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FLS Flashcards

1
Q

How do the types of laparoscopes vary?

A

Diameter (2-10mm), length (30-45cm), and degree (0, 30, 45)

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2
Q

What is the Hopkins rod lens system in a laparoscope? What is its limitations?

A

Susceptible to rod damage with use and processing, reduced light reaches the end of the endoscope

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3
Q

What is an alternative method to capture an image via laparoscope besides the Hopkins rod lens system?

A

Have an imaging chip at the end of the scope, no light is lost as the image travels back

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4
Q

When is a zero-degree laparoscope preferable?

A

When working in a small area where you need to directly visualize the field: pelvis, high in mediastinum

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5
Q

When is a 30 or 45-degree scope preferable?

A

allows you to see more breadth of the field

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6
Q

Why do you need standard open instruments when performing lap surgery?

A

to help open and close port sites as well as possible conversion to open

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7
Q

How can you check a rod-lens laparoscope for damage?

A

hold the lens end up to the light and look at the light cord attachment site for black spots indicating damage. Look at the lens end for obvious damage. Eval for moisture between scope and camera causing blurred image

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8
Q

Why does the laparoscope fog?

A

changes in temp and humidity between room and in the body

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9
Q

How can you prevent a foggy image?

A

anti-fogging solution, allow it to dry before entering the abdomen, rinse the scope in hot water, keep scope in an insulated bottle, or keep scope in a heated bath

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10
Q

what do you do if the lens is smudged?

A

wipe on clean tissue (liver, bowel), remove scope and clean on gauze + clean the mechanical seal of the port with gauze

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11
Q

what is the most commonly used gas for laparoscopy and why?

A

CO2 - readily available, inexpensive, non-combustible

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12
Q

What should you have available if your gas supply comes from a tank?

A

An additional full tank with appropriately sized wrench attached to the insufflator + supply of new gaskets for the tanks

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13
Q

what is the clincial difference in using warmed and humidified CO2 for laparoscopy and when is it relevant?

A

significant reductions in postop pain, not significant for operations lasting less than 90 minutes

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14
Q

what does the insufflator do?

A

controls the flow of CO2 gas into the abdomen

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15
Q

how fast does a high-flow insufflator deliver gas? (rate)

A

10-15 LPM

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16
Q

what are the two controllable panels on the insufflator

A

gas flow rate and preset max pressure in the abdomen

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17
Q

what is displayed on the insufflator?

A

current abdominal pressure and amount of gas used

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18
Q

what is the reason a filter is attached to the gas line?

A

to prevent patient’s body fluids refluxing back into the insufflator, risk of transmission to the next patient

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19
Q

how many suction devices do you need in the room at a minimum?

A

3: one for anesthesia, one for NGT, and one for the operation

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20
Q

how can using a suction device affect pneumoperitoneum and how can this be prevented

A

excessive suctioning can decrease pneumoperitoneum, prevent by fully immersing the suction catheter into the liquid being suctioned

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21
Q

What are the four components of the video tower?

A

light source, camera control unit, video monitor, insufflator

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22
Q

what is the most common light source?

A

300W Xenon lamp

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23
Q

why should you connect the light source to the laparoscope prior to turning it on?

A

to avoid blinding OR staff and risk of fire if light cord contacts OR drapes

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24
Q

what is used to help light travel from the light source to the laparoscope? What is it made of?

A

A light cable made of fiberoptic elements

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25
Q

How do you check a light cord for damage

A

hold one end of the cord to light and the other to your eye to look for black dots, which indicate broken fibers

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26
Q

How can you capture still images / video from laparoscopic surgery for inclusion in chart / literature?

A

digital capture that saves images to CD, DVD, hard disk, or other removable drive. Printers can be used as well.

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27
Q

What is the “Picture in Picture” Effect and when is it most useful?

A

Allows both images from the laparoscope and additional imaging to be projected on the same screen. Useful if you need to use intraoperative Doppler, ultrasound, or endoscopy

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28
Q

What are the 9 preoperative precautions the circulator RN must perform prior to the patient entering the OR?

A

1) Assure OR TABLE is properly set up for the procedure, ensure tilt mechanism is functional, have bean bag mattress avaible if needed, have lead shielding available if fluoroscopy is planned, have foot board ready if needed. 2) check all POWER SOURCES are connected and switched on. 3) check for adequate CO2 available, extra tanks prn, and insufflator alarm is functional. 4) BOVIE: proper audio alarm function, grounding pad available. 5) VIDEO monitors operational and positioned appropriately, test pattern appears before monitor plugged in. 6) SUCTION/IRRIGATION - canister set up, irrigation bag available if needed. 7) SCDs, Foley, NGT available. 8) video documentation with CD/DVD available. 9) minimize floor clutter

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29
Q

What are the 8 preop precautions the circulator RN must perform after the patient enters the OR?

A

1) preop timeout to verify pt ID and procedure being performed. 2) assist in proper patient positioning and padding. 3) safety strap to patient. 4) after induction, apply grounding pad to patient and attach to electrocautery unit. 5) after pt prepped/draped, connect all lines from sterile field (camera cord, light source, suction/irrigation, cautery, CO2 tubing). Verify suction function/connection. 6) position foot pedals prn (U/S, cautery). 7) Apply SCDs. 8) complete checklist of Pt Prep for Surgery

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30
Q

What 7 preop precautions should the Scrub Tech/RN perform after the patient enters the room?

A

1) check fx of reusable instruments: movement of instrument handles and jaws, sealing caps for cracked rubber, instrument cleaning channel screw caps in place. 2) Check Veress needle: proper plunger/spring action, easy flushing through stopcock/needle channel. 3) if Hasson entry - check for available stay sutures and retractors. Availability of accessory trocars. 4) close all stopcocks on all ports. 5) check laparoscope for clarity / vision. 6) draw up local anesthetic and injection syringe. 7) if cholangiography anticipated, mix and dilute cholangiogram contrast solution. Evacuate cholangiography tubing, syringe, and catheter of all bubbles.

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31
Q

Name nine possible reasons for poor insufflation / loss of pneumoperitoneum

A

CO2 tank empty / low volume; accessory port stopcock open; leak in sealing cap / reducer; excessive suctioning pressure; loose, disconnected, or kinked insufflation tubing; Hasson stay sutures loose; CO2 flow rate too low; valve on CO2 tank not fully open; leak at skin where port enters cavity

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32
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 CO2 tank empty / low volume

A

change tank

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33
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 accessory port stopcock open

A

inspect all accessory ports. Open or close stopcocks prn.

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34
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 leak in sealing cap / reducer

A

change cap or stopcock cannula

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35
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 excessive suctioning pressure

A

allow time to reinsufflate, lower suction

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36
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 loose, disconnected, or kinked insufflation tubing

A

tighten connections or reconnect at source / port or unkink tubing

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37
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 Hasson stay sutures loose

A

replace or secure sutures

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38
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 CO2 flow rate too low

A

adjust flow rate

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39
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 valve on CO2 tank not fully open

A

use valve wrench to open fully

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40
Q

What do you do for poor insufflation / loss of pneumoperitoneum 2/2 leak at skin where port enters cavity

A

apply penetrating towel clip or suture around port

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41
Q

What are five possible causes of excessive pressure required for insufflation (initial or subsequent)?

