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FES & FLS > FLS > Flashcards

FLS Flashcards

1
Q

Benefits of Laparoscopy

A
  1. Faster recovery
  2. Cosmesis
  3. Less post operative pain
  4. Reduced adhesion
  5. Equivocal surgical results
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2
Q

Benefits of laparotomy

A
  1. Direct palpation of tissue
  2. Intuitive motion
  3. Easy abdominal access with unrestricted movement
  4. 3D
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3
Q

Surgeries that can use local anesthetic +/- mild sedation

A
  1. Diagnostic laparoscopy
  2. Bilateral tubal ligation
  3. Select inguinal hernia repair
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4
Q

Laparoscopic surgery physiology: CV

A
  1. Dec Cardiac output (Dec flow in IVC -> Dec preload)
  2. Dec splanchnic blood flow
  3. Dec cardiac output -> Increases afterload
  4. HR: Sinus tachycardia, PVC
  5. Inc lower extremity stasis and higher risk of VTE

Mechanism: Pressure/mechanical
Chemical = Hypercarbia
Trendelenburg

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5
Q

Laparoscopic surgery physiology: Pulmonary

A

Inc minute ventilation (Min Vent = TV x RR) to expel CO2
Inc peak airway pressure
Dec Functional residual capacity
Dec pulmonary compliance
Dec residual volume
Reduced diaphragmatic excursion - Upward displacement and stiffening of diaphragm
Decreased FRS and Reserve Volume for oxygenation = Atelectasis/VQ mismatch

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6
Q

CO2 accumulation

A

Greatest in first 15-20 minutes
Requires monitoring with end tidal CO2
Then reaches steady state

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7
Q

Hypotensive patient during laparoscopy

A

Desufflate
Check insufflator setting
Confirm adequate relaxation
Check intravascular volume status
Look for bleeding

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8
Q

Laparoscopy physiology: Renal

A

Oliguria - Renal compression
UOP is unreliable indicator of volume status
Intraoperative bolus can lead to cardiac failure, pulmonary edema
Chemical: Renin & ADH release - Reabsorption of Na, H2O, K excretion
Intraoperative oliguria self limiting after a few hours

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9
Q

Hypercarbia

A

CO2 from pneumoperitoneum absorbed in circulation

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10
Q

Hypercarbia effect on BP

A

Increase
Hypercarbia -> Sympathetic stimulation -> Increased SVR & Pulmonary vascular resistance -> Increased BP

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11
Q

Hypercarbia effect on pH

A

Acidemia
If CO2 not cleared by compensatory ventilation

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12
Q

Hypercarbia effect on cardiac output

A

Decreased
Hypercarbia -> Acidemia -> Decrease myocardial contractility -> Decreased Cardiac output

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13
Q

Hypercarbia effect on HR

A

Tachycardia, arrhythmia

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14
Q

Venous flow during pneumoperitoneum

A

Venous flow decreased 20-40%

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15
Q

Vagal stimulation

A

Stretching of peritoneum, pelvic organ manipulation, cervical stretching with manipulation = Bradycardia

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16
Q

Pneumoperitoneum (CO2)

A

Use warm CO2 - Improves patient temperature and post operative pain
Gas embolus 0.015%
Clinically insignificant gas more common

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17
Q

Hypotension, Tachycardia, JVD, mill-wheel mumur

A

CO2 embolus

Treatment:
1. Desufflate
2. Place in left lateral Trendelenburg (prevents embolus from entering right ventricular outflow tract)
3. Aspirate from central line

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18
Q

Contraindications to laparoscopy (Absolute)

A

Inability to tolerate laparoscopy
Hypovolemic shock
Lack of proper surgeon training
Lack of institutional support

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19
Q

Contraindications to laparoscopy (Relative)

A

Inability to tolerate general anesthesia
Long standing peritonitis
Large abdominal or pelvic mass
Massive incarcerated ventral or inguinal hernia
Severe cardiopulmonary disease
Acute glaucoma, retinal detachment, Inc ICP, VP shunt

