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FLS > FLS Didactics Notes > Flashcards

FLS Didactics Notes Flashcards

1
Q

Scope diameters

A

2-10mm

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2
Q

Scope lengths

A

30-45cm

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3
Q

Options for gas

A

CO2, nitrous oxide, helium

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4
Q

Video tower consists of

A

Light source, camera control unit, video monitor, insufflator

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5
Q

What light source is used to illuminate the body?

A

300 watt xenon lamp

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6
Q

The current density is defined as:

A

the amount of current flowing through a cross sectional area of tissue

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7
Q

Current density is directly & inversely proportional to:

A

Directly proportional to applied power; inversely proportional to 1) tissue resistance AND 2) the square of the area of tissue through which the current must travel.

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8
Q

Current density formula

A

Current density = current (amps) / area (cm^2)

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9
Q

Don’t place dispersive electrode (grounding pad) on:

A

Hairy skin, scars, bony prominences (decrease contact surface & increase risk of burn)

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10
Q

Cutting mode

A
  • heats tissue quickly –> cell water converted to steam (explodes)
  • heat dissipation = minimal lateral spread, poor thermal coag
  • CONTINUOUS waveform, LOW voltage, little tissue resistance (steam bubble)
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11
Q

Fulguration definition

A

Rapid surface heating with superficial eschar formation and shallow depth of necrosis

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12
Q

Coag mode

A
  • rapid surface heating with superficial eschar formation & shallow depth of necrosis (fulguration)
  • INTERMITTENT (pulsed) waveform, HIGH voltage
  • heat widely dispersed so no significant cutting
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13
Q

What is current diversion?

A

When current, following the path of least resistance, passes through unintentional pathways.

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14
Q

Capacitative coupling

A

Involves transfer of current from an active electrode, through its insulation, to a passive electrode (must be two conductors separated by an insulator)

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15
Q

Direct coupling

A

“spark”

Unintended direct coupling: when the active electrode comes into contact with other metal instruments, cannulas, or the laparoscope

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16
Q

Vessel diameter for bipolar tissue sealing devices

A

Up to 7mm

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17
Q

Examples of bipolar devices

A

Kleppinger, Ligasure (tissue placed directly b/w two electrodes)

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18
Q

Hazards of tissue sealing devices

A

1) inadvertent thermal injury
2) inadvertent cutting of patent vessels before sealing
3) improper function if metal is w/in the jaws (staples or clips)

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19
Q

Ultrasonic dissection relies on what type of energy?

A

Mechanical

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20
Q

The tissue heating with ultrasonic devices is generated by:

A

Converting electrical energy into high frequency, ultrasonic vibration, utilizing a piezoelectric transducer. Vibration seals and divides tissue.

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21
Q

Ultrasonic high vs low power (cut vs coag)

A

LOWER power settings result in relatively more HEMOSTASIS and HIGHER power settings result in relatively more CUTTING.

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22
Q

What are blades/jaws on piezoelectric transducer?

A

Active: vibrating; can injure tissue if touched immediately after use
Passive: backstop to trap tissue against the active blade; minimal heat transferred

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23
Q

Avoiding inadvertent tissue:

A

1) be aware of contact points the blade is engaging
2) grab & elevate target tissue
3) keep active blade upwards, in view of surgeon

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24
Q

What happens to current density if you half the diameter of a ligature/surgical site?

A

Increases 16 fold

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25
Q

Cutting mode:

A

During electrosurgery, the method of heating tissue quickly, converting cell water to steam & causing the cell to explode. (low voltage)

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26
Q

Capacitative coupling is a result of using what?

A

Using a metal trocar with a plastic screw anchor. Prevents the trocar from draining its charge.

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27
Q

Where should monitor be positioned?

A

At or just below eye level

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28
Q

Where should surgeon stand?

A

Opposite of the operative field for best ergonomic position. Wrists slightly pronated, thumbs up.

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29
Q

Ideal ergonomic position for surgeon?

A

Arms at a 30 degree angle from the trunk & elbows flexed 60-120 degrees & the wrists slightly pronated, thumbs up & straight, both radial-ulnar axis and flexion-extension axis are no more than 2-3 degrees of either access.

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30
Q

When should anticoagulation be discontinued?

A

Most should be discontinued at least 3 days prior to elective surgery.

