FLS Flashcards
Benefits of Laparoscopy
- Faster recovery
- Cosmesis
- Less post operative pain
- Reduced adhesion
- Equivocal surgical results
Benefits of laparotomy
- Direct palpation of tissue
- Intuitive motion
- Easy abdominal access with unrestricted movement
- 3D
Surgeries that can use local anesthetic +/- mild sedation
- Diagnostic laparoscopy
- Bilateral tubal ligation
- Select inguinal hernia repair
Laparoscopic surgery physiology: CV
- Dec Cardiac output (Dec flow in IVC -> Dec preload)
- Dec splanchnic blood flow
- Dec cardiac output -> Increases afterload
- HR: Sinus tachycardia, PVC
- Inc lower extremity stasis and higher risk of VTE
Mechanism: Pressure/mechanical
Chemical = Hypercarbia
Trendelenburg
Laparoscopic surgery physiology: Pulmonary
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
CO2 accumulation
Greatest in first 15-20 minutes
Requires monitoring with end tidal CO2
Then reaches steady state
Hypotensive patient during laparoscopy
Desufflate
Check insufflator setting
Confirm adequate relaxation
Check intravascular volume status
Look for bleeding
Laparoscopy physiology: Renal
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
Hypercarbia
CO2 from pneumoperitoneum absorbed in circulation
Hypercarbia effect on BP
Increase
Hypercarbia -> Sympathetic stimulation -> Increased SVR & Pulmonary vascular resistance -> Increased BP
Hypercarbia effect on pH
Acidemia
If CO2 not cleared by compensatory ventilation
Hypercarbia effect on cardiac output
Decreased
Hypercarbia -> Acidemia -> Decrease myocardial contractility -> Decreased Cardiac output
Hypercarbia effect on HR
Tachycardia, arrhythmia
Venous flow during pneumoperitoneum
Venous flow decreased 20-40%
Vagal stimulation
Stretching of peritoneum, pelvic organ manipulation, cervical stretching with manipulation = Bradycardia
Pneumoperitoneum (CO2)
Use warm CO2 - Improves patient temperature and post operative pain
Gas embolus 0.015%
Clinically insignificant gas more common
Hypotension, Tachycardia, JVD, mill-wheel mumur
CO2 embolus
Treatment:
1. Desufflate
2. Place in left lateral Trendelenburg (prevents embolus from entering right ventricular outflow tract)
3. Aspirate from central line
Contraindications to laparoscopy (Absolute)
Inability to tolerate laparoscopy
Hypovolemic shock
Lack of proper surgeon training
Lack of institutional support
Contraindications to laparoscopy (Relative)
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
Obesity and Laparoscopy
- Dec lung compliance
- Dec abdominal wall compliance = Higher insufflation pressure
- Heavy omentum putting pressure on diaphragm
- Thick subcutaneous tissue causes tunneling and prevents motion
- Higher conversion laparotomy, longer operating times, longer hospitalization
Laparoscopy in thin patients
Elevate abdominal wall
Open/Hassan, Optic trocar
Place Veress away from midline near costic margin
Ergonomic position
10-20 degrees below eye level
Patient position: Supine
Do not abduct arms >90 degrees: Prevent brachial plexus injury
Hands to void table break
Patient positioning: Tucked arms
Pelvic surgery