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20
Q

Obesity and Laparoscopy

A
  1. Dec lung compliance
  2. Dec abdominal wall compliance = Higher insufflation pressure
  3. Heavy omentum putting pressure on diaphragm
  4. Thick subcutaneous tissue causes tunneling and prevents motion
  5. Higher conversion laparotomy, longer operating times, longer hospitalization
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21
Q

Laparoscopy in thin patients

A

Elevate abdominal wall
Open/Hassan, Optic trocar
Place Veress away from midline near costic margin

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22
Q

Ergonomic position

A

10-20 degrees below eye level

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23
Q

Patient position: Supine

A

Do not abduct arms >90 degrees: Prevent brachial plexus injury
Hands to void table break

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24
Q

Patient positioning: Tucked arms

A

Pelvic surgery

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25
Q

Patient positioning: Arms out

A

Upper abdominal surgery

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26
Q

Set up: Reverse trendelenburg

A

Foot board to prevent sliding
Belt across thighs to prevent knee buckling

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27
Q

Lithotomy

A

Allen stirrups > Candy canes (Femoral nerve hyperflexion)
Knees should be at level with abdomen to allow surgeon movement (upper abdominal/colon surgery)

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28
Q

Lateral decubitus surgery

A

Renal, Adrenal
Roll in axilla on dependent side - Prevent brachial plexus injury
Bean bag to hold patient up - Can cause pressure injury
Break bed to increase space between costal margin and iliac crest

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29
Q

Modified lateral decubitus

A

Splenectomy, Nephrectomy, Adrenalectomy

Allows rotation of operating table between lateral decubitus and supine
Allow for removal of large specimens
Easy conversion to laparotomy
Avoids flank incisions - Not tolerated well

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30
Q

Abdominal entry

A
  1. Blind trocar
  2. Open/ Hasson
  3. Opti view
  4. Varess
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31
Q

Blind trocar insertion contraindication (Relative)

A
  1. Previous abdominal surgery
  2. Previous intraabdominal inflammatory process
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32
Q

Blind trocar insertion contraindication (Absolute)

A
  1. Abdominal scar from prior open surgery in vicinity
  2. Placement of trocar through mesh
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33
Q

Diagnostic Laparoscopy

A

Reason: Uncertain etiology
3 port along the left abdomen (First - LUQ)

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34
Q

Laparoscopic Liver Surgery

A

Angled/ Flexible scope, may need ultrasound

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35
Q

Anterior abdominal wall surgery

A

30 degree scope

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36
Q

Appendicitis

A

Tuck both arms
Trendelenburg + Left tilt

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37
Q

Running small bowel

A

3 ports on left side of abdomen
Screen: Right shoulder & hip

Normal bowel: Ligament of Treitz -> Ileal cecal valve
SBO: Ileal cacal valve (decompressed) -> Ligament of Treitz

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38
Q

Trauma

A

Angled scope
Tuck both arms

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39
Q

Pelvic Surgery

A

Tucked arms
0 Degree scope

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40
Q

Mediastinum

A

Arms out
0 Degree scope

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41
Q

Set up: Retroperitoneal

A

Ports along costal margin (Access to kidney and adrenals)
Above Iliac bifurcation - Modified lateral decubitus
Mobilization of colon
Below Iliac bifurcation - Supine w/ Trendelenburg

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42
Q

Use electrocautery for biopsies?

A

No - makes patholgoy suboptimal

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43
Q

Large lesions

A

Incisional biopsy

44
Q

Small lesions

A

Excisional biopsy

45
Q

FNA

A

20-22 gauge needle

46
Q

Core needle biopsy

A

14-18 gauge needle

47
Q

Biopsy forcep

A

Small peritoneal implants (incisional or excisional)

48
Q

Wedge biopsy

A

Scaple, Scissors, stapler (Incisional or excisional)

49
Q

Liver biopsy

A

Most common: Core needle, Wedge resection
DO NOT biopsy vascular lesions
Cysts do not require biopsy

50
Q

Ovary biopsy

A

Oopherectomy vs Wedge biopsy vs Forcep biopsy
Type of biopsy determined by menopausal status, concern for malignancy

