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Advanced Principles > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What does the term general surgery refer to?

A

Surgery involving the abdominal organs

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2
Q

What is the highest ranked comorbidity in patients?

A

HTN 87%

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3
Q

What is the second highest comorbidity in patients?

A

Obesity 47%

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4
Q

What are some common advantages to general anesthesia?

A

Allows paralysis
Safely allows position extremes
Moe reliable, lower failure rate

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5
Q

What are some common disadvantage to general anesthesia?

A

Increased stress response
Known full stomach = increased aspiration risk
Post operative nausea and sedation

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6
Q

How are insufflation pressure affected if regional anesthesia is performed?

A

Lowered insufflation pressures

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7
Q

What medications can induce sphincter of Oddi pain?

A

Opioids

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8
Q

What is the treatment for sphincter of Oddi spasms?

A

Narcan
LA
Glucagon

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9
Q

What is the purpose of a laparoscopy?

A

Diagnostic and surgical intervention

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10
Q

What is the only absolute contraindication to laparoscopic surgery?

A

Hemodynamic instability

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11
Q

What are the telltale signs that a pulmonary embolus as occurred?

A 
Hypoxemia
Sudden increase in PAWP
Sudden HoTN
Bronchospasm
Sudden decrease in ETCO2
Increased CVP
Increased PAP
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12
Q

What is the safe range of insufflation pressures in the abdomen?

A

12-15mmHg

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13
Q

At what insufflation pressure will you see CO and lung compliance decrease

A

16-20mmHg

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14
Q

At what insufflation pressures will you see a decrease in Renal blood flow?

A

20-30mmHg

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15
Q

At what insufflation pressures will you see adverse hemodynamic outcomes?

A

30-40mmHg

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16
Q

What is the gas of choice for insufflation?

A

Carbon dioxide

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17
Q

What characteristics of CO2 make it the insufflation gas of choice?

A 
Easily absorbed by the tissues
Decreased risk of air emboli
Eliminated through respiration
Non-combustable
Colorless/Odorless
Inexpensive
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18
Q

What alternative gas can be used for insufflation?

A

Nitrous Oxide

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19
Q

Why did Nitrous Oxide lose favor as the gas of choice for insufflation?

A

It is combustable

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20
Q

What physiologic functions are increased by the pneumoperitoneum?

A

PaCO2, ETCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, dead space

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21
Q

What physiologic functions are decreased by the pneumoperitoneum?

A 
Cardiopulmonary function
Mean CO
Venous return
FRC/VC
Renal function
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22
Q

How does the pneumoperitoneum cause HTN and tachycardia?

A

Sympathetic stimulation

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23
Q

How does the pneumoperitoneum cause HoTN?

A

Impaired venous return

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24
Q

How does the pneumoperitoneum cause arrhythmias and bradycardia?

A

Vagal stimulation

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25
Q

How does the pneumoperitoneum cause increased ADH to be released?

A

Reduced renal perfusion causes activation of the RAAS system

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26
Q

What ventilatory setting may be most effective when a pneumoperitoneum is created?

A

Pressure control ventilation

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27
Q

What interventions can be done if there is pulmonary decompensation with the pneumoperitioneum?

A

Decrease the degree of trandelenburg
Use caution with PEEP
Consider increasing the volatile
Bronchodilators

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28
Q

What interventions can be done if there is cardiac decompensation with the pneumoperitioneum?

A

Vent the abdomen if IAP >20mmHg
Evaluate intravascular volume (fluid bolus)
Consider pre-existing cardiac disease

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29
Q

What is the goal of urine output during surgery?

A

0.5mL/kg/hr

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30
Q

What are the advantages to using a robot for laparoscopy?

A

3D view and depth perception
Increased precision
10-15x magnification
Increased free movement

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31
Q

What are the disadvantages to using a robot for laparoscopy?

A

Large system/limited working space
Limited patient access
Expensive/Maintenance cost
Instrument availability

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32
Q

What are the common indications for esophageal surgery?

A 
GERD
Cancer
Hiatal or Paraesophageal  hernia
Achalasia
Motility disorder
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33
Q

What is the Nissen fundoplication procedure?

A

Fundus is wrapped around LES and sutured to reinforce LES

The esophagus is narrowed to prevent/treat GERD or hiatal hernia

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34
Q

How is the nissen wrapped around the LES?

A

Posterior to anterior

35
Q

What can occur if the French esophageal dilator is advanced too quickly?

A

Risk of esophageal rupture

36
Q

What is the major indication for an esophagectomy?

A

Carcinoma

37
Q

Where would the incision be made in a trans-hiatal esophagectomy?

A

Neck and abdomen incisions

38
Q

Where would the incision be made in a trans-thoracic esophagectomy?

A

Thoracotomy

39
Q

What is the incidence of symptomatic AF or SVT after an esophagectomy?

A

17%

40
Q

What is a major complication associated with the THE approach?

A

RLN injury

41
Q

What should the provider be looking for post-op to determine if damage has been done to the RLN?

A

Voice quality
Coughing/Choking
Frequent breaths when speaking
Ineffective cough

42
Q

What is done during a gastrostomy?

A

An opening is made through the skin and the stomach wall to provide nutritional support or GI compression

43
Q

What complications should be assessed for after a gastrectomy is performed?