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31
Q

NSAIDs pre/peri-operative:

A

There is no proof that non-steroidal anti-inflammatory medication, including aspirin, need to be discontinued prior to safely proceeding with laparoscopic surgery

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32
Q

Pulmonary or cardiac medications recs in the perioperative period?

A

Any pulmonary or cardiac medications are important to continue throughout the perioperative period.

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33
Q

Which ASA Classes are contraindicated in LSC surgery?

A

ASA 4 and ASA 5; may not be appropriate candidates b/c their marginal cardiopulm. reserve is often unable to tolerate the physiological changes caused by pneumoperitoneum

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34
Q

ASA Class 1

A

Normal healthy person; no organic, physiologic, biochemical, or psych disturbance

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35
Q

ASA Class 2

A

Mild systemic disease (due to either surgical condition or to concomitant disease); normal pregnancy, smoker, social ETOH drinker, obesity (BMI 30-40), well controlled HTN/DM, mild lung dz

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36
Q

ASA Class 2 OB examples

A

normal pregnancy, well controlled GHTN, PreE without, diet controlled GDM

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37
Q

ASA Class 3

A

Severe systemic dz that causes functional limitations; morbid obesity BMI 40 and up, HTN, COPD, ETOH abuse, ESRD, h/o MI/CVA

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38
Q

ASA Class 3 Pregnancy examples

A

PreE with SF, GDM with complications or high insulin requirements, thrombolic dz requiring anticoag

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39
Q

ASA Class 4

A

Severe systemic dz that is life threatening; recent (<3 mo) MI/CVA/TIA/CAD/stents, ongoing cardiac ischemia, severe valve dysfunction, sepsis, shock, DIC, ESRD not on dialysis; HELLP

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40
Q

ASA Class 4 Pregnancy examples

A

PreE with SF complicated by HELLP, peripartum cardiomyopathy with EF <40, decompensated heart dz

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41
Q

ASA Class 5

A

Moribund pt who’s not expected to live w/o the surgery; uterine rupture

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42
Q

ASA Class 5 Pregnancy example

A

Uterine rupture

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43
Q

ASA Class 6

A

Brain dead pt whose organs are being removed for donation

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44
Q

Obese pts

A
  • Longer trocars placed PERPENDICULAR to abd wall

- Length: >100mm (>10cm)

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45
Q

Thin patient trocar placement

A
  • elevated abd wall, insert at 45 degrees towards pelvic
  • place veress away from midline & around costal margin
  • Open/hasson or optical trocar (rec’d if prior abd sx)
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46
Q

Absolute contraindications to LSC (4)

A

1) inability to tolerate OPEN
2) hypovolemic shock (if unable to resuscitate)
3) lack of surgeon training
4) lack of appropriate institutional support

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47
Q

Relative contraindications to LSC (5)

A

1) Inability to tolerate general
2) Long standing peritonitis
3) large abdominal or pelvic mass
4) Massive incarcerated ventral and inguinal hernias
5) severe cardiopulm dz (can’t tolerate positioning)

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48
Q

Considerations w/ prior abd surgery

A
  • increased adhesions
  • increased risk of enterotomy
  • veress insertion shouldn’t be close to previous incisions
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49
Q

Cirrhosis considerations

A
  • increased risk of bleeding and postop ascites leak from LSC wounds
  • medically manage ascites before sx
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50
Q

During which trimester is LSC safe in pregnancy?

A

ALL

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51
Q

Special precautions for pregnancy and LSC surgery:

A

1) Tailor initial access based on fundal height
2) lower insufflation pressures
3) FHTs pre and post op
4) lateral recumbent position

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52
Q

Anesthetic options for local anesthesia (3)

A
  1. Bupivocaine
  2. Lidocaine
  3. Ropivacaine
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53
Q

Arm positioning

A
  • pelvic/lower abd: tuck 1 or both arms, hands not flexed

- upper abdomen: arms on the side, ABducted at 90 degree (not >90 to avoid brachial plexus injury)

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54
Q

Allen stirrups vs candy cane?