51
Q

Bowel biopsy

A

Excise small lesions - Close serosa with stitch

52
Q

Laparoscopic suturing

A

Tapered needle > Cutting
Ports: 10 cm apart
Tension provided with continuous stitches (requires assistant) or locking

53
Q

Sliding square knot

A

Useful for tissue under tension
Controls suture tightening

54
Q

Intracorporeal knot tying

A

15 cm suture

55
Q

Extracorporeal knot tying

A

Suture 75 cm +
Knot pusher

56
Q

Roeder’s Knot (Endoloop)

A

End of blood vessel
Appendix
Fallopian tube
Cystic duct

57
Q

Port sizes: Needles

A

8 mm port

58
Q

Port sizes: Clips

A

8 mm , 10 mm
Good for tubular structure. Not good for bowel
Reusable - Requires reloading with each clip
Disposable - Can place multiple clips without reloading

59
Q

Port sizes: Staples

A

12 mm port
Length: 30-60 mm
Places 2-3 rows of staples on each side

60
Q

Staple sizes: White

A

Vascular: 2-2.5 mm

61
Q

Staple sizes: Blue

A

GI tract: 3-3.5 mm

62
Q

Staple sizes: Green

A

Distal stomach, Inflamed GI tract: 4-4.5 mm

63
Q

Port site bleeding

A

Suture (Keith, suture passer, spinal needle)
Clip
Foley catheter (Temporary)

64
Q

Peritoneal washing

A

100 mL NaCl
Wait 3-5 minutes before suction

65
Q

Port site closure

A

Hernia risk <5%
Open
Laparoscopic assisted
Sole laparoscopic

66
Q

Common causes of unrecognized bleeding

A
  1. Trocar injury
  2. Vessels/organs away from operative field (Liver, spleen)
  3. Venous bleeding tamponaded by pneumoneritoneum
67
Q

Post operative resolution of pneumoperitoneum

A

Peak decrease within 30 minutes
Resolution within 3 hours

68
Q

Post operative care: Nausea & Vomiting

A

Risk of aspiration
Wound breakdown
Failure of intraoperative hemostasis, tissue pedicle control

69
Q

Post operative care: Pain

A

Referred pain to the shoulder - Conversion of CO2 to carbonic acid irritating diaphragm (1-3 days post op)
Prevention: Local anesthetic, lower insufflation pressure, evacuation of pneumoperitoneum, multimodal analgesia

70
Q

Presentation of hollow viscus injury

A

Presents 1-7 days post surgery

71
Q

Solid organ injury

A

Bleeding not appreciated during operation
Pancreas injured in splenectomy, left adrenalectomy, colon surgery — Pancreatic ascites, pseudocyst development

72
Q

Bowel injury

A

0.0006 - 0.0016% (1 per 1000)

73
Q

Vascular injury

A

0.00009 - 0.005% (5 per 1000)

74
Q

Types of injuries during laparoscopic surgery

A
  1. Hollow viscus injury
  2. Solid organ injury
  3. Bowel
  4. Vascular
  5. Nerve
  6. Thermal burn
  7. Hernia
  8. Port site metastasis
75
Q

Port site metastasis

A

1%

76
Q

Types of gas supply

A

CO2, NO, Helium, Air, Argon

77
Q

Nitrous oxide

A

Advantage: Less acid/base disturbance
Less post operative pain
Inc tolerance of pneumoperitoneum without general anesthesia

Cannot be used in cases with bowel perforation - Inc fire risk

78
Q

Argon, Helium (Inert gas)

A

Advantage: Less acid/base disturbance

Disadvantage: Expensive
Inc extaperitoneal gas extavasation (Gas embolus)
Dec avalability

79
Q

CO2 - Gas supply

A

Advantage: Dec combustion
High diffusion coefficient (20x O2) -> Soluble in blood -> Eliminated in alveoli

80
Q

Dark or blurry image

A

Check fiberoptics - Hold lens up to light. Small black areas may present if damaged
Inspect lens
Moisture on eye piece

