FLS

Question 1

FLS equipment checklist

Answer 1

anesthesia, electronic table, two monitors, suction, electrosurgical unit, grounding pad, light source, insufflator, scalpels, towel clips, veress needle/hasson, gas insufflation tubing, fiber-optic cable light source, retractors, trocars

Question 2

considering a small room, how might the table need to be positioned?

Answer 2

diagonally

Question 3

if C arm is used, where should electronic set up be?

Answer 3

furthest away from door to clear path

Question 4

if the carbon dioxide cylinder tubing does not fit into the insufflator, what could it mean?

Answer 4

do not force it, the cylinder may contain a separate type of gas (O2)

Question 5

how do you set-up for a laparoscopic procedure once patient is prepped and draped?

Answer 5

connect the light cable and camera to the scope, focus the scope and white balance it, warm the laparoscope, check the Veress needle/Hasson stay sutures, close stopcocks, check sealing caps, assure free movements of instruments

Question 6

what is the of CO2 insufflation at low flow and high flow for a Veress needle?

Answer 6

1 L/min for low

2-2.5 L/min for high

Question 7

what does a pressure reading >3 mmHg mean if the insufflator is on but not attached?

Answer 7

blockage in the tubing

Question 8

what should the intra-abdominal pressure limit be for most surgeries?

Answer 8

12-15 mm Hg, greater pressures can decrease visceral blood flow, but may also be necessary for visualization in an obese patient

Question 9

describe the Veress needle technique

Answer 9

10-20 degrees Trendelenburg, stab incision to either superior or inferior portion, pass the Veress at a 45-degree angle, pass 2 points of resistance, “click” into peritoneal cavity

Question 10

once a Veress needle is placed, how do you test if it is in the correct position

Answer 10

aspirate for blood/feces/urine, flush w/ NS, aspirate for NS, allow fluid to “fall” into cavity from hub of syringe, advance 1-2 cm and check for resistance

Question 11

with a Veress needle placed initially, what should abdominal pressure register as when insufflation is started at low flow (1L/min)

Answer 11

<10 mmHg

Question 12

if high pressures are noted w/ initial insufflation through a Veress needle, what should be done?

Answer 12

high pressure is >10 mmHg; rotate the needle, make another pass w/ the Veress, do not continue insufflation

Question 13

during initial insufflation with a Veress needle, what could it mean to have CO2 bubbles coming up around the needle?

Answer 13

preperitoneal placement

Question 14

monitor the patient’s pulse and blood pressure closely for during the early phase of insufflation for what insufflation specific reason?

Answer 14

a vagal reaction

Question 15

during initial insufflation w/ a Veress, if the pulse falls precipitously, what should be done?

Answer 15

allow the CO2 to escape, administer atropine, and reinstitute insufflation slowly after a normal heart rate has returned

Question 16

what is the next step after insufflation of about 1 L of CO2

Answer 16

change from low flow to high flow

Question 17

in general, patients with prior low vertical midline scars should be approached through a trocar placed where?

Answer 17

at the lateral border of the rectus muscle in either the left or right upper quadrant

Question 18

with previous upper vertical midline incision or multiple incisions near the midline, where can a trocar be placed?

Answer 18

right lower quadrant site may be appropriate

Question 19

what exam and risk-reducing steps should be taken if placing a trocar in the upper abdomen?

Answer 19

percuss the positions of the liver/spleen, place the trocar two fingerbreadths below the costal margin, place NGT to decompress stomach

Question 20

when placing a non-midline trocar in the lower abdomen, what is the preferred location? what risk-reducing steps should be taken?

Answer 20

right lower quadrant, near McBurney’s point, is preferable to the left because many individuals have congenital adhesions between the sigmoid colon and anterior abdominal wall; decompress the bladder

Question 21

describe how you would place a Hasson trocar?

Answer 21

2-3 cm incision, dissect the underlying tissue to reveal fascia, place S-retractors, Allis forceps can be used to grasp and raise the fascia, incise the fascia sharply, place stay sutures, hemostasts can be used grasp and raise the peritoneum, divide this sharply, insert the Hasson

Question 22

in regards to trocar placement, what is the presentation and management of bleeding from the abdominal wall?

Answer 22

continuous dripping into the peritoneum or delayed hematoma, usually from inf epigastric; manage with direct pressure or suture ligation

Question 23

in regards to Veress placement, what is the presentation and management of visceral injury?

Answer 23

if yellow/cloudy fluid is aspirated through a Veress, it may be d/t bowel injury; d/t small caliber of Veress, can simply remove and reattempt at another site w/ laparoscopic evaluation of the bowel later

Question 24

in regards to laparoscopic trocar placement, what is the presentation and management of visceral injury?

Answer 24

formal open laparotomy and bowel repair or resection; laparoscopic suture repair of the bowel injury; laparoscopic resection of the injured bowel and reanastomosis; minilaparotomy, using an incision just large enough to exteriorize the injured bowel segment for repair or resection and reanastomosis

Question 25

in regards to Veress placement, what is the presentation and management of vascular injury?

Answer 25

if Veress, remove and repuncture at another site, then re-evaluate laparoscopically to look for an expanding retroperitoneal hematoma; if there is a central or expanding retroperitoneal hematoma, laparotomy with retroperitoneal exploration is mandatory to assess for and repair major vascular injury; hematomas of the mesentery and those located laterally in the retroperitoneum are generally innocuous and may be observed

Question 26

in regards to trocar placement, what is the presentation and management of vascular injury?

Answer 26

if there is a rush of blood through the trocar with associated hypotension, leave the trocar in place (to provide some tamponade of hemorrhage and assist in identifying the tract) and immediately perform laparotomy to repair what is likely to be an injury to the aorta, vena cava, or iliac vessels