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Principles > General and Laparoscopic sx > Flashcards

General and Laparoscopic sx Flashcards

1
Q

What and when was laparoscopy first used

A

Diagnosis of gynecologic conditions
1970’s

Cholecystectomy
Late 1980’s

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2
Q

How to creat a pneumoperitoneum

A

Intraperitoneal insufflation of CO2
Identification of intraperitoneal space
Room to work

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3
Q

What happens when insufflation onset?

A

Release of catecholamines and vasopressin at onset of pneumoperitoneum= increased cardiac parameteres

Compression of arterial vasculature

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4
Q

normal IABP

A

20 mmhg (actually 15 mmhg)

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5
Q

Reason for increase PaCO2 with insufflation (5)

A

-Decreased compliance 30-50%
-Increased PIP
-Decreased FRC
-Development of atelectasis
-Absorption (adding Co2 all the time)

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6
Q

if trendelenburg and insullated for a long period of time what can develop?

A

dev of atelectasis

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7
Q

When does increase PaCO2 from insuflation plateau?

A

Plateau 10-15 minutes

can continue to increase Co2 from pulmonary effects, not from insufflation

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8
Q

Treatment of increased PaCO2 from insufflation

A

increase minute volume (vt or rr) - consider pip

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9
Q

When do you not want to increase mv for elevated CO2

A

end of case - need Co2 to trigger respiration / drive to breathe

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10
Q

Pulmonary complications from instufflation

A

Subq emphysema/pneumothorax/pneumomediastinum (trocar in subq, diaphragm or bv))
Endobronchial intubation
gas embolism

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11
Q

When do Subq emphysema/pneumothorax/pneumomediastinum resolve?

A

Usually resolves in 30-60minutes

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12
Q

When do gas embolisms occur?

A

Gas infused directly into vessel

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13
Q

What happens when gas is locked in the venta cava?

A

Obstruction to venous return

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14
Q

Diagnosis of Gas embolism (6)

A

Tachycardia
Cardiac dysrhythmias
Hypotension with increased CVP
Millwheel murmur
Hypoxemia
Decreased ETCO2- best for early clue

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15
Q

Treatment for gas embolism (4)

A

Cessation of insufflation/release of pneumoperitoneum
Trendelenburg, fluid bolus, 100% O2
Aspiration of air
Vasopressor support

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16
Q

How can endobronchial intubation occur?

A

Diaphragm elevation
Cephalad displacement of carina

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17
Q

What to monitor for endobronchial intubation

A

Monitor position of ETT
Bilateral breath sounds
Pulse oximetry
-Decrease sat
-Etco2 aren’t good

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18
Q

Onset of insufflation hemodynamic effects

A

Decreased cardiac output; proportional
Increased arterial pressure
Increased SVR/PVR

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19
Q

What pressure can hemodynamic effects occur at during insufflation

A

Occur at > 10mm Hg IAP

Resolves in several minutes

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20
Q

Treatment for hemodynamic changes from insufflation

A

vasodilating agents;
Vapor
Nitroglycerin
Cardene
Remifentanil
esmolol
propofol

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21
Q

Cardiac arrhythmias with insufflation

A

Do not correlate with level of PaCO2

Reflex increases in vagal tone
-Peritoneal stretch
-Electrocautery/stretch of fallopian tubes

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22
Q

How to limit stretch/ treat of vagal tone increasing

A

Limit insufflation pressures
Glycopyrolate

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23
Q

Insufflation and reverse T causes what? (3)

A

Decreased CO, venous stasis
Favorable ventilation

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24
Q

Insufflation and T causes what? (4)

A

-Facial/pharyngeal/laryngeal airway edema
-Increased CVP/CO
-Increased intraocular pressure
-Altered pulmonary mechanics…FRC, TLV, compliance

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25
Q

When can brachial plexus nerve injury happen? (2)

A

Overextension of arm
Shoulder support

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26
Q

What nerve injuries can lithotomy position cause? (2)

A

Peroneal nerve
Compartment syndrome

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27
Q

Laparoscopy vs Laparotomy must demonstrate (3)

A

More rapid recovery
Better maintenance of hemostasis
Less risk

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28
Q

Results of using laparoscopy rather than laparotomy (3)

