FLS Flashcards
Laparoscopes come in what range of diameters?
2 mm - 10 mm
Laparoscopes come in what range of lengths?
30 cm - 45 cm
What is the most common lens system used?
Hopkins Rod Lens System
Which size scopes are more susceptible to damage?
Increases as length increases
Increases as diameter decreases
When is a 0 degree laparoscopic most helpful?
working in a small area in line with the scope and working ports
I.E. Deep in the pelvis or high in the mediastinum
What causes fogging of the laparoscope?
temperature and humidity discrepancy between the OR and peritoneal cavity
What is the commonly used gas of laparoscopy?
Carbon Dioxide
What are the benefits of using carbon dioxide for laparoscopy?
- Readily Available
- Inexpensive
- Does not support combustion
- Easily eliminated
- Rapidly Absorbed
What equipment controls the supply of CO2 gas from the source to the abdomen?
Insufflator
What settings need to be set on the insufflator?
- Max Abdominal Pressure (15)
- Gas Flow Rate
How can you prevent loss of pneumoperitoneum when suctioning?
Fully submersing the suction cannula below the fluid
What should you do if there is loss of working space during laparoscopy?
Check insufflator settings immediately!
What could be the cause of the problem if measured pressure is > than set pressure?
Relaxation problem or insufflation obstruction
What could be the problem if there is low pressure and high flow?
Gas leak!
Check insufflation circuit:
- Tubing disconnected
- Port leaking
- Valve at trocar is open
- CO2 escaping into hollow organs (check organ distention or inflation of the foley bag)
What could be the problem if there is low pressure and no flow?
Insufflator/Gas problem!
- Check insufflator is on
- Check CO2 tank
Describe the circuit of monopolar current
- Low frequency current from wall source (generator)
- High frequency current in active electrode (lap instrument)
- The tissue the current passes through
- Dispersive electrode connect to the generator
Describe coagulation setting on monopolar
*Protein denaturation and reformation
Occurs as a result of tissue heating- as temp is > 60 C, protein denaturation occurs
When tissue cools bonds are reformed in a haphazard fashion
Describe cut setting on monopolar
*Water evaporation/desiccation
As temp rises, water is evaporated, as desiccation increases, tissue impedance increases
When complete desiccation occurs, current stops flowing due to high resistance
Hemostasis achieved by protein binding between dehydrated/denatures cells of the vessel endothelium
What is “tissue heating” dependent on?
= (Current density)^2 = the amount of current flowing through a cross-sectional area of tissue
How does current density relate to applied power?
They are directly proportional
How does current density relate to tissue resistance?
Indirectly proportional
the smaller the contact area, the faster the heating
Tip of the active electrode is so small, contacting a small area of tissue delivers a lot of current density
Conversely, large area of tissue contact for the dispersive electrode (bovie pad) makes for low current density and minimal heating
Where should you avoid placing the bovie pad?
Hairy skin
Boney prominence
Scars
**these decrease the contact surface area and thus increase the risk of burn to the patient
Describe the voltage pattern for cut vs coag
Cut = shorter amplitude of voltage, more frequent spikes
Coag= higher amplitude of voltage, less frequent spikes
Describe coagulation setting
Rapid surface heating
Superficial eschar formation
SHALLOW depth of necrosis (fulguration)
= intermittent wave from with relatively high voltage
Describe cutting setting
Heat tissue quickly
Cell water is converted to steam causing the cell to “explode”
Heat is dissipated in the steam with MINIMAL LATERAL TISSUE DAMAGE, but poor thermal coagulation
Unmodulated waveform with relatively low voltage
What is current diversion?
Current follow the path of least resistance, and thus passes through unintentional pathways
IE: Laparoscopic instrument near trocar burns bowel
What is narrow circuit return?
If current is allowed to pass through (suture) LIGATED TISSUE this will INCREASE the local current density in a logarithmic fashion and unintended excessive heating can occur
IE: applying monopolar instrument to the end of a structure that has been ligated, such as an appendiceal stump
Excessive heating may occur at the ligature, resulting in delayed perforation or appendiceal stump blowout
What is direct coupling?
Second instrument IS touching tissue
can occur if the active electrode comes into contact with other instruments, cannulas or the laparoscope
IE: If an active electrode comes in contact with a grasper holding bowel, then a thermal injury is likely
What is capacitive coupling?