A

Veress needle/cannula is not in the peritoneal space; occlusion of tubing (kinking, table joints, etc.); CO2 port stopcock is turned off; patient is “light” on anesthesia; morbidly obese patient

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42
Q

What do you do for excessive insufflation pressure 2/2 Veress needle/cannula is not in the peritoneal space

A

reposition needle or cannula under visualization if possible

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43
Q

What do you do for excessive insufflation pressure 2/2 occlusion of tubing (kinking, table joints, etc.);

A

inspect full length of tubing

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44
Q

What do you do for excessive insufflation pressure 2/2 CO2 port stopcock is turned off

A

fully open stopcock

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45
Q

What do you do for excessive insufflation pressure 2/2 patient is “light” on anesthesia

A

communicate to anesthesia

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46
Q

What do you do for excessive insufflation pressure 2/2 morbidly obese patient

A

use a longer Veress needle

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47
Q

What are 10 possible reasons for inadequate lighting during lap surgery?

A

light is dim; light is on standby; loose connection at source or scope; light is on “manual-minimum”; fiber optics are damaged; automatic iris adjusting to bright reflection from instrument; monitor brightness is turned down; room brightness floods monitors; bulb is burned out; scope is dark

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48
Q

What should you do for inadequate lighting during lap surgery 2/2 light is dim

A

increase gain, check scope for adequate fiberoptics, replace light cable, laparoscope and/or camera

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49
Q

What should you do for inadequate lighting during lap surgery 2/2 light is on standby

A

take light off standby

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50
Q

What should you do for inadequate lighting during lap surgery 2/2 loose connection at source or scope

A

adjust connection

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51
Q

What should you do for inadequate lighting during lap surgery 2/2 light is on “manual-minimum”

A

go to “automatic”

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52
Q

What should you do for inadequate lighting during lap surgery 2/2 fiber optics are damaged

A

replace light cable

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53
Q

What should you do for inadequate lighting during lap surgery 2/2 automatic iris adjusting to bright reflection from instrument

A

reposition instruments or switch to “manual”

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54
Q

What should you do for inadequate lighting during lap surgery 2/2 monitor brightness turned down

A

readjust brightness settings, adjust gain

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55
Q

What should you do for inadequate lighting during lap surgery 2/2 room brightness floods monitors

A

dim room lights

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56
Q

What should you do for inadequate lighting during lap surgery 2/2 bulb is burned out

A

replace bulb

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57
Q

What should you do for inadequate lighting during lap surgery 2/2 scope is dark

A

check white balance

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58
Q

What are three reasons you could have a poor quality picture with lap surgery?

A

flickering electrical interference / poor cable shielding; color problems; glare not caused by lighting

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59
Q

What should you do for poor quality picture 2/2 flickering electrical interference / poor cable shielding

A

replace cautery cables, switch camera head, make sure cables don’t cross, use different plug points

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60
Q

What should you do for poor quality picture 2/2 color problems

A

white balance camera, check chrome on monitor, check printer/VCR/digital capture cables

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61
Q

What should you do for poor quality picture 2/2 glare not caused by lighting

A

check for loose cables not plugged in

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62
Q

What are two reasons lighting could be too bright during lap surgery?

A

light is on “manual - maximum”; monitor brightness is turned up

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63
Q

What should you do if lighting is too bright 2/2 light is on “manual - maximum”

A

“Boost” on light source is activated - go to “automatic and deactivate “boost”

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64
Q

What should you do if lighting is too bright 2/2 monitor brightness is turned up

A

readjust setting

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65
Q

What are five reasons there is no picture on the monitor during lap surgery?

A

camera control / other components (VCR, printer, light source, monitor) are not turned “on”; cable connector between camera control unit and/or monitors are not attached properly; cables between monitors are not connected; input select button on monitor doesn’t match “video in” choice; input selection button on monitor or video peripherals (VCR/digital capture/printer) are not selected

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66
Q

What should you do if there is no picture on the monitor 2/2 camera control / other components (VCR, printer, light source, monitor) are not turned “on”

A

make sure all power sources are plugged in and turned on

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67
Q

What should you do if there is no picture on the monitor 2/2 cable connector between camera control unit and/or monitors are not attached properly

A

cable should run from “video out” on camera control unit to “video in” on primary monitor. Use compatible cables for camera in and light source.

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68
Q

What should you do if there is no picture on the monitor 2/2 ables between monitors are not connected

A

cable should run from “video out” on primary monitor to “video in” on secondary monitor

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69
Q

What should you do if there is no picture on the monitor 2/2 input select button on monitor doesn’t match “video in” choice

A

assure matching selection

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70
Q

What should you do if there is no picture on the monitor 2/2 input selection button on monitor or video peripherals (VCR/digital capture/printer) are not selected

A

adjust input selection

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71
Q

What are two reasons that you could have poor quality picture with fogging/haze?

A

condensation on lens from cold scope entering warm abdomen; condensation on scope eyepiece / camera lens

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72
Q

What should you do with poor quality picture with fogging/haze 2/2 condensation on lens from cold scope entering warm abdomen

A

use anti-fog solution or hot water, wipe lens externally

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73
Q

What should you do with poor quality picture with fogging/haze 2/2 condensation on scope eyepiece / camera lens

A

detach camera from scope (or camera from coupler); inspect and clean lens as needed

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74
Q

what are three reasons you could have poor quality picture with flickering / electrical interference

A

moisture in camera cable connecting plug; poor cable shielding; insecure connection of video cable between monitors

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75
Q

what should you do with poor quality picture with flickering / electrical interference 2/2 moisture in camera cable connecting plug

A

use suction or compressed air to dry out moisture (don’t use cotton tip applicators on multi-pronged plug)

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76
Q

what should you do with poor quality picture with flickering / electrical interference 2/2 poor cable shielding

A

move electrosurgical unit to different circuit or away from video equipment, make sure cables do not cross, switch camera head; replace cables as necessary

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77
Q

what should you do with poor quality picture with flickering / electrical interference 2/2 insecure connection of video cable between monitors

A

reattach video cable at each monitor

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78
Q

What are three reasons for poor quality picture with blurring / distortion?

A

incorrect focus, cracked lens/internal moisture, too grainy

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79
Q

What should you do for poor quality picture with blurring / distortion 2/2 incorrect focus

A

adjust camera focus ring

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80
Q

What should you do for poor quality picture with blurring / distortion 2/2 cracked lens / internal moisture

A

inspect scope / camera, replace if needed

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81
Q

What should you do for poor quality picture with blurring / distortion 2/2 too grainy

A

adjust enhancement and/or grain setting for units with this option

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82
Q

What are four reasons for inadequate suction / irrigation?

A

occlusion of tubing (kinking, blood clot, etc.); occlusion of valves in suction / irrigator device; not attached to wall suction; irrigation fluid container not pressurized

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83
Q

What should you do for inadequate suction / irrigation 2/2 occlusion of tubing (kinking, blood clot, etc.)

A

inspect full length of tubing. Detach from instrument and flush with sterile saline prn.