A

-Decreases postop pain
-Decreases postop nausea/vomiting
-Less pulmonary dysfunction (but not none)

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29
Q

Surgical complications of laparoscopy

A

Intestinal injuries: perforations, CBD injury
Vascular injuries
Burns
Infection
Contraindicated in increased ICP…tumor, trauma, hydrocephalus

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30
Q

Incidence of intestinal injuries with laparoscopy

A

30-50% of serious complications
May remain undiagnosed

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31
Q

when is laparoscopy contraindicated

A

Contraindicated in increased ICP…tumor, trauma, hydrocephalus

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32
Q

Vascular injuries associated with laparoscopy?

A

Retroperitoneal hematomas often insidious
Great vessel injury emergent

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33
Q

Positioing for gal bladder sx

A

reverse T and rotate to the L.
tuck L arm

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34
Q

Postop laparoscopy (3)

A

Oxygen

Prevention of nausea and vomiting

Treatment of surgical pain or referred pain
Discuss referred pain preop

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35
Q

SCIP

A

Surgical care improvement project

Antibiotics

Beta-blockers

Temperature

Time out

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36
Q

Complications of gerd that could lead to Nissen fundoplication

A

Stricture
Aspiration pneumonia
Esophageal ulcerations
Barrett’s esophagus

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37
Q

Indications for Nissen fundoplication

A

-To increase lower esophageal sphincter pressure
-Gerd complications
-Failure or unwillingness to commit to medication

38
Q

Preop meds for Nissen fundoplication

A

PPI
Prokinetic drugs
Documented esophageal hyperacidity

39
Q

PPIs

A

Decrease acid production…block ATPase in parietal cells
“prazoles”… nexium, prevacid, protonix, prilosec

40
Q

Prokinetic drugs

A

Strengthen LES, increase gastric emptying
metoclopramide, cisapride

41
Q

Position for nissen fudoplication

A

Supine, low lithotomy, reverse Tburg

surgeon stands between legs

42
Q

Extra needs for nissen fudoplication

A

OGT
Esophageal dilator (60 F) - gauges pressure at the end of the esophagus

43
Q

Pointy esophageal dilator

A

Maloney- less likely to perforate
tapered end

44
Q

Dull esophageal dilator

A

hurst

45
Q

Lap chole indications

A

Symptomatic cholelithiasis

Symptomatic cholecystitis

5 F’s: female, forty, fair, flatulent, fat

46
Q

Preoperative considerations for lap cholecystectomy

A

Full stomach
prokinetics
Bicitra

47
Q

Position for lap cholecystectomy

A

Supine, reverse Tburg, left tilt

48
Q

Intraoperative Considerations for lap cholecystectomy

A

Sphincter of Oddi spasm
Glucagon

49
Q

Indications for spleenectomy (4)

A

ITP

Lymphoma

Hemolytic anemia

Trauma

50
Q

Preoperative for splenectomy considerations (2)

A

Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop

Evaluate LLL atelectasis

51
Q

type and cross

A

type, blood ready to go with antibodies, waiting for them on the shelf
expensive

52
Q

type and screen

A

know what type they are

53
Q

Position for spleenectomy

A

45 degree right lateral decubitus
Kidney rest, table flexed

54
Q

Indications for bowel resection (5)

A

Ulcerative colitis

Crohn’s disease

Diverticular disease

Cancers

Ischemic bowel

55
Q

Preop for bowel resection (3)

A

Bowel prep

Mu-opioid antagonists (entereg/alvimopan)- fent and sufent cant bind.

ERAS;Preop warming
Gabapentin, acetaminophen, scopolamine
Gatorade

56
Q

Position for bowel resection

A

Supine or low lithotomy

57
Q

fluids for bowel resection

A

Consider albumin vs crystalloid

58
Q

Indications for appendectomy

A

Suspected appendicitis

lymph nodes in the groin that are close by that can complicate picture

59
Q

Preoperative Considerations for Appendectomy

A

Consider full stomach

May be dehydrated d/t fever/N&V
Hemoconcentration, elev. BUN

60
Q

Position for appendectomy

A

Supine, left arm tucked; trendelenburg

61
Q

lap banding features

A

slow; 55% excess over 5yrs
easily removed
nutrients not affected
brand erosion

62
Q

Sleeve gastrectomy features

A

rapid initial
not easily reversible
nutrients not affected
suture line; overeating

63
Q

Gastric bypass features

A

rapid initial
not reversible
protein/ nutrients affected
suture line x2 malabsorption.