Second instrument is NOT touching tissue
Transfer of current to passive electrode which will store energy (i.e. metal port or the camera)
*There must be two conductors separated by an insulator for this to occur
Charge of the capacitor transferred to adjacent tissue may result in a burn
IE: L hook contacting tip of a grasper which is NOT in contact with tissue, grasper stores energy > grasper will touch tissue and cause inadvertent tissue injury
What is another name for a passive electrode that can store a charge?
Capacitor
Describe Bipolar Current
Tissue to be treated is placed directly between two electrodes, so that current flows only through the tissue which is contiguous between both electrodes (eliminating the need for dispersive electrodes (bovie pads) and the hazards of straight current
Describe the difference in current flow between bipolar and monopolar?
Bipolar- current flow is through a much smaller volume of tissue, unlike the high resistance circuit present with monopolar
**Decrease the output of the generator when compared to monopolar
Up to what vessel diameter can a vessel sealing device be used, such as the Ligasure?
Vessels up to 7 mm in diameter
Describe how a vessel sealing device works
Instrument w/ computer to control energy delivery and tissue heating by measuring the IMPEDANCE of grasped tissue or through Nanotechnology jaw sensors
Controlled heating/pressure > denaturation of collagen > creation of a permanent seal
What hazards are associated with bipolar sealing devices?
Inadvertent lateral thermal spread
Inadvertent cutting of patent vessel before adequate sealing
Improper device function if metal is contained within the jaws (staples, etc)
Which type of dissector relies on mechanical energy?
Ultrasonic dissection
Tissue heating is generated by converting electrical energy into high-frequency ultrasonic vibrations (uses a piezoelectric transducer)
How does a harmonic scalpel work?
Vibrating jaw or blade and a passive jaw (which acts as a backstop to stop tissue against the blade)
How fast does the transducer vibrate on the ultrasound coagulation shears?
50,000 Hertz (50,000 times per second)
Excursion of 25-100 microns depending on the power setting
Does low power on the harmonic cause more hemostasis or cutting?
Hemostasis
Does high power on the harmonic cause more hemostasis or cutting?
Cutting
If the laparoscopic view of the operative field is reduced in size, thus compromising proper exposure of the operative field, which of the following should be immediately checked?
Check insufflator display
All of the following are pre-operative checks except?
A. Check that a spare CO2 tank is in the OR
B. Check the availability of ancillary equipment
C. Assure all power sources are connected and appropriate units were switched “on”
D. Check for adequate muscle relaxation
D. this is an intra operative check
During monopolar electrosurgery, the method of heating tissue quickly, converting cell water to steam and causing the cell to explode, is descriptive of which of the following
A. Cutting mode
B. Coagulation mode
C. Blend option
A. Cutting Mode
The use of all plastic or all metal trocars can avoid which problem during electrosurgery
A. Unintended direct coupling
B. Insulation failure
C. Capacitive coupling
C. Capacitative Coupling
When using the ultrasonic shears, the entire portion of the active blade is exposed. In order to avoid inadvertent delivery of energy to tissue in contact with the bottom portion of the active blade, one should do which of the following?
A. Be aware of the contact points the blade is engaging
B. Grab the target tissue and elevate it
C. Keep the active blade upwards, in view of the surgeon
D. All of the above
D. All of the above
What are the ideal ergonomics of the surgeon?
Arm should be 30 degrees or less from trunk
Elbow should bend 60-120 degrees with wrist slightly pronated
Where should the surgeon stand in regards to the expected operating feild?
Opposite side
Define Class 1 ASA
no organic, physiologic, biochemical, or psychiatric disturbance
Define Class 2 ASA
Mild to moderate systemic disease, due either to surgical condition or to a concomitant disease
Define Class 3 ASA
Severe systemic disease that limits the patient’s activity and may or may not be related to the reason for surgery
Define Class 4 ASA
Severe systemic disturbances that markedly limit the patient, and are life-threatening with or without surgery
Define Class 5 ASA
Moribund patient who has a little change for survival but is submitted to surgery as a last resort (resuscitative effort)
What ASA classes are appropriate for laparoscopic surgery?
