General and Laparoscopic sx Flashcards
What and when was laparoscopy first used
Diagnosis of gynecologic conditions
1970’s
Cholecystectomy
Late 1980’s
How to creat a pneumoperitoneum
Intraperitoneal insufflation of CO2
Identification of intraperitoneal space
Room to work
What happens when insufflation onset?
Release of catecholamines and vasopressin at onset of pneumoperitoneum= increased cardiac parameteres
Compression of arterial vasculature
normal IABP
20 mmhg (actually 15 mmhg)
Reason for increase PaCO2 with insufflation (5)
-Decreased compliance 30-50%
-Increased PIP
-Decreased FRC
-Development of atelectasis
-Absorption (adding Co2 all the time)
if trendelenburg and insullated for a long period of time what can develop?
dev of atelectasis
When does increase PaCO2 from insuflation plateau?
Plateau 10-15 minutes
can continue to increase Co2 from pulmonary effects, not from insufflation
Treatment of increased PaCO2 from insufflation
increase minute volume (vt or rr) - consider pip
When do you not want to increase mv for elevated CO2
end of case - need Co2 to trigger respiration / drive to breathe
Pulmonary complications from instufflation
Subq emphysema/pneumothorax/pneumomediastinum (trocar in subq, diaphragm or bv))
Endobronchial intubation
gas embolism
When do Subq emphysema/pneumothorax/pneumomediastinum resolve?
Usually resolves in 30-60minutes
When do gas embolisms occur?
Gas infused directly into vessel
What happens when gas is locked in the venta cava?
Obstruction to venous return
Diagnosis of Gas embolism (6)
Tachycardia
Cardiac dysrhythmias
Hypotension with increased CVP
Millwheel murmur
Hypoxemia
Decreased ETCO2- best for early clue
Treatment for gas embolism (4)
Cessation of insufflation/release of pneumoperitoneum
Trendelenburg, fluid bolus, 100% O2
Aspiration of air
Vasopressor support
How can endobronchial intubation occur?
Diaphragm elevation
Cephalad displacement of carina
What to monitor for endobronchial intubation
Monitor position of ETT
Bilateral breath sounds
Pulse oximetry
-Decrease sat
-Etco2 aren’t good
Onset of insufflation hemodynamic effects
Decreased cardiac output; proportional
Increased arterial pressure
Increased SVR/PVR
What pressure can hemodynamic effects occur at during insufflation
Occur at > 10mm Hg IAP
Resolves in several minutes
Treatment for hemodynamic changes from insufflation
vasodilating agents;
Vapor
Nitroglycerin
Cardene
Remifentanil
esmolol
propofol
Cardiac arrhythmias with insufflation
Do not correlate with level of PaCO2
Reflex increases in vagal tone
-Peritoneal stretch
-Electrocautery/stretch of fallopian tubes
How to limit stretch/ treat of vagal tone increasing
Limit insufflation pressures
Glycopyrolate
Insufflation and reverse T causes what? (3)
Decreased CO, venous stasis
Favorable ventilation
Insufflation and T causes what? (4)
-Facial/pharyngeal/laryngeal airway edema
-Increased CVP/CO
-Increased intraocular pressure
-Altered pulmonary mechanics…FRC, TLV, compliance
When can brachial plexus nerve injury happen? (2)
Overextension of arm
Shoulder support
What nerve injuries can lithotomy position cause? (2)
Peroneal nerve
Compartment syndrome
Laparoscopy vs Laparotomy must demonstrate (3)
More rapid recovery
Better maintenance of hemostasis
Less risk
Results of using laparoscopy rather than laparotomy (3)
-Decreases postop pain
-Decreases postop nausea/vomiting
-Less pulmonary dysfunction (but not none)
Surgical complications of laparoscopy
Intestinal injuries: perforations, CBD injury
Vascular injuries
Burns
Infection
Contraindicated in increased ICP…tumor, trauma, hydrocephalus
Incidence of intestinal injuries with laparoscopy
30-50% of serious complications
May remain undiagnosed
when is laparoscopy contraindicated
Contraindicated in increased ICP…tumor, trauma, hydrocephalus
Vascular injuries associated with laparoscopy?
Retroperitoneal hematomas often insidious
Great vessel injury emergent
Positioing for gal bladder sx
reverse T and rotate to the L.