A

Dumping syndrome
Vitamin B12 deficiency
Iron deficiency anemia
Poor calcium absorption

44
Q

What are the differences in the two types of gastrectomy approaches?

A

Bilroth1: remaining portion of the stomach is attached to the duodenum
Bilroth2: seal off remaining portion of the stomach and attached to the jejunum

45
Q

What types of surgeries can be performed for peptic ulcer disease?

A

Vagotomy of the parietal cells

Pylorplasty

46
Q

How can a vagotomy cause pernicious anemia?

A

By denervating the parietal cells, intrinsic factor is not produced leading to a B12 deficiency and pernicious anemia

47
Q

When operating on the stomach, what tool can cause an acute change in PAWP?

A

Liver retractor

48
Q

What should be considered if a bowel prep is given to a patient pre-operatively?

A

Hypovolemia and Electrolyte abnormalities

49
Q

What are some complications that can occur with a small bowel resection?

A

Pulmonary embolism
Anastomotic leak
Short Bowel syndrome

50
Q

What is the most common acute surgical procedure of the abdomen?

A

Appendectomy

51
Q

What complications can occur if the appendix perforates before removal?

A

Septic shock

Peritonitis

52
Q

What two antibiotics are known to affect the duration of neuromuscular blockade?

A

Gentamicin

Clindamycin

53
Q

What might the surgeon ask the patient to do prior to induction?

A

Cough to see where the hernia bulges

54
Q

What is a hernia?

A

It is a defect in muscles of the abdomen wall

55
Q

What two occurrences require emergency hernia surgery?

A

Incarcerated

Strangulated

56
Q

What is a major post operative consideration for patients that have undergone hernia surgery?

A

Avoid straining, help them move to the bed, avoid bucking and plan for a smooth wake up

57
Q

What can result from peritoneal retraction?

A

Bradycardia

58
Q

What is the rate of conversion from a laparoscopic to an open cholecystectomy?

A

5-10%

59
Q

What are risk factors associated with a conversion from a laparoscopic to open cholecystectomy?

A 
Choledocholithiasis
Bile duct injury
Bleeding
Obesity
Male Gender
Advanced age
Previous abdominal surgery
Thickened wall
60
Q

What is the breakdown of open versus laparoscopic cholecystectomies?

A

25% Open

75% Laparoscopic

61
Q

What are potential complications associated with a cholecystectomy?

A

Bleeding from cystic artery and cystic duct
Liver laceration
Pneumothorax

62
Q

What are the major functions of the liver?

A

Metabolic: carbohydrate metabolism (gluconeogenesis, glycogenolysis and glycogenesis)
Hematologic: synthesis of heparin, synthesis of bile pigment from worn Hgb

63
Q

How many lobes are in the liver?

A

Four lobes –> eight segments

64
Q

Why is the liver considered a blood reservoir?

A

It receives 1.5L/min
80% Blood flow from portal vein
20% hepatic artery

65
Q

How does the liver participate in lipid metabolism?

A

Cholesterol synthesis

Production of triglycerides

66
Q

What does the liver store?

A

Glycogen, B12, iron and copper

67
Q

What coagulation factors are produced by the liver?

A

I, II, V, VII, IX, XI, C, S and antithrombin

68
Q

What is considered a major hepatectomy versus a minor one?

A

Minor: removes less or equal to 2 liver segments
Major: removes more than or equal to 3 liver segments

69
Q

Why does a hepacectomy have a 3-5% mortality rate?

A

Major bleeding since the liver is a blood reservoir

70
Q

Why might the provider consider a RSI on a patient undergoing a liver resection?

A

Ascites

71
Q

What is the paralytic of choice for a patient undergoing a liver resection?

A

Cisatracurium - Hoffman elimination

72
Q

What is an appropriate clamp time in a healthy liver and cirrhosis?

A

Healthy 60m

Cirrosis 20m

73
Q

What is the pringle maneuver?

A

Compression of hepatoduodenal ligament, eliminated blood flow to the liver which can decrease CO and increase afterload

74
Q

Why does significant bleeding occur in hepatic veins?

A

There are no valves in hepatic veins

75
Q

What is the most common postoperative complication requiring surgical exploration after a liver resection?

A

Bleeding and bile leak

76
Q

What are the functions of the spleen?

A

Filters foreign substances from the blood and removes blood cells
Regulates blood flow to the liver and sometimes stores blood cells

77
Q

What percentage of platelets are sequestered in the spleen in a healthy patient?

A

30%

78
Q

What is the purpose of give a patient vaccines prior to a splenectomy?

A

Helps to rev up the patients immune system prior to removing the spleen

79
Q

What type of immunoglobulins should be administered to a patient that has had a splenectomy?

A

IgM

80
Q

How does the gastric band work?

A

It limits the amount of food taken in by placing an adjustable silicone band around the upper stomach

81
Q

What type of surgery accounts for 80% of the weight loss surgeries in the US?

A

Roux-en Y Gastric Bypass

82
Q

What drugs for bariatrics should be dosed based on their ideal body weight?

A

Propofol
Vec
Roc

83
Q

What anesthetic drugs can bariatric patients be dosed on their total body weight?

A 
Remifentanil
Midazolam
Succinylcholine
Cisatracurium
Fentanyl
Sufentanil
84
Q

Why is succinylcholine dosed based on total body weight?

A

Obesity causes an increase in pseudocholinesterase activity

Advanced Principles (16 decks)

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