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84
Q

What should you do for inadequate suction / irrigation 2/2 occlusion of valves in suction / irrigator device

A

detach tubing, flush device with sterile saline

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85
Q

What should you do for inadequate suction / irrigation 2/2 not attached to wall suction

A

inspect and secure suction & wall source connector

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86
Q

What should you do for inadequate suction / irrigation 2/2 irrigation fluid container not pressurized

A

inspect pressure bag / compressed gas source, connector, pressure dial setting

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87
Q

What are six reasons for absent or “weak” cauterization

A

patient not grounded properly; connection between electro-surgical units and instrument loose; foot pedal or hand switch not connected to electrosurgical unit; wrong output selected; connected to wrong socket on electrosurgical unit; instrument insulation failure outside of surgeons view

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88
Q

What should you do for absent / weak cauterization 2/2 patient not grounded properly

A

assure adequate grounding pad contact

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89
Q

What should you do for absent / weak cauterization 2/2 connection between electro-surgical units and instrument loose

A

inspect both connecting points

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90
Q

What should you do for absent / weak cauterization 2/2 foot pedal or hand switch not connected to electrosurgical unit

A

make connection

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91
Q

What should you do for absent / weak cauterization 2/2 wrong output selected

A

correct output choice

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92
Q

What should you do for absent / weak cauterization 2/2 connected to wrong socket on electrosurgical unit

A

check that cable is attached to endoscopic socket

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93
Q

What should you do for absent / weak cauterization 2/2 instrument insulation failure outside of surgeons view

A

use new instrument and inspect insulation

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94
Q

what does a low pressure and high flow rate on the insufflator indicate?

A

leak in the insufflation circuit

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95
Q

what should you suspect if the foley bag begins to inflate?

A

insufflation of bladder

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96
Q

what should you suspect if you have a small working space and dilation of bowel?

A

insufflation of bowel

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97
Q

what should you do if there is a loss of working space and no flow on the insufflator?

A

make sure the power is on and the insufflator is not in standby mode

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98
Q

what are the two choices of delivery of electrocautery to the patients?

A

monopolar or bipolar instruments

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99
Q

how does the monopolar current flow?

A

from the wall source, through the instrument, grounded by the patient

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100
Q

what two processes occur to tissue to allow electrocautery to assist with hemostasis

A

protein coagulation and tissue dessication. You get fibrous binding of dehydrated and denatured cells and vessel endothelium

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101
Q

Define current density. What is it directly and indirectly proportional to?

A

the amount of current flowing through a cross-sectional area of tissue. directly proportional to applied power (amps), inversely proportional to tissue resistance and area of tissue through which the current must travel (cm2)

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102
Q

where should the grounding pad NOT be placed on the patient?

A

should not be bent or placed on hairy skin, bony prominences, or scars b/c they decrease contact surface area and = increased current density and increased risk of burns

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103
Q

what are the three modes of monopolar electrocautery?

A

cut, coag, or blended

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104
Q

what is the goal of cutting mode and how does it work?

A

quickly heat tissue, vaporize, cause cells to explode. heat is dissipated in the steam, causing minimal lateral thermal tissue damage and poor thermal coagulation

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105
Q

what is the goal of coagulation mode and how does it work?

A

rapid surface heating with superficial eschar formation and shallow depth of necrosis, this process is aka fulguration. This is seen with an intermittent, high-voltage waveform, minimal cutting, relies on sparking between electrode and tissue

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106
Q

What does the blend mode accomplish

A

blends the cutting and coag modes to allow the surgeon to adjust for desired tissue effects

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107
Q

What is “current diversion”?

A

Current, following the path of least resistance, current passes through unintentional tissue. Relevant to laparoscopic surgery b/c the entire field is not always in the surgeons view.

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108
Q

name eight precautions you can take to minimize risk of electrosurgical injury during lap surgery

A

1) inspect insulation carefully; 2) use lowest possible power setting; 3) use lowest voltage waveform possible; 4) use brief intermittent activation rather than prolonged activation; 5) do not activate unless in proximity to target tissue; 6) do not activate in close proximity or direct contact with another instrument; 7) use bipolar instrumentation when appropriate; 8) do not use hybrid laparoscopic ports that mix metal with plastic

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109
Q

What is “Capacitive Coupling”?

A

transfer of current from active electrode through its insulation through passive electrode. There must be two conductors separated by an insulator for this to occur and may result in burns from the passive electrode.

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110
Q

What happens with capacitive coupling if the passive electrode is in constant contact with adjacent tissue

A

no burns because this allows the passive electrode to release charge through the tissue to the ground without holding onto/building up the charge

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111
Q

How can Capacitive Coupling occur with another laparoscopic instrument?

A

When the electrocautery instrument comes into contact with another insulated instrument. Particularly dangerous if the second instrument is not in constant contact with tissue, allows the instrument to store energy –> means that it will discharge next time it touches tissue –> tissue injury

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112
Q

What is Direct Coupling and how can it result in tissue injury?

A

when electrocautery touches metallic portion of another instrument, charge goes down through instrument to any tissue its touching. With laparoscopes in particular, can result in damage to tissue outside the field of view.

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113
Q

What is a Narrow Return Circuit and how can it result in tissue injury?

A

if monopolar electrocautery applied to ligated tissue, the current will pass through the smaller ligated area with increased current density –> may result in delayed tissue blowout

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114
Q

How does bipolar cautery differ from monopolar in terms of current flow, patient prep, and danger to surrounding tissues?

A

Bipolar has the current flow between the two electrodes in the field, so only the tissue in between has electric flow through it. No need for grounding pad and reduced risk of damage to surrounding tissue (lower energy requirement, less risk of coupling).

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115
Q

Name three potential hazards of bipolar tissue sealing devices

A

inadvertant thermal injury; inadvertant cutting off patent vessels before adequate sealing; improper device function if metal is contained within the jaws (ie clips or surgical staples)

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116
Q

what type of energy does ultrasonic coagulation rely on to produce its effects?

A

mechanical energy –> heating through high frequency ultrasonic vibration

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117
Q

how does sealing occur with ultrasonic coagulation in terms of tissue in between the jaws of the instrument?

A

when the tissue is in between the vibrating and heated metallic jaw (active blade) and the passive plastic jaw (acts as a backstop to hold tissue against the active blade

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118
Q

what is the most common use of the ultrasonic coagulation

A

ultrasonic shears

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119
Q

what is the danger of injury to surrounding tissue with ultrasonic coagulation with shears and what can you do to prevent injury?

A

the passive jaw does not transfer energy but the unprotected active jaw will transfer energy so you need to be sure its not touching other tissue. Be aware of the contact points, grab the target tissue and elevate it, and keep the active blade upward.

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120
Q

What is the frequency of oscillation of the ultrasonic coagulation?

A

50,000 Hz (x/second)

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121
Q

What are the effects of different power settings with ultrasonic coagulation?

A

lower power settings: hemostasis. Higher power settings: cutting

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122
Q

what should you consider with patient positioning if they will require X-rays during surgery?

A

make sure you can fit the C-arm or plate under the patient during surgery

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123
Q

where should monitors be placed during surgery and why?

A

at or below eye level to reduce strain

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124
Q

where should the insufflator be placed during surgery and why?

A

in a location where surgeon and assistants can view it during the procedure

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125
Q

where should the surgeon stand and what should their hand/arm/shoulder position be?

A

opposite to the operative field, shoulders within 30 degrees of body, forearm at 60 to 120 degrees, wrist slightly pronated, thumbs up

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126
Q

what are six important aspects of medical history to obtain preop?