tuck L arm
Postop laparoscopy (3)
Oxygen
Prevention of nausea and vomiting
Treatment of surgical pain or referred pain
Discuss referred pain preop
SCIP
Surgical care improvement project
Antibiotics
Beta-blockers
Temperature
Time out
Complications of gerd that could lead to Nissen fundoplication
Stricture
Aspiration pneumonia
Esophageal ulcerations
Barrett’s esophagus
Indications for Nissen fundoplication
-To increase lower esophageal sphincter pressure
-Gerd complications
-Failure or unwillingness to commit to medication
Preop meds for Nissen fundoplication
PPI
Prokinetic drugs
Documented esophageal hyperacidity
PPIs
Decrease acid production…block ATPase in parietal cells
“prazoles”… nexium, prevacid, protonix, prilosec
Prokinetic drugs
Strengthen LES, increase gastric emptying
metoclopramide, cisapride
Position for nissen fudoplication
Supine, low lithotomy, reverse Tburg
surgeon stands between legs
Extra needs for nissen fudoplication
OGT
Esophageal dilator (60 F) - gauges pressure at the end of the esophagus
Pointy esophageal dilator
Maloney- less likely to perforate
tapered end
Dull esophageal dilator
hurst
Lap chole indications
Symptomatic cholelithiasis
Symptomatic cholecystitis
5 F’s: female, forty, fair, flatulent, fat
Preoperative considerations for lap cholecystectomy
Full stomach
prokinetics
Bicitra
Position for lap cholecystectomy
Supine, reverse Tburg, left tilt
Intraoperative Considerations for lap cholecystectomy
Sphincter of Oddi spasm
Glucagon
Indications for spleenectomy (4)
ITP
Lymphoma
Hemolytic anemia
Trauma
Preoperative for splenectomy considerations (2)
Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop
Evaluate LLL atelectasis
type and cross
type, blood ready to go with antibodies, waiting for them on the shelf
expensive
type and screen
know what type they are
Position for spleenectomy
45 degree right lateral decubitus
Kidney rest, table flexed
Indications for bowel resection (5)
Ulcerative colitis
Crohn’s disease
Diverticular disease
Cancers
Ischemic bowel
Preop for bowel resection (3)
Bowel prep
Mu-opioid antagonists (entereg/alvimopan)- fent and sufent cant bind.
ERAS;Preop warming
Gabapentin, acetaminophen, scopolamine
Gatorade
Position for bowel resection
Supine or low lithotomy
fluids for bowel resection
Consider albumin vs crystalloid
Indications for appendectomy
Suspected appendicitis
lymph nodes in the groin that are close by that can complicate picture
Preoperative Considerations for Appendectomy
Consider full stomach
May be dehydrated d/t fever/N&V
Hemoconcentration, elev. BUN
Position for appendectomy
Supine, left arm tucked; trendelenburg
lap banding features
slow; 55% excess over 5yrs
easily removed
nutrients not affected
brand erosion
Sleeve gastrectomy features
rapid initial
not easily reversible
nutrients not affected
suture line; overeating
Gastric bypass features
rapid initial
not reversible
protein/ nutrients affected
suture line x2 malabsorption.
indications for bariatric surgery
Morbid obesity associated with
-HTN
-Diabetes
-Sleep apnea
-Asthma
BMI > 35 with associated comorbidities
BMI > 40
Preoperative considerations for bariatric surgery (4)
Review medication list- appetite suppressors?
Assess airway- limit preoperative sedation?
Commonly have undiagnosed OSA
VTE prophylaxis
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
Long term concers for bariatric surgery (4)
Diarrhea
Dysphagia
Protein malabsorption
Vitamin malabsorption
Vitamin malabsorption with bariatric surgery
A,D,E,K,B12,calcium
indications for laparotomy (9)
Obesity
Adhesions
Bleeding
Unclear anatomy
Staple misfire
Inability to ventilate
Trauma
Abdominal catastrophes
Staging
Risk factors for gyn surgery PONV
Female
Laparoscopy or Laparotomy
Opioids
Volatile anesthetics
D&C
Removes endometrial lining of uterus
Indications for D&C
Diagnoses and treats bleeding from uterus or cervix
The instrument that moves the cervix
Tenaculum- single or double tooth
vagal down -> bradycardia
Position for D and C
Lithotomy (stirrups)
-Peroneal nerve injury
-Table
When is no SCIP needed
D and C
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
D&E state variables
20-24 weeks
Counseling/Waiting period
Parental involvement
Pitocin secreted from ____ stimulates _____
Secreted from the neuro-hypophysis
Stimulates uterine contraction
Similar to vasopressin
Increases water reabsorption from glomerular filtrate
20u/liter
Reason for hysteroscopy
Allows examination of the endometrial cavity
Investigates IUB
Inflate the uterus with NS/LRS or sorbitol
In = Out
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
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
position for sling procedure
lithotomy
Condyloma things to remember
Laser evacuation procedures
Laser masks a must
Smoke evacuation
causes of Bladder prolapse
Caused by weakened pelvic floor
Delivery…repair postponed…
Aging
Previous pelvic surgery
Cystocele
Anterior prolapse
Rectocele
Posterior prolapse
Hysterecomy abdominal
Pfannenstiel or midline
Hysterecomy abdominal
Pfannenstiel or midline
LAVH
3 D features of robotic surgery (3)
Improved dexterity
Increased cost
Added operating room time
Position for robotic surgery + gyn procedure
extreme trendelenburg
Anesthesia extreme trendelenburg considerations
Fluid resitrction
good muscle relaxation