81
Q

Defogging laparoscope

A

Wipe lens with defogging agent
Heated bath or scope warming device

82
Q

Light source

A

300 W Xenon light source
Fire risk to sterile drapes

83
Q

No CO2 (gas supply)

A

Confirm tank is full - May read empty if connected to central CO2 supply
Spare CO2 gasket available
Confirm for air leaks

84
Q

No image

A

Ascertain monitor is plugged in

85
Q

Impeded laparoscopic view/loss of working space

A

Check insufflator control panel

86
Q

If measured pressure is < or = to preset pressure but flow is absent

A

Insufflator problem

  1. Wrong pressure for pneumoperitoneum
  2. Inadequate muscle relaxation
  3. Incorrect valve connection for insufflator
  4. Tubing obstruction
87
Q

Low pressure, High flow

A

Check insufflator tubing is connected
Check all port valves are closed
Check for leaking CO2 from port sites
Check for distention of bowel or foley bag (Bowel/bladder injury)

88
Q

Low pressure, absent flow

A

Power off
CO2 running low

89
Q

Blank video screen

A

Disconnected power cord
Disconnected video cable
Disconnected light cable (scope or light source)
Blown light source bulb

90
Q

Monopolar

A

Low -> High frequency

Required dispersive electrode (Bovie pad)
High resistance
Lateral spread
High energy requirement
Needs dry operative field

91
Q

Cut

A

Low voltage
Tissue desiccation due to temperature rise -> Water evaporation = Desiccation
Inc Desiccation -> Inc tissue impedance until complete -> Current stops flowing due to high resistant -> Tissue turn brown, steam, bubbles

  • Minimal lateral tissue damage
  • Limited thermal coagulation
  • Does not need direct contact
92
Q

Coagulation

A

High voltage, intermittent wave form
Tissue coagulation due to tissue heating (>60C) -> Protein denaturing -> Cool 0> Reform in new pattern -> Tissue coagulation
Rapid surface heating, shallow depth of necrosis (fulguration)

Noncontact - Relies on sparking between device and tissue

93
Q

Blend

A

Adds hemostatic effect to cutting

94
Q

Current Diversion

A

Current passes through unintentional tissue due to path of least resistance

Fix: Insulate scope
Use low voltage and power
Activate when close to target
Use bipolar
Do not use hybrid ports (plastic/metal)

95
Q

Capacitive coupling

A

Transfer of current from active electrode (scope, port) —> Insulator —> Passive electrode (capacitor)
Needs 2 conductors to be separated by insulator
Metal object holds charge until it can release on another object causing inadvertent injury

Example: Metal port with plastic screw
Fix: Using plastic ports or all metal trocars

96
Q

Direct coupling

A

Transfer of current from active electrode to metal

97
Q

Narrow return circuit

A

Current passes through ligated tissue in logarithmic fashion -> Excessive tissue heating -> Delayed perforation

If the largest part of tissue is touches, the most narrow region with be affected

98
Q

Bipolar

A

Low resistance circuit
Tissue placed between both electrodes
Does not need dispersive electrode (bovie pad)
Less lateral spread
Lower energy requirement
Works in wet environment

99
Q

Disadvantage of Bipolar

A

Inadvertent thermal injury to adjacent organs
Inadvertent cutting of patent vessels before adequate sealing
Device will not work if metal within jaws (staples, clips)

100
Q

Disadvantage of Monopolar

A

Direct coupling
Capacitive coupling
Narrow return circuit

101
Q

Port placement if prior surgery, umbilical hernia, mesh

A

Palmar point

102
Q

Laparoscopy in pregnancy

A

2nd trimester

103
Q

Bleeding staple line after use on omentum

A

Staples too large

104
Q

Repairing enterotomy

A

Leave long tails for stay sutures
Absorbable sutures

105
Q

Serosal bleeding

A

Oversew

106
Q

Ultrasonic energy (Harmonic)

A

Mechanical energy
- Electric energy -> High frequency vibration (50,000 Hz)
- Passive blade (hold tissue) and active blade (transfers heat)
- Higher power = more cutting
- Lower power = more coagulation

FES & FLS (3 decks)

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