal tone

Glycopyrrolate to pre-treat

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16
Q

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

A

Head Up/ Reverse Trendelenburg

Favorable Ventilation

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17
Q

What are some effects seen in the Trendelenburg position?

A
  • Facial/pharyngeal/laryngeal airway edema
  • Increased CVP/CO
  • Increased intraocular pressure, ICP can worsen
  • Altered pulmonary mechanics… FRC, TLV, compliance
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18
Q

Most common nerve injuries when the patient is NOT in stirrups, and when they ARE in stirrups (Lithotomy):

A

No Stirrups: Brachial Plexus
In Stirrups: Common Peroneal Nerve

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19
Q

What are some surgical complications of Laparoscopy?

A
  • Intestinal Injuries (Perforations, CBD injury)
  • Vascular Injuries
  • Burns
  • Infection
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20
Q

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

A

30-50%

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21
Q

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

A

From the camera.
15-20%

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22
Q

Relative Contraindications of laparoscopic surgeries:

A

Increased ICP
Tumor
Trauma
Hydrocephalus

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23
Q

Anesthesia Plan for Laparoscopic surgeries:

A

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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24
Q

What type of referred pain may be present after a laproscopic surgery?
Is this an emergency?

A

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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25
Q

SCIP protocol for laparoscopic procedures:

A

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

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26
Q

Another term for a “Partial Mastectomy”

A

Lumpectomy (Lesion of 2.5-5cm)

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27
Q

Definition of a simple mastectomy:

A

Removal of breast and nipple.
No lymph node involvement or poor surgical risk

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28
Q

Excision of breast lesion with margins:

A

Biopsy

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29
Q

What all is removed for a radical mastectomy?

A

Entire breast, nodes, pectoralis muscle

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30
Q

What is removed in a modified radical?

A

breast, nipple, axillary lymph nodes

(Possible reconstruction)

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31
Q

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?

A

Methylene Blue: CI with renal insuff.
Indigo Carmine: CI in sulfa allergy
Lymphazurin: Most commonly used

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32
Q

What is the nerve innervating the breast that, if injured, can cause lots of pain and altered shoulder movement?

A

The Long Thoracic Nerve

Can cause “Wing Scapula”

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33
Q

Which type of reconstruction is below the scapula and is cut away as a pedicle graft and tunneled through the axilla?

A

Latissimus dorsi myocutaneous (LDM)

34
Q

Which type of reconstruction removes the skin and fat from the abdomen but not the muscle?

A

Deep inferior epigastric perforators (DIEP)

35
Q

This type of procedure is done to increase lower esophageal sphincter pressure:

A

Nissen Fundoplication

36
Q

What are some of the complications of GERD, that support the indication of performing a Nissen fundoplication?

A

Stricture
Aspiration pneumonia
Esophageal ulcerations
Barrett’s esophagus

37
Q

What are a couple of drug classes that are beneficial to give pre-op to a patient undergoing a Nissen fundoplication?

A

PPI’s
Prokinetics (Reglan, Domperidone)

38
Q

True or False:
Nissen Fundoplications should be treated as an RSI?

A

TRUE

39
Q

Positioning intra-op for Nissen Fundoplication

A

Supine, Low lithotomy, Reverse trendelenburg

40
Q

What size esophageal dilator should be used for a Nissen fundoplication?

A

60 French

41
Q

What is the important landmark we need to know in regard to a cholecystectomy?
What is this landmark bordered by?

A

Triangle of Calot

Bordered by the:
* Cystic Duct
* Hepatic Duct
* Liver Border

42
Q

What are the 5 F’s that relate to indications of a Cholecystectomy?

A

Fair
Fat
Female
Forty
Flatulent

43
Q

What is one important anesthesia consideration pre-op for cholecystectomy cases?

A

Many of them are emergent, so think of them as full-stomachs

44
Q

Intra-op positioning for cholecystectomy cases?

A

Supine, Reverse T, Left tilt

45
Q

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?

A

Sphincter of Oddi spasms (caused by opioids)

Glucagon will help stop the spasms and spread the dye out more

46
Q

Indications for Spleenectomy:

A
  • Immune Thrombocytopenic Purpura (ITP)
  • Lymphoma
  • Hemolytic Anemia
  • Trauma
47
Q

Pre-op Evaluations for Spleenectomy:

A

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)

48
Q

Intra-op positioning for spleenectomy:

A

45 Degree Right lateral decubitus
Kidney rest, table flexed

49
Q

Indications for a Bowel resection:

A
  • Ulcerative colitis
  • Crohn’s disease
  • Diverticular disease
  • Cancers
  • Ischemic bowel
50
Q

Pre-op considerations for a bowel resection:

A

Bowel Prep
Mu-opioid antagonist (Alvimopan)
Pre-op warming
Multi-modal approach (Gabapentin, ACET, Scopolamine)
Gatorade (up until about 2 hrs prior to surgery)

51
Q

Intra-op positioning for bowel resections:

A

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.

