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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
When can brachial plexus nerve injury happen? (2)
Overextension of arm Shoulder support
26
What nerve injuries can lithotomy position cause? (2)
Peroneal nerve Compartment syndrome
27
Laparoscopy vs Laparotomy must demonstrate (3)
More rapid recovery Better maintenance of hemostasis Less risk
28
Results of using laparoscopy rather than laparotomy (3)
-Decreases postop pain -Decreases postop nausea/vomiting -Less pulmonary dysfunction (but not none)
29
Surgical complications of laparoscopy
Intestinal injuries: perforations, CBD injury Vascular injuries Burns Infection Contraindicated in increased ICP…tumor, trauma, hydrocephalus
30
Incidence of intestinal injuries with laparoscopy
30-50% of serious complications May remain undiagnosed
31
when is laparoscopy contraindicated
Contraindicated in increased ICP…tumor, trauma, hydrocephalus
32
Vascular injuries associated with laparoscopy?
Retroperitoneal hematomas often insidious Great vessel injury emergent
33
Positioing for gal bladder sx
reverse T and rotate to the L. tuck L arm
34
Postop laparoscopy (3)
Oxygen Prevention of nausea and vomiting Treatment of surgical pain or referred pain Discuss referred pain preop
35
SCIP
Surgical care improvement project Antibiotics Beta-blockers Temperature Time out
36
Complications of gerd that could lead to Nissen fundoplication
Stricture Aspiration pneumonia Esophageal ulcerations Barrett’s esophagus
37
Indications for Nissen fundoplication
-To increase lower esophageal sphincter pressure -Gerd complications -Failure or unwillingness to commit to medication
38
Preop meds for Nissen fundoplication
PPI Prokinetic drugs Documented esophageal hyperacidity
39
PPIs
Decrease acid production...block ATPase in parietal cells “prazoles”… nexium, prevacid, protonix, prilosec
40
Prokinetic drugs
Strengthen LES, increase gastric emptying metoclopramide, cisapride
41
Position for nissen fudoplication
Supine, low lithotomy, reverse Tburg surgeon stands between legs
42
Extra needs for nissen fudoplication
OGT Esophageal dilator (60 F) - gauges pressure at the end of the esophagus
43
Pointy esophageal dilator
Maloney- less likely to perforate tapered end
44
Dull esophageal dilator
hurst
45
Lap chole indications
Symptomatic cholelithiasis Symptomatic cholecystitis 5 F’s: female, forty, fair, flatulent, fat
46
Preoperative considerations for lap cholecystectomy
Full stomach prokinetics Bicitra
47
Position for lap cholecystectomy
Supine, reverse Tburg, left tilt
48
Intraoperative Considerations for lap cholecystectomy
Sphincter of Oddi spasm Glucagon
49
Indications for spleenectomy (4)
ITP Lymphoma Hemolytic anemia Trauma
50
Preoperative for splenectomy considerations (2)
Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop Evaluate LLL atelectasis
51
type and cross
type, blood ready to go with antibodies, waiting for them on the shelf expensive
52
type and screen
know what type they are
53
Position for spleenectomy
45 degree right lateral decubitus Kidney rest, table flexed
54
Indications for bowel resection (5)
Ulcerative colitis Crohn’s disease Diverticular disease Cancers Ischemic bowel
55
Preop for bowel resection (3)
Bowel prep Mu-opioid antagonists (entereg/alvimopan)- fent and sufent cant bind. ERAS;Preop warming Gabapentin, acetaminophen, scopolamine Gatorade
56
Position for bowel resection
Supine or low lithotomy
57
fluids for bowel resection
Consider albumin vs crystalloid
58
Indications for appendectomy
Suspected appendicitis lymph nodes in the groin that are close by that can complicate picture
59
Preoperative Considerations for Appendectomy
Consider full stomach May be dehydrated d/t fever/N&V Hemoconcentration, elev. BUN
60
Position for appendectomy
Supine, left arm tucked; trendelenburg
61
lap banding features
slow; 55% excess over 5yrs easily removed nutrients not affected brand erosion
62
Sleeve gastrectomy features
rapid initial not easily reversible nutrients not affected suture line; overeating
63
Gastric bypass features
rapid initial not reversible protein/ nutrients affected suture line x2 malabsorption.
64
indications for bariatric surgery
Morbid obesity associated with -HTN -Diabetes -Sleep apnea -Asthma BMI > 35 with associated comorbidities BMI > 40
65
Preoperative considerations for bariatric surgery (4)
Review medication list- appetite suppressors? Assess airway- limit preoperative sedation? Commonly have undiagnosed OSA VTE prophylaxis
66
position for induction for bariatric surgery
Reverse Tburg/HOB up 30 degrees…..GOOD pre-oxygenation GETA/RSI- obese patients do NOT tolerate supine position Induction based on end-point
67
Long term concers for bariatric surgery (4)
Diarrhea Dysphagia Protein malabsorption Vitamin malabsorption
68
Vitamin malabsorption with bariatric surgery
A,D,E,K,B12,calcium
69
indications for laparotomy (9)
Obesity Adhesions Bleeding Unclear anatomy Staple misfire Inability to ventilate Trauma Abdominal catastrophes Staging
70
Risk factors for gyn surgery PONV
Female Laparoscopy or Laparotomy Opioids Volatile anesthetics
71
D&C
Removes endometrial lining of uterus
72
Indications for D&C
Diagnoses and treats bleeding from uterus or cervix
73
The instrument that moves the cervix
Tenaculum- single or double tooth vagal down -> bradycardia
74
Position for D and C
Lithotomy (stirrups) -Peroneal nerve injury -Table
75
When is no SCIP needed
D and C
76
Pitocin and D & C
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
D&E state variables
20-24 weeks Counseling/Waiting period Parental involvement
78
Pitocin secreted from ____ stimulates _____
Secreted from the neuro-hypophysis Stimulates uterine contraction Similar to vasopressin Increases water reabsorption from glomerular filtrate 20u/liter
79
Reason for hysteroscopy
Allows examination of the endometrial cavity Investigates IUB Inflate the uterus with NS/LRS or sorbitol In = Out
80
Indications for sling procedures
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
Indications for sling procedures
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
position for sling procedure
lithotomy
83
Condyloma things to remember
Laser evacuation procedures Laser masks a must Smoke evacuation
84
causes of Bladder prolapse
Caused by weakened pelvic floor Delivery…repair postponed… Aging Previous pelvic surgery
85
Cystocele
Anterior prolapse
86
Rectocele
Posterior prolapse
87
Hysterecomy abdominal
Pfannenstiel or midline
88
Hysterecomy abdominal
Pfannenstiel or midline
89
LAVH
90
3 D features of robotic surgery (3)
Improved dexterity Increased cost Added operating room time
91
Position for robotic surgery + gyn procedure
extreme trendelenburg
92
Anesthesia extreme trendelenburg considerations
Fluid resitrction good muscle relaxation

Principles (34 decks)

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