A

Allen is better to avoid less extreme angulation

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55
Q

Lateral decubitus position

A

-avoid stretch on brachial plexus
-**Roll on dependent side can -protect axilla & plexus
upper arm in a sling
- bean bag can hold pt a the right angle but can cause pressure injuries b/c its stiff (use padding on the bean bag)

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56
Q

Modified decubitus

A

Used to allow rotation b/c full lateral decub. and supine

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57
Q

Entry site for establishing pneumoperitoneum:

A

Umbilicus is most common

58
Q

Alternative entry site for establishing pneumoperitoneum if:

A
  • previous umbilical scar, h/o umbilical hernia repair, if site not optimal location for surgery
59
Q

Most accurate intraperitoneal check

A

Low insufflation pressure (<8mmhg) w/ low to medium flow of CO2

60
Q

Absolute contraindication to blind trocar insertion:

A

1) abdominal scar from prior OPEN surgery in immediate vicinity of trochar insertion
2) Through previously placed intraperitoneal mesh for hernia repair

61
Q

Palmer’s point

A

LUQ midclavicular at anterior axillary line 3cm or two finger breadths below ribs

  • *go lateral to epigastric vessels when using site off midline
    • avoid rectus muscles
62
Q

Most common vessel injured with veress insertion

A

The take off of the right common iliac artery from aorta lies directly below umbilicus; it’s most commonly injured in thin patients (retroperitoneal injury)

63
Q

Hasson (open) technique:

A
  • Make a 2 cm vertical or horizontal skin incision
  • Carry incision down through the skin & subQ
  • incise fascia with scalpel or monopolar cautery on CUT
  • anchor fascia w/ 0 or 2-0 absorbable suture (simple or horizontal matress) (placed before OR after entering peritoneum)
  • dissect preperitoneal fat
  • grasp peritoneum w/ 2 clamps & incise sharply
  • insert blunt tipped trocar under direct visualization
  • secure trocar to the fascia with the previously placed stay sutures
  • connect insufflator tubing & initiate pneumoperitoneum
64
Q

What gas preferred and why?

A

CO2
Available, inexpensive, rapidly absorbed and SOLUBLE in blood, easily eliminated by alveoli in lungs, suppresses combustion

65
Q

CO2 effects

A

INC arterial CO2&raquo_space; INC end tidal CO2&raquo_space; DECR serum pH

66
Q

CO2 pulmonary effects

A
  • INC minute ventilation to eliminate absorbed CO2
  • INC pressure pushing diaphragm cephalad&raquo_space; DECR func residual capacity, INCR peak airway press, DECR pulm compliance & diaphragmatic excursion
67
Q

Cardiac output response

A

Usually DECREASES due to both chemical and pressure effects

68
Q

Cardiac output response (preload, afterload, CO)

A

INCREASED preload, INCREASED afterload, DECREASED cardiac output

69
Q

CO decrease exacerbated by:

A

Reverse T-burg, hypovolemia, underlying cardiac dz, pneumo/vagally induced bradycardia&raquo_space; decreased tissue perfusion manifests as HYPOTENSION, arrhythmia, decr UOP, & INC end tidal CO2

70
Q

decreased tissue perfusion manifests as:

A

HYPOTENSION, arrhythmia, decr UOP, & INC end tidal CO2

71
Q

Intraop actions if symptomatic decreased cardiac output:

A
  • desufflate immediately
  • check insufflator settings/function
  • check for adequate relaxation
  • check intravascular volume status
  • check for other causes such as bleeding
72
Q

Most common cardiac change

A

Sinus tachycardia (mild and self limited)

73
Q

PVCs are due to what affect of CO2?

A

Chemical (PVCs rarely problematic)

74
Q

Bradycardia due to what?

A
  • Vagally mediated & occurs soon after pneumo is established due to PRESSURE effect
  • if severe, stop insuf. & release pneumo. Once stable, can re-establish pneumo w/ lower flow & pressure.
75
Q

Persistent arrhythmia

A

Open or abort procedure

76
Q

Increased IVC resistance due to what?