A

1) prior abdominal / pelvic surgery; 2) prior abdominal radiation - including site; 3) hip prosthesis/other prosthetic device (affects positioning); 4) pulmonary / cardiac disease; 5) previous DVT / coagulation disorders; 6) anesthetic complications from prior surgeries

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127
Q

what patient home medications are important to know about preop

A

steroids, immunosuppressants, pulm/cardiac meds, anticoagulation (hold coumadin 3 days prior), NSAIDS (don’t need to hold)

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128
Q

what pt allergies are important to know about preop

A

meds (local anesthetics), skin prep (betadine)

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129
Q

define ASA class I

A

no organic, physiologic, biochemical, or psychiatric disturbance

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130
Q

define ASA class II

A

mild to moderate systemic disease, due either to surgical condition or to a concomitant disease

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131
Q

define ASA class III

A

severe systemic disease that limits the patients activity and may / may not be related to the reason for surgery

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132
Q

define ASA class IV

A

severe systemic disturbances that markedly limit the patient and are life threatening with or without surgery

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133
Q

define ASA class V

A

moribund patient who has little chance for survival but is submitted to surgery as last resort (resuscitative effort)

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134
Q

which ASA classes cannot tolerate lap surgery and why?

A

ASA IV and V cannot usually tolerate the decreased venous return, decreased diaphragmatic excursion, and hyperventilation a/w pneumoperitoneum

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135
Q

Name four absolute contraindications to lap surgery

A

inability to tolerate laparotomy, hypovolemic shock, lack of proper surgeon training/experience, lack of appropriate institutional support

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136
Q

name five relative contraindications to lap surgery

A

inability to tolerate general anesthesia, long-standing peritonitis, large abdominal / pelvic mass, massive incarcerated ventral / inguinal hernias, severe cardiopulmonary disease

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137
Q

What preop precautions should you take for visceral arterial aneurysm?

A

increased risk of injury with trocar insertion

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138
Q

What preop precautions should you take for previous abdominal surgery?

A

pt may have extensive adhesions, increased risk of enterotomy, do not insert Veress needle to close to previous scar

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139
Q

What preop precautions should you take for history of peritonitis?

A

higher risk of extensive adhesions and increased risk of enterotomy

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140
Q

What preop precautions should you take for umbilical abnormalities? (mass, existing hernia, or history of previous umbilical hernia / ventral hernia repair)

A

difficulty gaining access intraabdominally or closing fascia. Avoid blind techniques near umbilicus to gain access to abdomen

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141
Q

What preop precautions should you take for previous ventral hernia repair with mesh? Why is this particularly important for laparoscopic ventral hernia repair?

A

Risk of injury with trocar insertion, extensive adhesions, difficulty closing abdominal wall, risk of infection. If previous lap ventral hernia repair with mesh, you may not be able to see the scars. You should never attempt entering the abdomen through previous mesh.

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142
Q

What preop precautions should you take for pts with hepatosplenomegaly?

A

increased risk of solid organ injury or poor exposure

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143
Q

What preop precautions should you take for pts with cirrhosis?

A

increased risk of ascites leak and bleeding. Should attempt to medically control ascites prior to elective lap surgeries.

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144
Q

What preop precautions should you take for intestinal obstruction

A

bowel dilation increases risk of enterotomy and decreases visualization

145
Q

What preop precautions should you take for pregnancy

A

precautions to avoid entry to the gravid uterus and optimize for physiology of the pregnant patient

146
Q

What preop precautions should you take for thin body habitus

A

less space between intraabdominal organs and anterior abdominal wall - especially important with blind insertion

147
Q

What are five relative contraindications to lap chole?

A

gallbladder cancer, portal HTN, cirrhosis, acute cholecystitis, and Mirizzi syndrome

148
Q

What are two relative contraindications to lap appy?

A

phlegmon, large abscess

149
Q

What are four relative contraindiations to lap colectomy?

A

large fixed mass, dense pelvic adhesions, massive bowel dilation, and T4 tumors

150
Q

what are three relative contraindications to emergency laparoscopy?

A

longstanding peritonitis, hemodynamic instability partially correctable with resuscitation, massive bowel dilation

151
Q

what are two relative contraindications to pelvic laparoscopy?

A

large, fixed masses; inability to tolerate Trendelenburg postion

152
Q

what are two relative contraindications to lap foregut procedures?

A

previous gastric operation, especially at GE junction; hepatosplenomegaly

153
Q

What are five relative contraindications to lap antireflux surgery?

A

esophageal shoreting, epihtelial dysplasia, previous gastric surgery (especially operations at the GE junction), liver enlargement, and large hiatal hernias

154
Q

Wha are five relative contraindications to lap hernia repair

A

large, chronically incarcerated hernias; acutely incarcerated hernias requiring bowel resection, need for removal of large prosthetics; need for skin graft removal or large scar revision

155
Q

Name 9 conditions that are commonly mistaken as contraindications to laparoscopy

A

diaphragm injury, GI bleed, perforated viscus, bowel obstruction, abdominal trauma intrauterine/ectopic pregnancy, obesity, COPD, renal insufficiency

156
Q

When should you consider laparoscopy and/or thoracoscopy for trauma?

A

only when there are no life-threatening injuries to the patient and they do not have an uncorrectable hemodynamic instability. laparoscopy can determine if there is peritoneal violation and injury after penetrating abdominal wounds.

157
Q

What is the initial imaging test of choice in pregnant patients?

A

ultrasound is safe and effective in identifying etiology of acute abdominal pain.

158
Q

What is your ddx for the pregnant patient with acute abdominal pain:

A

adnexal mass, torsion, placental abruption, placenta previa, uterine rupture, fetal demise, sx cholelithiasis, cholecystitis, appendicitis.

159
Q

what should be the limit of ionized radiation exposure to the fetus and why?

A

limit cumulative radiation to 50-100 mGy during pregnancy to reduce risk of teratogenesis and childhoood leukemia

160
Q

how much ionized radiation is associated with radiographs?

A

1-3 mGy

161
Q

how much ionized radiation is a/w a CT pelvis?

A

30 mGy

162
Q

when should a CT scan be used in pregnancy?

A

may be used in emergency settings but is not the initial test of choice

163
Q

what is the role of MRI in abdominal imaging in pregnancy

A

MRI without IV gadolinium can be performed at any stage of pregnancy and is preferred over CT for diagnosis of non-obstetric abdominal pain in gravid patients

164
Q

why should you avoid gadolinium in the pregnant patient

A

IV Gadolinium crosses the placenta and may cause teratogenesis

165
Q

when and how can intraop cholangiography be used in the pregnant patient

A

can use during surgery, shield the lower abdomen to protect the fetus

166
Q

what are two alternatives to intraop cholangiogram in the pregnant patient

A

EUS, choledochoscopy

167
Q

when is diagnostic laparoscopy indicated in the pregnant patient

A

start with imaging, if its unavailable or inconclusive, can move on to dx lap. Be careful bc it can have increased risk of preterm labor and fetal demise.

168
Q

what are the benefits of laparoscopy in pregnant compared to nonpregnant patients

A

similar benefits between these two patient populations: less postop pain, reduced ileus, reduced LOS, faster return to work, reduced wound complications

169
Q

how should you position the gravid patient and why?

A

Gravid patients beyond the first trimester should be placed in full /partial left lateral decub to minimize compression of the IVC

170
Q

where and how should you access the gravid abdomen?

A

use Veress, Hasson, or optical trocar technique via a subcostal approach. Can use u/s guidance to avoid uterine injury.

171
Q

what intraabdominal insufflation pressure can be used in the pregnant patient?

A

10-15mmHg, adjust for patient physiology

172
Q

How should you monitor intraop CO2 in the gravid patient?