52
Q

What is a cardinal lab finding of dehydration rather than renal failure?

A

Elevated BUN with a normal creatinine

Appendectomy cases = dehydrated from fever or N/V

53
Q

Intra-op positioning for Appendectomy:

A

Supine, Left arm tucked, trendelenburg

54
Q

Which of the 3 bariatric surgeries is considered irreversible and has protein and nutrient deficiencies?

A

Gastric Bypass

55
Q

True or False:
Initially there is rapid weight loss from all three of the bariatric surgeries discussed in lecture?

A

FALSE:
Lap banding is slow, the sleeve and bypass are rapid initially.

56
Q

Pre-op considerations for bariatric surgeries:

A

Review medication list- appetite suppressors?

Assess airway- limit preoperative sedation?

Commonly have undiagnosed OSA

VTE prophylaxis!!!

57
Q

Intra-op Anesthesia plan for bariatric surgeries:

A
  • 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)
58
Q

Long term concerns with Bariatric surgeries:

A
  • Diarrhea
  • Dysphagia (Banding)
  • Protein malabsorption
  • Vitamin Malabsorption (A, D, E, K, B12, Calcium)
59
Q

What are some reasons as to why we may switch from a laparoscopic procedure to a laparotomy?

A
  • Obesity
  • Adhesions
  • Bleeding
  • Unclear anatomy
  • Staple misfire
  • Inability to ventilate
60
Q

Important intra-op considerations for an exploratory laparatomy include:

A
  • GETA
  • Profound muscle relaxation!
  • NGT
  • Epidural/multimodal pain control?
  • Keep them WARM!
61
Q

Describe the D&C procedure:

A

Dilation and Curettage:

Removes the endometrial lining of uterus
Can be used to diagnose and treat bleeding from the uterus or cervix

62
Q

What are some intra-op considerations for a D&C?

A

Lithotomy position
GETA
May need pitocin IV (titrate based off bleeding/feel)
Monitor for bradycardia

63
Q

This procedure is variable depending on the State you work in:

A

D&E

Abortions or accidental miscarriages

64
Q

This is naturally secreted from the neuro-hypophysis and stimulates uterine contractions.
What is this similar to?

A

Pitocin

Similar to vasopressin

Dose is approximately 20u per Liter

65
Q

This procedure allows for examination of endometrial cavity:

A

Hysteroscopy

66
Q

How are we able to view the endometrial cavity better during a hysteroscopy?

A
  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)
67
Q

Depending on the fluid used when inflating the uterus, there can be adverse effects:

Normal Saline:
Sorbitol:

A

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

68
Q

Intra-op considerations for a Hysteroscopy:

A

Lithotomy positioning
SCIP ABX
Possible bradycardia

69
Q

Sling procedures are done in approximately ___ to ___ % of women.

A

15-60%

70
Q

The sling procedure allows for support of these two structures:

A

Bladder neck
Pelvic Floor

Assists with stress urinary incontinence

71
Q

Which populations specifically are sling procedures more common?

A

Older women that have had mulitple children
College athletes that are involved in gymnastics/other “jumping sports” (volleyball)

72
Q

Intra-op considerations for the Sling procedure:

A

Lithotomy position
LMA’s work great

73
Q

Special intra-op considerations for condylomas.

A

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.

74
Q

Differentiate a Cystocele and Rectocele:

A

Cystocele: Anterior Prolapse, bladder through the vaginal wall.

Rectocele: Posterior Prolapse, “intestinal prolapse”
* Also can be called “enterocele”

75
Q

Per Dr. Kane, if surgeries are expected to last longer than ___ hrs, then the patient will likely need a foley catheter.

A

2-3 hrs

76
Q

Describe what is being removed in the following procedures:

Partial Hysterctomy:
Total Hysterectomy:

A

Partial Hysterectomy: Just uterus

Total Hysterectomy: Uterus and cervix

77
Q

Positioning for Hysterectomy:

Vaginal Incision:
Pfannenstiel:
LAVH:

A

Vaginal Incision: Lithotomy
Pfannenstiel: Supine
LAVH: Both

78
Q

Robotic assistance was first used in the late 90’s for…?

A

1st used in gyn for fallopian tubal anastomoses (1999)

79
Q

This procedure, that is done in many older men, has reduced ocurrences of ___ due in part to the use of robot-assisted surgeries.

A

Prostatectomies:

Reduced post-op impotence

80
Q

What is one very important intra-op consideration for robotic surgeries in regard to fluid admin.

A

Fluid Restriction! (< 500 mls)
* Edematous airways can occur

DH: Principles I (50 decks)

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