64
Q

indications for bariatric surgery

A

Morbid obesity associated with
-HTN
-Diabetes
-Sleep apnea
-Asthma

BMI > 35 with associated comorbidities
BMI > 40

65
Q

Preoperative considerations for bariatric surgery (4)

A

Review medication list- appetite suppressors?

Assess airway- limit preoperative sedation?

Commonly have undiagnosed OSA

VTE prophylaxis

66
Q

position for induction for bariatric surgery

A

Reverse Tburg/HOB up 30 degrees…..GOOD pre-oxygenation

GETA/RSI- obese patients do NOT tolerate supine position

Induction based on end-point

67
Q

Long term concers for bariatric surgery (4)

A

Diarrhea

Dysphagia

Protein malabsorption

Vitamin malabsorption

68
Q

Vitamin malabsorption with bariatric surgery

A

A,D,E,K,B12,calcium

69
Q

indications for laparotomy (9)

A

Obesity

Adhesions

Bleeding

Unclear anatomy

Staple misfire

Inability to ventilate

Trauma

Abdominal catastrophes

Staging

70
Q

Risk factors for gyn surgery PONV

A

Female
Laparoscopy or Laparotomy
Opioids
Volatile anesthetics

71
Q

D&C

A

Removes endometrial lining of uterus

72
Q

Indications for D&C

A

Diagnoses and treats bleeding from uterus or cervix

73
Q

The instrument that moves the cervix

A

Tenaculum- single or double tooth

vagal down -> bradycardia

74
Q

Position for D and C

A

Lithotomy (stirrups)
-Peroneal nerve injury
-Table

75
Q

When is no SCIP needed

A

D and C

76
Q

Pitocin and D & C

A

20 units/ ml - 20 units into IV bag -> hundreds of ml/hr. dilute in 500 and 600 -> clamp down on uterine arteries -> decrease uterine bleeding after finished

77
Q

D&E state variables

A

20-24 weeks
Counseling/Waiting period
Parental involvement

78
Q

Pitocin secreted from ____ stimulates _____

A

Secreted from the neuro-hypophysis
Stimulates uterine contraction

Similar to vasopressin
Increases water reabsorption from glomerular filtrate

20u/liter

79
Q

Reason for hysteroscopy

A

Allows examination of the endometrial cavity

Investigates IUB

Inflate the uterus with NS/LRS or sorbitol
In = Out

80
Q

Indications for sling procedures

A

15-60% of women
Older, multiparous women
¼ of nulliparous, college athletes

Loss of support to the bladder neck and pelvic floor (SUI)

Stress urinary leak point
(abdominal leak point pressure)

Prolene mesh

81
Q

Indications for sling procedures

A

15-60% of women
Older, multiparous women
¼ of nulliparous, college athletes

Loss of support to the bladder neck and pelvic floor (SUI)

Stress urinary leak point
(abdominal leak point pressure)

Prolene mesh

82
Q

position for sling procedure

A

lithotomy

83
Q

Condyloma things to remember

A

Laser evacuation procedures
Laser masks a must
Smoke evacuation

84
Q

causes of Bladder prolapse

A

Caused by weakened pelvic floor
Delivery…repair postponed…
Aging
Previous pelvic surgery

85
Q

Cystocele

A

Anterior prolapse

86
Q

Rectocele

A

Posterior prolapse

87
Q

Hysterecomy abdominal

A

Pfannenstiel or midline

88
Q

Hysterecomy abdominal

A

Pfannenstiel or midline

89
Q

LAVH

A
90
Q

3 D features of robotic surgery (3)

A

Improved dexterity
Increased cost
Added operating room time

91
Q

Position for robotic surgery + gyn procedure

A

extreme trendelenburg

92
Q

Anesthesia extreme trendelenburg considerations

A

Fluid resitrction
good muscle relaxation

Principles (34 decks)

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