A

via capnography (ETCO2)

173
Q

what DVT prophylaxis should be used in lap surgery for the pregnant patient?

A

SCDs, early ambulation. Can use unfractionated heparin if needed.

174
Q

What is the recommended treatment of symptomatic gallbladder disease in the pregnant patient and why

A

Treat with lap chole regardless of trimester. If gallbladder dz remains uncomplicated, rates of spont abortion and preterm labor are similar between op and nonop management. If pts have recurrent symptoms and develop complicated disease (acute cholecystitis, cholangitis, gallstone pancreatitis) can result in higher rates of preterm labor and fetal loss

175
Q

what is the recommended treatment for choledocholithiasis in pregnancy?

A

preop ERCP with sphincterotomy then lap chole with lap CBD exploration or postop ERCP

176
Q

what is the treatment of choice for pregnant patients with acute appendicitis?

A

lap appy , very low rates of preterm labor and fetal demise

177
Q

what type of imaging reduces the negative exploration rate for suspected appendicitis in pregnant patients?

A

MRI reduces the negative exploration rate by 50%

178
Q

how should you manage a pregnant patient who requires a lap adrenalectomy, nephrectomy, or splenectomy?

A

can be performed safely during pregnancy, but if it can be delayed until after childbirth, it should be

179
Q

in a pregnant patient, what is the management of symptomatic ovarian cystic masses that are less than 6cm and u/s is not concerning for malignancy + negative tumor markers (CA125, LDH)?

A

laparoscopy and observation

180
Q

when should an ovarian mass be removed in the pregnant patient?

A

if it persists after 16 weeks and is > 6cm in diameter

181
Q

what is the treatment of ovarian torsion in the pregnant patient?

A

laparoscopy for dx and tx of ovarian torsion. If treated early, can just detorse. If later, may have to resect the gangrenous ovary to prevent peritonitis which could –> spontaneous abortion

182
Q

when during laparoscopic surgery should the fetal heart be monitored?

A

pre and postoperative fetal heart monitoring for viable fetuses (lower limit of viablity 22-24 wks)

183
Q

when are tocolytics indicated in pregnant patients undergoing laparoscopic surgery?

A

do not give prophylactically, but can be used when the patient has signs of preterm labor perioperatively

184
Q

how is laparoscopy useful for peritonitic patients

A

can assist in dx and planning for an open or lap approach to treatment

185
Q

what type of abdominal entry is preferable for bowel obstruction patients and why?

A

prefer direct visualization to enter the abdomen to prevent enterotomy, especially with SBO

186
Q

how can you find the transition point for SBO during lap surgery?

A

go from the decompressed loops of bowel and travel proximally to avoid handling the dilated loops of bowel

187
Q

what is the laparoscopic surgical intervention for large bowel obstruction?

A

proximal diverting ostomy

188
Q

what can you do to establish intraabdominal access in the obese patient?

A

longer Veress needle perpendicular to the abdominal wall, use of spinal needles, trocars > 100mm in length

189
Q

why is there a high risk of vascular injury in entering the abdomen of thin or muscular patients?

A

aorta and iliac vessels are in close proximity to the abdominal wall

190
Q

how can you avoid vascular injury when entering the abdomen in thin / muscular patients

A

elevating the abdominal wall, entering the abdomen by the costal margin, use open approach or visual trocar

191
Q

what three laparoscopic procedures can be performed under local anesthetic?

A

diagnostic laparoscopy, tubal ligation, select inguinal hernia repairs

192
Q

what is the max dose of lidocaine without epi? (mg/kg)

A

4 mg/kg

193
Q

what is the max dose of lidocaine with epi? (mg/kg)

A

7 mg/kg

194
Q

what is the max dose of bupivicaine without epi? (mg/kg)

A

2 mg/kg

195
Q

what is the max dose of bupivicaine with epi? (mg/kg)

A

3 mg/kg

196
Q

what is the max dose of ropivacaine without epi? (mg/kg)

A

2 mg/kg

197
Q

what is the max dose of ropivacaine with epi (mg/kg)?

A

3 mg/kg

198
Q

when should epidural anesthesia be used with laparoscopy? What are its benefits?

A

may be used alone in selected cases, adjunct to GA sometimes. Helps reduce postop pain and postop ileus.

199
Q

what are the indications for using atropine and/or glycopyrrolate during laparoscopy?

A

the pneumoperitoneum may cause bradycardia, however atropine is a/w dry mouth so preferable to use after patient is induced and only prn not preventive

200
Q

why should a patient receive H2 blocker or sodium citrate prior to general anesthesia?

A

to reduce effects of aspiration if it occurs

201
Q

how should patient’s arms be positions for procedures in the pelvis / lower abdomen?

A

tuck one or both arms to allow surgeons to position themselves by the mid/upper abdomen

202
Q

how should the patient’s arms be positioned for procedures in the upper abdomen?

A

shoulders /arms can be left out at a 90 degree angle

203
Q

why is it important to keep arms at 90 degrees and pad them?

A

to avoid brachial plexus injury and pressure point injuries

204
Q

when tucking arms, why is it important to keep them away from a break in the table?

A

avoiding hand injury if the table is flexed during the operation

205
Q

what two additional safety measures / equipment should be used if you plan on using reverse trendelenberg during the surgery?

A

safety strap across the knees to prevent buckling, foot board to prevent sliding

206
Q

what should be placed under the dependent axilla to prevent brachial plexus injury in lateral decub?

A

place shoulder roll under axilla to prevent brachial plexus injury

207
Q

how shoudl the upper arm be positioned when the patient is in lateral decub?

A

place in a sling or on a padded surface (stack of blankets/towels) to allow it to have adequate support

208
Q

when using a beanbag for a patient in lateral decub, how far up the abdomen can the beanbag go and why?

A

can go up to midline of the abdomen, should not go past that b/c will interfere with port placement

209
Q

why should you pad the beanbag when required for patient positioning?

A

becasue it can be harder than pillows, so should pad it to prevent injury

210
Q

what adjustment can be made in positioning when the patient is lateral decub to plan for lap nephrectomy / adrenalectomy to optimize working space

A

can flex the OR table to allow increased space between the costal margin and iliac crest

211
Q

What is the Veress Needle?

A

A spring-loaded needle witha sharp tip that serves as the conduit for insufflation gas

212
Q

why is the umbilicus the most frequently chosen location for entry into abdomen?

A

abdominal wall is thinnest at that location and its centrally located

213
Q

list the steps of veress needle insertion

A

skin incision below the umbilicus to allow the needle to pass through (size of incision depends on if you will be placing trocar through the site); lift up the abdominal wall (both surgeon and assist do this) by grasping skin and muscle to allow increased distance; hold veress needle like a pencil; pass needle thru incision perpendicular to the abdominal wll; can feel a pop / hear a click when you pass through the peritneum; if no further resistance, you are likely in and the tip of the needle should be mobile;

214
Q

how can you verify that the veress needle is intraperitoneal? (8 ways)

A

loss of resistance with insertion ; audible click as inner blunt, spring-loaded trocar releases; freely mobile tip; no aspiration of blood or enteric contents; low insufflation pressure with low to medium flow; free flow of saline; hanging drop test; tympany with percussion of abdomen after insufflation

215
Q

what is the most accurate way to verify the Veress needle is intraperitoneal

A

attaching gas at a low - medium flow rate and, if pressure stays low, you are likely intraperitoneal.