Classes 1-3
What are absolute contraindications to laparoscopy? (4)
- Inability to tolerate laparotomy
- Hypovolemic shock
- Lack of proper surgeon training and/or experience
- Lack of appropriate institutional support
What are the RELATIVE contraindications to laparoscopy? (5)
- Inability to tolerate general anesthesia
- Long-standing peritonitis
- Large abdominal or pelvic mass
- Massive incarcerated ventral and inguinal hernias
- Severe cardiopulmonary disease
Select the risk classification that corresponds to ASA Class 3:
A. Mild-to-moderate systemic disease, due to either surgical condition to a concomitant disease
B. Severe systemic disease that limits the patient’s activity and may or may not be related to the reason for surgery
C. No organic, physiologic, biochemical or psychiatric disturbance
D. Moribound patient who has little chance of survival but is submitted to surgery as last resort
Severe systemic disturbance that markedly limit the patient, and are life-threatening with or without surgery
B. Severe systemic disease that limits the patient’s activity and may or may not be related to the reason for surgery
The initial consultation should include which of the following:
A. Types of trocars to be used
B. Details to the physiology of pneumoperitoneum
C. Possibility of conversion to open surgery
D. Type of insufflation gas to be used during the procedure
C. Possibility of conversion to open surgery
Which of the following is a relative contraindication?
A. Uncorrectable hypovolemic shock
B. Previous abdominal surgery
C. Inability of the patient to tolerate laparotomy
D. Lack of appropriate facilities to provide peri-procedural care
B. Previous Abdominal Surgery
Which of these is not an absolute contraindication?
A. Uncorrectable hypovolemic shock
B. Lack of proper surgical training
C. Inability to tolerate laparotomy
D. Bowel obstruction
D. Bowel Obstruction
What technique can you use to help avoid damaging the aorta and IVC with Veress Needle pleacement/
- Lifting up abdominal wall
- Place Veress needle off midline (LUQ)
- Open approach including optical trocar for direct visualization
When is just local anesthesia considered “appropriate” in laparoscopy?
- Diagnostic laparoscopy
- Tubal ligation
- Select inguinal hernia repairs
Which procedure may be performed using a local anesthetic alone or with mild sedation?
A. Appendectomy
B. Ectopic Pregnancy
C. Diagnostic Laparoscopy
D. Cholecystectomy
C. Diagnostic Laparoscopy
Important factors in patient positioning for laparoscopic surgery include:
A. Avoidance of position related complications
B. Prevention of DVT
C. Location of the target organ
D. All of the above
D. All of the above
The most commonly used anesthetic for laparoscopic procedures is general anesthesia. All of the following are true EXCEPT:
A. It allows for complete neuromuscular relaxation
B. It provides good control of ventilation
C. There are few hemodynamic changes compared to a local anesthetic
D. It allows for more flexibility of patient positioning.
C.
What type of pain is local anesthesia good for?
PARIETAL pain related to trochar sites, NOT shown to be helpful for VISCERAL pain related to pneumoperitoneum or manipulation of viscera
What are signs the veress needle is intraperitoneal?
- 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
What are relative contraindications to blind initial trocar insertion?
- Previous abdominal surgery
- Previous intra-abdominal inflammatory process
What are absolute contraindications to blind initial trocar insertion?
- Abdominal scar from prior open operation in immediate vicinity of trocar insertion
- Through previously placed intraperitoneal mesh for hernia repair
Click on the most common site for initial trocar insertion?
A. RUQ
B. Umbilicus
C. LLQ
B. Umbilicus
When checking placement of the Veress needle, which of the following is the most accurate method to detect proper intraperitoneal placement?
A. Aspirating blood
B. Aspirating enteric contents
C. Insufflator display revealing flow of CO2 and low initial pressure
D. Insufflator display revealing no flow of CO2 and high initial pressure
C.
Umbilical veress needle insertion and blind trocar insertion is contraindicated in all of the following situations except?
A. Previous left hemicolectomy through midline incision
B. Previous open cholecystectomy via right subcostal incision
C. Previous hysterectomy through midline incision
D. Previous Crohn’s disease with enterocutaneous fistula
Previous umbilical hernia repair
B.
Click on the most common site for initial trocar insertion (when previous VML scar)?
A. 2 cm supraumbilical B. Umbilical C. 2 cm infraumbilical D. LUQ E. LLQ
D. LUQ
Extra caution must be taken when placing the Verees needle and primary trocar in the midline, such as the umbilicus due to concerns with injury to what organ?