A

PRESSURE effect of pneumo

reduced LE venous flow rate

77
Q

Alternative gases

A

Nitrous oxide, air, helium, argon

78
Q

Nitrous oxide benefits

A
  • less acid base disturbances
  • better for pts w/ severe cardiopulm dz
  • slightly less postop pain
  • tolerated well w/o gen anesth.
79
Q

Nitrous oxide risks

A
  • does NOT suppress combustion
  • **Fire hazard if using electrocautery in the presence of open bowel (from combustible gas in the bowel)
  • do not use in pts w/o bowel prep or if high risk of bowel perf
80
Q

Renal effects

A
  • UOP unreliable due to PRESSURE effect
  • INCR intra-abd pressure DECREASES renal blood flow & UOP&raquo_space; RENIN/ADH INCREASES
  • intraop oliguria is common
81
Q

Gas embolus

A
  • Small asymptomatic emboli occur frequently

- symptomatic = rare (0.015%)

82
Q

Symptoms of gas embolus

A
  • sudden cardiovasc collapse

- severe hypotension, JVD, tachycardia, MILL WHEEL murmur

83
Q

Treatment of gas embolus

A
  • stop insufflation & evacuate pneumo
  • Place in Tburg, LEFT lateral decubitus w/ head down to prevent embolus from going to R outflow tract “Durants position”
  • Rapid crystalloid fluid administration, 100% O2, TEE to dx if needed
  • Central line placement to evacuate or break up embolus in R heart chamber
84
Q

Core needle biopsy

A
  • Tissue for histology eval (form of incisional bx)
  • 14-18 gauge needle
  • used for bx of liver
85
Q

Incisional bx used for

A

Larger lesions

86
Q

Excisional bx used for

A

Smaller lesions

87
Q

FNA biopsy

A

Cytology specimen, higher yield than washings

20-22 gauge needle

88
Q

Electrocautery and bx

A

Avoid when obtaining specimen. Use only after to help w/ hemostasis (it can alter or distort specimen)

89
Q

Bx of peritoneal lesions

A
  • bx forceps, grasper, scissors
  • small lesion > excisional
  • large lesion > incisional
  • remove via 5 or 10 mm port
90
Q

LN bx

A
  • usually EXCISIONAL bx is done
  • Careful use of energy during bx
  • smaller nodes removed via 10-12mm port, larger nodes using a sac
91
Q

Bx of liver lesions below surface

A

FNA or core needle bx, may need US; hemostasis AFTER specimen is collected

92
Q

Bx of fluid filled liver lesions

A
  • cysts don’t need bx

- avoid vascular lesions b/c they can bleed

93
Q

Bx of generalized liver parenchymal dz (cirrhosis)

A

Core needle bx, wedge bx of edge of liver

94
Q

Bx of solid liver lesion

A
  • small surface lesion: incisional or excisional; if flat, core needle or wedge
  • large surface lesion: incisional bx (core needle or wedge)
  • below surface: FNA or core needle
95
Q

Bx of ovary if high suspicion of cancer

A

Oophorectomy (removal of cyst wall or wedge bx of solid lesion okay if not)

96
Q

Options for bx of ovary (3)

A

1) oophorectomy
2) wedge resection (of solid lesion)
3) bx forceps (on antimesenteric portion)

97
Q

Small superficial lesion on hollow viscous mgmt

A

Can be removed and serosal stitch placed over top

98
Q

Retroperitoneal bx hemostasis

A

Avoid monopolar near major structures; use bipolar, endoloop, clips, etc.
use US if lesion not visible

99
Q

MC bx under US

A

Core needle or FNA

100
Q

Hemostasis after bx in general

A

PRESSURE first, monopolar, bipolar, topical agents, suture, ultrasonic

101
Q

Braided suture (vs monofilament)

A
  • easier to handle
  • lack elastic memory
  • less likely to fray
  • requires less throws
102
Q

Undyed suture

A
  • can absorb blood and are hard to see

- dyed suture preferred

103
Q

Which is preferred? Dyed or undyed suture?

A

Dyed

104
Q

Which is preferred? tapered or conventional needle?

A

Tapered/smooth…they’re safer compared to conventional/cutting needle

105
Q

How far apart should ports be w/ intracorporeal tying?

A

Greater than or equal to 10cm

106
Q

Intracorporeal knot tying ideal suture length

A

15cm or 6in

107
Q

Extracorporeal knot tying ideal suture length

A

76cm or 30in

108
Q

Trocar size for SH needle

A

10-12mm

109
Q

Port size for staples

A

12mm port

110
Q

Clips used for

A
  • small tubular structures

- **NOT for closing openings in hollow organs

111
Q

Clip sizes

A
  • 5 and 10 mm
  • disposable applier: can place multiple clips w/o changing out instrument
  • reusable: metal and plastic clips
112
Q

Linear staplers…general mechanism

A

Places two or three rows of staples on either side of a knife plate that divides the tissue between the staple lines.