216
Q

After you place the Veress needle and attach gas, pressure is high. What could this mean and how do you fix it?

A

Could mean that you are still in the abdominal wall or up against the viscera. If the latter is true, lifting up the abdominal wall should reduce the pressure and allow gas to fill the peritoneal cavity.

217
Q

how do you perform the “hanging drop test” for Veress needle placement?

A

fill the needle with saline up to the brim. If you lift the abdominal wall and the saline does not flow out, you are still in the abdominal wall. If you lift the abdominal wall and the saline flows out, you are in the peritoneum.

218
Q

what is the desired intraabdominal pressure and how much CO2 does it take to get there?

A

desire 10-15mmHg, requires 1-3L CO2

219
Q

name two relative contraindications to blind initial trocar insertion

A

previous abdominal surgeries, previous intraabdominal inflammatory process

220
Q

name two absolute contraindications to blind initial trocar insertion

A

abdominal scar from previous open operation in immediate vicinity of trocar insertion; placing trocar through previously placed intraperitonelal mesh for hernia repair

221
Q

describe the technique for inserting a trocar after Veress needle pneumoperitoneum

A

trocar against thenar eminence; shaft between middle and index fingers, keep wrist straight, twisting motion combined with pushing motion, minimal pushing as possible

222
Q

what is the first step after Veress needle and initial trocar placement

A

laparoscopic inspection of area immediately below needle and trocar insertion, scan surfaces of organs to eval for injury (enteric contents, blood)

223
Q

what can you do if a patient has a midline abdominal scar and you want to use a Veress needle?

A

you can use a LUQ insertion, be sure to avoid epigastrics, can also use Hasson or optical trocar

224
Q

Name eight potential complications of Veress needle insertion

A

bowel injury, mesenteric/omental vascular injury, RP vascular injury, cardiac arrhythmia, hypotension, high airway pressures, PTX, gas embolism

225
Q

what should you immediately do if a patient has cardiopulmonary compromise?

A

immediate evacuation of pneumoperitoneum, eval for vascular injury

226
Q

list the steps of the Hasson insertion

A

2cm periumbilical incision after elevating skin with 11 blade; carry down through SQ to fascia; use Kocher to elevate the fascia; use S retractor to expose fascia, incise with blade or cautery; Place anchoring sutures on each side or horizontal mattress while the fascia is exposed; lift up peritoneum with clamps and cut open with scissors / scalpel; palpate and sweep with index finger

227
Q

how do you insert the first trocar after Hasson entry

A

insert the trocar, secure with stay sutures; establish pneumoperitoneum; evaluate area around port entry for injury

228
Q

how do you place additional trocars?

A

under direct visualization - push with finger or add in needle with local anesthetic and place trocar under direct visualization

229
Q

how do you prevent hitting the epigastric vessels with trocar insertion?

A

avoid placing trocars in the middle of the rectus muscles, not usually able to see these vessels with transillumination

230
Q

Name six patient signs / vitals that must be monitored during pneumoperitoneum

A

cardiac rhythm, pulse ox, ETCO2, heart rate, blood pressure, UOP

231
Q

name five reasons why CO2 is preferred for pneumoperitoneum

A

rapidly absorbed, easily eliminated, suppresses combustion, readily available, relatively inexpensive

232
Q

what happens to patient’s pH and ETCO2 duringthe first 20 minutes of insufflation? How does this affect anesthesia monitoring?

A

CO2 absorbed by the blood, overwhelms the buffering system, leading to increased PaCO2, decreased serum pH, and increased end tidal CO2. This means that you need to monitor ETCO2 vigilantly during the establishment of pneumoperitoneum, especially in severe cardiopulmonary dz.

233
Q

name four alternative bases to CO2 to establish pneumoperitoneum

A

nitrous oxide; air; helium; argon

234
Q

what are the risks and benefits of nitrous oxide for pneumoperitoneum

A

Benefits: less acid-base disturbances, may be better tolerated in pts with severe cardiopulmonary dz, tolerated relatively well without GA, slightly less postop pain. RISKS: fire hazard if using electrocautery in presence of open bowel (supports combustion b/c O2 from tract)

235
Q

what are the risks and benefits of argon and helium for pneumoperitoneum

A

much less soluble in blood, increased risk of extraperitoneal gas extravasation, much more expensive, insufflators for their use are not readily available

236
Q

what are the 3 CV changes with pneumoperitoneum

A

increased preload, increased afterload, and decreased CI

237
Q

HOw is cardiac output affected by CO2 pneumoperitoneum

A

decreased CO exacerbated by reverse trendelenberg, hypovolemia, underlying cardiac disease, and vagally induced bradycardia

238
Q

What should you do preoperatively to reduce risk of cardiovascular collapse during pneumoperitoneum?

A

make sure pt received all prescribed cardiac meds the AM of surgery, account for pt hydration status especially if they had a bowel prep

239
Q

What should you do intraoperatively if a pt develops cardiac collapse?

A

Desufflate immediately, check insufflator settings and fx, check for adequate relaxation, check intravascular volume status, check for other causes of hypotension (bleeding)

240
Q

is urine output a reliable indicator of intravascular volume during lap surgery?

A

no - pneumoperitoneum causes decreased renal blood flow, decreased UOP. Also increased renin and increased ADH release, reducing urine output further. This resolves within a few hours after surgery. Must be careful not to prescribe too much fluid –> fluid overload

241
Q

What are the risks of hypothermia with lap surgery

A

warmed IVF and warmed CO2 helps reduce risk, higher risk with longer cases

242
Q

what are the risks of extraperitoneal gas extravasation

A

may be intentional, subcutaneous, thoracic, delayed CO2 toxicity, and gas embolus

243
Q

What three maneuvers should be performed with laparoscopic equipment to prevent complications with pneumoperitoneum?

A

filter to protect insufflator, use clean tubing, keep cylinder upright to avoid liquid CO2 from escaping

244
Q

what is the most common change in cardiac rhythm with pneumoperitoneum?

A

sinus tachycardia

245
Q

what change in cardiac rhythm is associated with the pressure of pneumoperitoneum?

A

bradycardia - vagally mediated

246
Q

what should you do if a patient becomes profoundly bradycardia during establishment of pneumoperitoneum

A

let out the air, stabilize patient, restart flow at lower rate, if pt cannot tolerate consider open procedure or aborting procedure

247
Q

What are two procedure specific risk factors for DVT?

A

duration of procedure > 1 hour (reduced lower extremity blood flow), pelvic procedures

248
Q

What are 15 pt-specific risk factors for DVT?

A

history of VTE, age > 40, immobility, varicose veins, CA, chronic renal failure, obesity, peripartum, CHF, MI, hormone replacement therapy, OCPs, multiparity (3), IBD, severe infection

249
Q

what should you do before you leave the abdomen?

A

one last check for any visceral injury. Reduce pneumoperitoneum slightly to check for venous ooze.

250
Q

Name three MC sources of unrecognized bleeding

A

trocar injury of abdominal wall vessels, injury to vessels or organs away from the operative field, or tamponade of venous bleeding

251
Q

how can you laparoscopically place drains?

A

may pull through a 5mm port site with grasper or push through a 10-12mm port. Clamp drain tubing to prevent loss of pneumoperitoneum.

252
Q

Why should you try to evacuate as much CO2 as possible after lap surgery?

A

to avoid postop pain

253
Q

what are the three types of closures for port sites?