A. Liver B. Spleen C. Ovary D. Aorta E. Femoral artery
D. Aorta
Why is the Veress usually placed at the umbilicus?
- Central location
- Where the abdominal wall is the thinnest
How many L of CO2 is usually required to achieve 10-15 mm Hg of pressure?
1-2 L (if less CO2 achieves pressure, check your placement of the Veress, and ensure adequate relaxation of the patient
How does CO2 affect the end tidal CO2?
Increases
How does CO2 affect serum pH
Decreases! (More acidic)
When is the greatest physiological change during laparoscopy?
First 20 minutes
How does CO2 effect minute ventilation?
Increases (to eliminate absorbed CO2)
How does the pressure of pneumoperitoneum affect functional residual capacity (FRC)?
Reduces FRC!! (Pressure from inflated diaphragm)
How does the pressure of pnemoperitoneum affect peak airway pressure?
It increases peak airway pressure
How does the pressure of pneumoperitoneum affect pulmonary complicance?
Reduce pulmonary compliance
What vascular changes does CO2 cause?
Increased Preload
Increased afterload
DECREASED cardiac ouput
What can slightly lessen post op abdominal and shoulder pain?
Low initial insufflation rate and set pressure
What other gases can be used to achieve pneumoperitoneum?
- Nitrous Oxide > fire hazard if using electrocautery in the presence of open bowel (supports combustion of methane)
- Argon (expensive, higher risk of gas embolism)
- Helium (expensive, higher risk of gas embolism)
- Air
What can exacerbate decreased cardiac output during laparoscopy?
Reverse trendelenberg position
Hypovolemia
Underlying cardiac disease
Vagally induced bradycardia
What is the most common cardiac arrhythmias due to pneumoperitoneum/anesthestics/pressure effects?
Sinus tachycardia
Usually mild and self limited!
What is a common cause of bradycardia during laparoscopy?
Pressure effects of pneumoperitoneum, vagally medicated
If sever STOP insufflation!!
How much does venous extremity flow rate decrease during laparoscopy? (due to increased vena cava resistance)
26-39% during pneumoperitoneum
Does laparoscopy have increased risk of DVT compared to open abdominal surgery?
Nope!
How does laparoscopy cause oliguria?
increased intraabdominal pressure
decreased renal blood flow
Decreased filtration and UOP
Secondary release of Renin and ADH
Results in Na and free water reabsorption = oliguria
What are some signs of a gas embolism?
Sudden cardiovascular collapse
HYPOTENSION
JVD
TACHYCARDIA
MILL WHEEL MURMUR
BLEEDING
PNEUMOTHORAX
PRIMARY CARDIAC FAILURE
What is the treatment for a symptomatic gas embolism?
Trendelenberg (left side down)
Rapid fluid administration
Central line placement to evacuate or break up embolism in the right heart chambers
Which of the following is most likely due to the pressure effects of pneumoperitoneum?
A. Tachycardia
B. Ventricular fibrillation
C. Premature Ventricular contractions
D. Bradycardia
D. Bradycardia
When a patient is experiencing gas embolism during a laparoscopic procedure, the appropriate emergency position would be?
A. Supine
B. Left lateral decubitus, w/ trendelenburg
C. Left lateral decubitus w/ reverse trendelenburg
D. Dorsal lithotomy
B. Left lateral decubitus w/ reverse trendelenberg
The development of hypercarbia is influenced by which of the following?
A. The body’s buffer system B. The patient’s pulmonary system C. Extraperitoneal insufflation D. A&B E. All of the above
E. All of the above
Which of the following is not a sign of gas embolism?
A. Hypotension B. Bradycardia C. Tachycardia D. Mill wheel murmur E. Jugular venous distension
B. Bradycardia
Significant cardiovascular effects of pneumoperitoneum can be caused by:
A. Pressure of pneumoperitoneum B. Patient position C. Acid-base disturbance from CO2 D. All of the above E. None of the above
D. All of the above
Pneumoperitoneum affects ventilation in all of the following ways except?
A. Reduced thoracic compliance
B. Increased peak airway pressure
C. Hypocapnia
D. Reduced functional residual capacity
C. Hypocapnia
Select the variable that will be decreased by establishment of pneumoperitoneum
A. Renal vascular resistance
B. Pulmonary capillary wedge pressure
C. Pulmonary vascular resistance
D. Cardiac Index (CO/BSA)
D. Cardiac Index (CO/BSA)
What are three common causes of unrecognized bleeding during laparoscopy?