113
Q

Staple length and height ranges

A

Length of staple cartridges range from 30mm to 60 mm. Staple size or height ranges from 2mm-4.5mm.

114
Q

Smaller staples vs larger staples

A
  • Smaller: more hemostasis, thinner tissue (vessels or mesentery)
  • larger: thicker tissue
115
Q

Staple color, height, examples

A

1) White/gray = 2-2.5mm = vascular application
2) blue = 3-3.5mm = majority of GI tract
3) green = 4-4.5mm = distal stomach, thick portions of GI tract

116
Q

Choice of staple height depends on:

A

the thickness of the tissue

117
Q

Good maneuvers to control bleeding

A
  • *grasp & hold bleeding source
  • *5mm atraumatic grasper to tamponade
  • add extra trocars/maintain exposure
  • 10 mm suction
  • minimize irrigation
118
Q

Highest risk of injury to epigastics

A

Trocars placed through rectus muscles

119
Q

Port site bleeding: slow, visible source

A

energy source/electrocautery or direct pressure

120
Q

Port site bleeding: high rate, no visible source

A
  • control w/ grasper
  • place foley catheter
  • dissection to find source
  • suture and/or energy source
121
Q

Port site bleeding: heavy bleeding

A
  • full thickness abdominal wall suture
122
Q

Retroperitoneal bleed suspected when

A

Free blood seen in abd cavity with no identifiable source (presume a major vascular injury)&raquo_space; convert to OPEN!!!

123
Q

Management of LSC retroperitoneal bleed

A

CONVERT TO OPEN

124
Q

Retroperitoneal hemorrhage due to veress needle injury

A
  • MC vessel injured is iliac vein during trocar placement
  • can have concomitant bowel injury, inspect bowel
  • may have overlying viscera or be in mesentery of bowel
125
Q

Retroperitoneal hemorrhage due to trocar injury

A
  • more immediate blood loss, more easily dx’d

- attempt to tamponade bleeding while converting to open

126
Q

Monopolar electrocautery for hemostasis used for:

A

small vessels, slow rate of bleeding, need relatively dry operative field

127
Q

Bipolar electrocautery for hemostasis used for:

A

larger vessels, works in “wet” operative field, less lateral spread, lower energy requirement (advanced bipolar = improved hemostatic capability)

128
Q

Hemostatic agents for bleeding control

A
  • *useful for raw surfaces
  • slow rate of bleeding
  • not effective for large vessels
  • some require special applicator
129
Q

Prevention of shoulder pain

A
  • *wound infiltration w/ local anesthetic
  • lower insufflation pressure
  • deliberate evacuation of pneumo after sx
  • multimodal anesthesia
130
Q

Tissue heating relationship to current density

A

**Tissue heating = (current density)^2

131
Q

Cumulative radiation dosage during pregnancy

A

5-10 rads

132
Q

Fetal mortality is greatest when radiation exposure occurs when?

A

w/in 1st week of conception

133
Q

Most sensitive time period for CNS teratogenesis is:

A

b/w 10-17wga
avoid routine radiographs during this time (later in pregnancy, concern shifts towards increased risk of childhood hematologic malignancy)

134
Q

No single diagnostic study should exceed _ rads.

A

FIVE

135
Q

MRI recs in pregnancy

A

MRI without IV Gadolinium can be done at any stage of preg

  • no adverse effects of amIR on fetal development have been reported
  • Gadolinium crosses placenta & can be detrimental
136
Q

CT scan in preg

A
  • may be used judiciously
  • rads can range from 2-5 (pelvis only vs abd/pelvis)
  • safe rad dose but think about teratogenesis & childhood blood cancer
137
Q

PET scan in pregnancy (radionucleotides)

A

safe
including technetium-99m
fetal exposure is <0.5rad

138
Q

Cholangiography

A

may be used selectively

shield lower abdomen to decrease fetal exposure

139
Q

Pregnant patient positioning

A

Left lateral decubitus

Minimize compression of vena cava

140
Q

Pregnant initial port placement

A
  • adjust based on fundal height and previous incisions

- open, veress, or optical trocar

141
Q

Pregnant insufflation pressure

A

10-15mmHg

142
Q

VTE ppx pregnant pt

A

Intra and post-op SCDs and early ambulation

FLS (1 decks)

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