A

open, lap-assisted, entirely lap

254
Q

what size port site does not need fascial closure and what is the exception

A

5mm dont need it except in peds

255
Q

what is the rate of post op trocar site hernia?

A

5%?

256
Q

How do you perform open closure of the fascia?

A

direct visualization with S-retractors, exaggerated needles, and may need to enlarge incision to alllow for exposure

257
Q

what are two methods of fascial closure using lap-asssisted techniques?

A

use the carter-thompson to pass the suture through and bring it back out or use a keith needle to push the needle through, reverse intracorporeally, and back out

258
Q

why are purely laparoscopic techniques of fascial closure not recommended?

A

exposure of the fascia is poor

259
Q

name 10 peds surgical procedures performed laparoscopically

A

appy, undescended testes, anti reflux surgery, Hirschsprungs disease surgery, pectus repair, CV: PDA; esophageal / intestinal atresia, thoracic procedures, pyloromyotomy, exploration for contralateral hernia

260
Q

name 12 gyn surgeries performed laparoscopically

A

tubal ligation, hysterectomy, hysteroscopy, endometriosois, LOA, adnexal surgery, myomectomy, CA staging, bladder neck suspension, pelvic floor procedures, ovarian procedures, oophorectomy

261
Q

when is a diagnostic laparoscopy indicated?

A

can be under elective (cancer staging, chronic abdominal pain), urgent (SBO, ileus), or emergent (trauma, iatrogenic injury, perforated viscus) situations - if you need to determine dx

262
Q

how can you take down adhesions during laparoscopically?

A

combination of sharp and blunt (sweeping motions) dissection, sparing use of electrocautery for hemostasis

263
Q

when is diagnostic laparoscopy of the diaphragm indicated?

A

trauma

264
Q

when is diagnostic laparoscopy of the liver indicated?

A

mass, tumor

265
Q

when is diagnostic laparoscopy of the stomach/duodenum indicated?

A

PUD, perf, mass, tumor

266
Q

when is diagnostic laparoscopy of the gallbladder indicated?

A

cholecystitis

267
Q

when is diagnostic laparoscopy of the spleen indicated?

A

trauma, mass, infection

268
Q

when is diagnostic laparoscopy of the LNs indicated?

A

cancer diagnosis or staging

269
Q

when is diagnostic laparoscopy of the pancreas indicated?

A

mass, CA staging

270
Q

how do you position the patient for upper abdominal laparoscopy?

A

arms out, reverse T (may need strap and foot board)

271
Q

where should you place ports for upper abdominal diagnostic laparoscopy?

A

left - sided ports to allow you to visualize the entire abdomen. If you need to see the left abdomen as well, place a right port.

272
Q

how should you position a patient for pelvic diagnostic laparoscopy?

A

arms tucked, trendelenburg

273
Q

How should you plan to retract uterus for pelvic dx laparoscopy? (3 ways)

A

vaginal uterine manipulator, lap retractor, or suture retraction to abdominal wall

274
Q

how should you run the bowel to evaluate for injury?

A

bowel runs from LUQ and RLQ. use atraumatic bowel graspers, typically all on left side. Begin at one end of the bowel and go to the other end, do not lose orientation. Try to grasp at the mesenteric fat rather than bowel wall. Avoid torquing the bowel wall when possible, esp with dilated bowel

275
Q

what modifications should you make for dx lap for SBO

A

start at distal small bowel to start at decmopressed bowel. Work carefully b/c you have a reduced working space

276
Q

how should you position a patient for a RP dx lap (spleen, aorta, kidney)

A

lateral decub +/- trendelenberg or RT.

277
Q

what would you need to mobilize to eval RP structures?

A

may need to mobilize colon and periaortic LNs

278
Q

how should you position a patient for dx lap for trauma?

A

arms tucked, supine

279
Q

what is the benefit of dx lap for trauma?

A

good visualization of all organs, helps detect diaphragm and small bowel injury. Reduces nontherapeutic laparotomy rate

280
Q

what type of scope should you use for dx lap for trauma?

A

30 degree scope

281
Q

name five methods of laparoscopic bx

A

peritoneal washings and scrapings; FNA, core needle bx, incisional/wdge bx, excisional bx

282
Q

why should you avoid electrocautery during biopsy

A

alters structure and compromises pathology exam. Get hemostasis after you obtain the specimen.

283
Q

how do you perform FNA laparoscopically?

A

long enough needle (spinal) to reach target tissue thru abdominal wall, 20-22G needle, use short rapid strokes to hold suction and then pull out biopsy. Expel into container for cytology.

284
Q

how do you perform core bx laparoscopically?

A

14-18G needle, usually used for liver. must avoid hemangiomas. specialized needles for this. Higher risk of bleeding after these bx, so need to either hold pressure, coagulation, or suture

285
Q

what are biopsy forceps? What are they used for?

A

lap instrument with a cutting rim and hollow inside to avoid crushing the sample. Can be excisional or incisional depending on size of lesion.

286
Q

How do you perform a wedge biopsy?

A

use scissors to get the sample, avoid use of energy source after tissue sample collected

287
Q

what is the purpose of peritoneal washings?

A

cancer staging, planning therapy

288
Q

when should you obtain peritoneal washings and how?

A

infuse 100cc of NS into the cavity immediately upon entering the abdomen. can agitate the abdomen and then collect the fluid with a collection device between the suction device and main suction canister. Sometimes needs to be mixed with heparin. Can also obtain cultures to ID infections. Dont need saline if pt has ascites.

289
Q

how should you bx peritoneal lesions?

A

biopsy forceps, grasper + scissors, remove thru 5-10mm port

290
Q

how do you bx LNs? Where are they ?

A

porta hepatis, peripancreatic, RP/periaortic. Tend to be excisional. Be gentle and then can use cautery or topical topical hemostatic agents or endoloop. Remove smaller nodes through 10-12mm port. Larger nodes through endocatch

291
Q

how do you biopsy small surface lesions of the liver? liver?

A

incisiona or excisional biopsy. Can use core needle or wedge

292
Q

how do you bx a large surface lesion of the liver?

A

core needle or wedge bx

293
Q

how do you bx a lesion below the surface of the liver?

A

may need u/s to locate - FNA or core needle bx.

294
Q

how do you bx liver cysts or vascular lesions

A

generally cysts don’t need to be bx and you should avoid liver vascular lesion bx

295
Q

what are the three methods to bx an ovary

A

oophorectomy, bx forceps, or small wedge resection on the antimesenteric section + fenestration of cyst wall

296
Q

what three clinical factors are bx technique of the ovary based on?

A

menopausal status, suspicion for malignancy (if yes, oophorectomy), and frozen section findings

297
Q

what is the full staging procedure for ovarian mass?

A

peritoneal washings, diaphragmatic sampling, paracolic gutter sampling bilaterally, periaortic LN sampling

298
Q

how should you remove ovarian specimens and what are you trying to avoid

A

smaller specimens thru port, larter thru retrieval sac. You are trying to avoid seeding the abdominal wall

299
Q

what is ovarian remnant syndrome

A

Ovarian remnant syndrome (ORS) occurs if any ovarian tissue is left after surgery to remove both ovaries and fallopian tubes, called a bilateral salpingo-oophorectomy. The syndrome occurs if this ovarian tissue causes severe pelvic pain and/or a pelvic mass.