Trocar injury of abdominal wall vessels
Injury to vessels or organs away from the operative field (spleen or liver)
Tamponade of venous bleeding due to pneumoperitoneum
How long for resolution of CO2 peritoneum following laparoscopy?
Usually gone by 3 hours
When should a check for venous bleeding be performed?
A. During final abdominal check
B. While releasing abdominal pressure
C. During trocar removal
D. All of the above
D. All of the above
Once the operative procedure is finished, the surgeon should check which of the following areas before exiting the abdomen?
A. The operative field
B. The dependent portions of the abdomen away from the field of view at the operative site
C. The abdominal wall at each port site once the port has been removed
D. All of the above
D. All of the above
Reasons to close the fascia of trocar sites include:
A. Prevent escape of gas
B. Prevention of hernia
C. Prevention of infections
D. All of the above
B. Prevention of hernia
What are options for drain placement during laparoscopy?
may PULL through 5 mm port site with grasper
may PUSH through 10/12 port
**clamp drain to prevent loss of pneumo
Select the correct position for a female patient who is to undergo standard diagnostic laparoscopy for pelvic procedures
A. Supine w/ trendelenburg
B. Dorsal lithotomy
C. Left lateral decubitus w/ trendelenburg
D. Left lateral decubitus w/ reverse trendelenburg
B. Dorsal Lithotomy
Select the correct position for appendectomy
A. Dorsal supine
B. Dorsal lithotomy
C. Dorsal supine w/ trendelenburg
D. Left lateral decubitus w/ reverse trendelenburg
C. Dorsal supine w/ trendelenberg
Intestinal pathology which cannot be identified laparoscopically include:
A. Crohn’s disease
B. Traumatic diaphragm injury
C. Ovarian cyst
D. All can be diagnosed laparoscopically
D. All can be diagnosed laparoscopically
Click on the area for best placement of ports to view the kidneys and adrenal glands:
A. Umbilical
B. RLQ
C. Along costal margin
C. Along costal margin
Retraction of the uterus can be accomplished by:
A.Transvaginal uterine manipulator B. Blunt grasper C. Laparoscopic retractor D. Suture placed through the abdominal wall E. All of the above
E. All of the above
Where should you place ports to help to visualize entire small bowel?
Places 3 ports on left abdomen
When running bowel- handle mesenteric fat rather than bowel wall when possible
What position should the patient be in for diagnostic laparoscopy for retroperitoneal structures below the aortic bifurcation
Supine and reverse trendelenberg (with or without lithotomy)
What position should the patient be in for diagnostic laparoscopy for structures above the aortic bifurcation and spleen?
Lateral and semi lateral
What size needle is used for Fine Needle Aspiration?
20-22 gauge needle
Need sufficient needle length
Cytology > little to no info regarding architecture
What size needle is used for a core needle biopsy?
14-18 gauge needle
Which has a high risk of bleeding- FNA or core needle bx?
Core needle biospy
What type of biopsy would be used for large lesions?
Incisional (wedge) biopsy
What type of biopsy would be used for a smaller lesion?
Excisional biopsy
Should you biopsy a cyst vascular lesions?
No! May cause excessive bleeding if vascular
When should you achieve hemostasis when doing a biopsy?
AFTER biopsy (to avoid damaging specimen)
Click on the correct needle for performing core biopsies
A. 20-25 gauge
B. 14-18 gauge
B. 14-18 gauge
If an ovary is larger than 5 cm, or has complex internal ultrasound characteristics, biopsy should be by:
A. FNA
B. Oophorectomy
C. Wedge Biopsy
D. Core Biopsy
B. Oophorectomy
General principles of successful laparoscopic tissue biopsy include all of the following except:
A. Avoid contacting tissue of extraction site with specimen
B. Remove biopsy specimen with an energy source to avoid bleeding
C. Excisional biopsy of small lesions is appropriate
D. Generally avoid biopsy of fluid filled liver lesions
B. Remove biopsy specimen with an energy source to avoid bleeding
What is a downside to FNA?
Provides cytology but little to no information about architecture
A core needle biopsy does provide pathologic architecture
How far apart should ports be from tissue for intracorporeal knot tying techniques?
at least 10 cm apart
What type of knot is one the endoloop?