300
Q

how do you bx a visceral leison (on hollow viscus)

A

have a low threshold to close up the bx area to prevent postop leakage

301
Q

when do you perform RP bx?

A

to get LNs or RP mass bx. can be transperitoneal or RP.

302
Q

name six methods of hemostasis after bx

A

direct pressure, monopolar / bipolar electrocautery, argon beam, topical hemostatic, or sutures

303
Q

why do you need to minimize bx exposure to port site?

A

to prevent seeding or losing the specimen

304
Q

if an ovary is larger than 5cm or has complex internal us characteristics, what type of bx should you do?

A

oophorectomy

305
Q

why are braided sutures easier to handle in laparoscopy

A

less memory and less kinking

306
Q

why are dyed sutures preferred

A

becasue they don’t blend into the background

307
Q

what type of needle is preferred in laparoscoic surgery?

A

tapered needle

308
Q

how far apart should ports be for intracorporeal knot tying?

A

ideally 10 cm apart

309
Q

where should you grasp the needle wehn introducing into the abdomen?

A

5-10mm from the needle end

310
Q

how can you introduce a needle into 5mm port sites?

A

put the port on the instrument itself and then the needle, introduce both into the abdomen

311
Q

what are the sizes of lap clips?

A

5 and 10mm

312
Q

what can be closed with clips?

A

used to close smaller tubular structures

313
Q

linear staplers - what do they do?

A

place 2-3 rows of staples on each side of a knife blade and cut tissues between rows

314
Q

how long are linear staple cartridges?

A

30-60mm

315
Q

what type of port do staplers go through?

A

10-12mm port

316
Q

what are smaller vs larger staples used for

A

smaller staples: hemostasis and thinner tissue, larger staplers for thicker tissue

317
Q

what is a white/grey load height and whats it used for?

A

2-2.5mm, vascular & mesentery

318
Q

what is a blue load height and whats it used for?

A

3-3.5mm, used for most of the GI tract

319
Q

what is a green load height and what is it used for

A

4-4.5mm, used for distal stomach or unusally thick GI tract portions

320
Q

how can you be sure the stapler is fully and appropriately engaged?

A

use articulating feature, view all the jaws

321
Q

what do mechanical suturing devices accomplish?

A

needle introduction, needle positioning, passing needle thru tissue, tying the knot

322
Q

name the five steps to laparoscopically control bleeding

A

1) optimize visualization: keep scope and port clean, may need to switch port. 2) grasp and hold bleeding source: atraumatic grasper, may apply direct pressure with instrument tip, gauze, pad, or hemostatic agent. 3) maintain exposure: use suction irrigator, may require additional port. 4) ID bleeding source: may need further dissection. 5) apply proper hemostatic techniques.

323
Q

when should you consider conversion to open with bleeding?

A

failure to maintain hemodynamic stability or adequately control bleeding laparoscopically

324
Q

what causes external port site bleeding and how can you control it

A

often from skin, SQ vessels, or muscle, caused by scalpel or trocar. Use electrocautery / sutures, may need to extend skin incision to get hemostasis

325
Q

why is internal port site bleeding not always apparent?

A

because tamponaded with the port

326
Q

why should you always remove ports under visualization

A

to see if any internal vessels injured with placement

327
Q

what trocars are at highest risk of injuring epigastrics?

A

trocars through the rectus muscles

328
Q

how do you stop internal hemorrhage from port site that has a slow rate of bleed with a visible source?

A

direct pressure or electrocautery

329
Q

how do you control internal hemorrhage from port site with a high rate of bleed and no visible source?

A

control with grasper, may ontrol with foley cathter balloon if available, dissection to ID source, suture ligation and/or energy source as appropriate. May need full thickness adominal wall sutures with lap-assisted techniques. May need additional sutures or ports.

330
Q

how do you perform a full thickness abdominal wall suture to control bleeding

A

small skin incision over bleeding site, place sutures procximal and distal to expected direction of vessels using lap-assisted technique: spinal needle, suture passer, or straight needle

331
Q

what should you do with RP bleeding?

A

most likely convert to laparotomy to eval for source of bleedign: vascular or mesenteric

332
Q

how can RP hemorrhage occur 2/2 Veress needle injury?

A

may have caused IVC or aortic injury with entry, be sure to evaluate for concomitant bowel injury

333
Q

how can RP injury occur due to Trocars?

A

usually cause immediate blood loss, so lap control until you open

334
Q

what are the indications for monopolar electrocautery for hemostasis

A

smaller vessels, slow rate of bleed, need a dry operative field

335
Q

what are the indications for bipolar electrocautery for hemostasis?

A

larger vessels, works in wet operative fields, less lateral thermal spread, lower energy requirement

336
Q

when can clips be used for hemostasis? what are the risks and benefits

A

need to be placed precisely on vessel, may dislodge if vessel is not completely dissected, may hamper subsequent efforts. Easy, single-handed deployement

337
Q

what are the three types of suture that can be used for hemostasis

A

single, simple suture; figure of eight; endoloop / Roeder’s knot

338
Q

what is the use of hemostatic agents for control?

A

useful for slower rate of bleeding or raw surfaces. Not good for arterial bleeding b/c will just float off

339
Q

what steps should you take with larger vessel ligation?

A

dissect, avoid endoloop with large arteries - prep for proper suture ligation, appropriate energy source, or vascular stapler. Prepare to immediately grasp vessel with grasper in case hemostatic method is not completely successful

340
Q

how long do laparoscopic patients need to keep their wounds dry?

A

24-48 hours after surgery

341
Q

how many days after a lap appy till a patient can tolerate a regular diet

A

0-1 days

342
Q

how many days after a lap chole till a patient can tolerate a regular diet

A

0-1 days

343
Q

how many days after a lap fundoplication till a patient can tolerate a regular diet

A

1-2 days

344
Q

how many days after a lap colectomy till a patient can tolerate a regular diet

A

3-6 days

345
Q

what are the three subtypes of postop complications?

A

injuries not identified at the time of the operation, partial thickness injuries, and other complications secondary to laparoscopy

346
Q

what 5 viscera are most commonly injured by lap surgery?

A

stomach, small bowel, colon, bladder, ureters

347
Q

what are four mechanisms of injury of viscera?

A

electrosurgical burn, full/partial thickness tear, anastomotic leak, devascularization/ischemia

348
Q

how do visceral injuries present

A

4-7 days postop with fever, tachycardia, leukocytosis, and pain

349
Q

what solid organs are most commonly injured by lap surgery?

A

liver, spleen, kidney, pancreas

350
Q

what are four MOIs of solid organs?

A

capsular tear, retractuion injury, failed hemostasis, Veress needle

351
Q

how do solid organ injuries present?

A

tachycardia, pain, anemia. Eval with CT if HDS

352
Q

what vessels are most commonly injured and present postop?

A

tend to be smaller. Superior/inferior epigastric vessels or mesenteric arteries and veins

353
Q

how do vascular injureis in the postop period present and how is it managed?

A

p/w anemia and hematoma, usu self limited but may require evacuation, may become infected

354
Q

what are four mechanisms of nerve injury during lap surgery?

A

positioning, traction, division, entrapment

355
Q

how do nerve injuries preesent

A

numbness, tingling, pain

356
Q

name four wound complications after lap surgery?

A

seroma (MC with hernia repair), SSI, hematoma, hernia

357
Q

What is this position

A

Reverse trendelenburg

358
Q

What is this position?

A

Trendelenburg

FLS (1 decks)

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