Pre-tied Roeder’s knot
What size staple should you use for vascular applications?
2-2.5 mm (white or gray)
What size staple should you use for the GI tract?
3-3.5 mm (blue)
What size staple should you use for the distal stomach, or unusually thickened portions of the GI tract?
4-4.5 mm (green)
What size trocar will accommodate placing a standard SH type needle through the cannula?
A. 3 mm trocar
B. 5 mm trocar
C. 10-12 mm trocar
C. 10-12mm trocar
What is the ideal suture length for intracorporeal knot tying:
A. 2 inches (5 cm)
B. 6 inches (15 cm)
C. 10 inches(25 cm)
D. 30 inches (75 cm)
B. 6 inches (15 cm)
What is the ideal suture length for extracorporeal knot tying?
A. 4 inches (10 cm)
B. 6 inches (15 cm)
C. 8 inches (20 cm)
D. 30 inches (75 cm)
D. 30 inches (75 cm)
Which of the following statements about intracorporeal suturing is NOT true?
A. Grasping the needle is the ideal way to control it when transporting the suture in and out of the abdomen
B. The ideas suture length is about 6 inches (15 cm)
C. The ideal orientation for suturing is from 3 o’clock to the 9 o’clock position
D. Pulling the needle along its arc through the tissue will minimize tissue damage
A.Grasping the needle is the ideal way to control it when transporting the suture in and out of the abdomen
What should you do in the event if you are unable to control bleeding laparoscopically?
Covert to open!
In what locations are trocars at highest risk of injuring epigastric muscles?
Trocars placed through the rectus muscles
What are some signs/symptoms of retroperitoneal bleeding?
- Retroperitonal hematoma
- Mesenteric hematoma
- Free blood that is not from the port or operative site
- Hypovolemic shock that is not otherwise explained.
What type of cautery works best in “wet” operative field?
Bipolar!
Use for larger vessels, less thermal spread, lower energy requirement
General principles regarding hemostasis during laparoscopy include all of the following except:
A. It is best to specifically identify the bleeding point
B. Avoiding injury to adjacent structures is important
C. Adding extra ports may be necessary
D. Conversion to open may be necessary
E. Applying vascular clips to the general area is usually sufficient
E. Applying vascular clips to the general area is usually sufficient
All of the following are generally true regarding port site bleeding except:
A. External hemorrhage may require extension of skin incision
B. Internal hemorrhage may not be present while port is in place
C. Internal hemorrhage may not be visible from skin incision
D. Ports placed through the rectus muscle should be done under direct laparoscopic visualization
E. There is no need to remove ports under direct laparoscopic visualization
E. There is no need to remove ports under direct laparoscopic visualization
When compared to monopolar cautery, bipolar cautery affords all of the following advantages except:
A. Useful for larger vessels
B. Function better in “wet” operative field
C. More beneficial for capillary sized vessels
D. Has advanced computer enhanced devices available
E. Has less lateral thermal spread
C. More beneficial for capillary sized vessels
When dividing a large vascular structure, which of the following is true?
A. It is not necessary to gain proximal and distal control prior to vessel transection
B. Vascular clips are always sufficient
C. The surgeon must be prepared to immediately intervene in case vascular control is lost
D. Endoloops are the most appropriate device for large arteries
E. Vascular staplers never result in bleeding through the staple line
C. The surgeon must be prepared to immediately intervene in case vascular control is lost
What medications can be used empirically for PONV?
Serotonin 5-HT3 antagonist Antihistamine Metoclopramide Dexamethasone Droperidol
How long does shoulder pain from laparoscopy usually last?
1-3 days
Which of the following classes of medications/medications should NOT be considered to treat a patient with postoperative nausea and vomiting?
A. Morphine sulfate
B. Antihistamines
C. Serotonin receptor antagonists
D. Corticosteroids
A. Morphine Sulfate
A patient in the early postoperative period following laparoscopic surgery who complains of several days of increasing pain should be managed by:
A. Calling in a narcotic refill to the pharmacy
B. Instituting multimodal therapy with a combination of opiates and NSAIDS
C. Reassuring the patient that increasing pain is a normal and expected part of the postoperative course
D. Instructing the patient that he/she needs to be evaluated to determine the cause of increasing pain
D. Instructing the patient that he/she needs to be evaluated to determine the cause of increasing pain
