General Surgery - Laparoscopy

Question 1

What is laparoscopy?

Answer 1

Minimally invasive surgical technique using gas to insufflate the peritoneum and instruments manipulated through ports introduced through small incisions with video camera guidance

Question 2

What gas is used and why?

Answer 2

CO2 because of better solubility in blood and, thus, less risk of gas embolism; noncombustible

Question 3

Which operations are performed with the laparoscope?

Answer 3

Frequently:

cholecystectomy, appendectomy, inguinal hernia repair, ventral hernia repair, Nissen fundoplication

Infrequently:

Bowel resection, colostomy, surgery for PUD (PGV, perforation), colectomy, splenectomy, adrenalectomy

Question 4

Contraindications of laparoscopy?

Answer 4

Absolute:

hypovolemic shock, severe cardiac decompensation

Relative:

Extensive intraperitoneal adhesions, diaphragmatic hernia, COPD

Question 5

What are the associated complications?

Answer 5

CO2 EMBOLUS, pneumothorax, bleeding, perforating injuries, infection, intestinal injuries, solid organ injury, major vascular injury, bladder injury, hernia at larger trocar sites, DVT

Question 6

What are the classic findings with a CO2 gas embolus?

Answer 6

Triad:

1. Hypotension
2. Decreased end tidal CO2 (low flow to lung)
3. Mill-wheel murmur

Question 7

What prophylactic measure should every patient get when they are going to have a laparoscopic procedure?

Answer 7

SCD boots - Sequential Compression Device (and most add an OGT to decompress the stomach; Foley catheter is usually used for pelvic procedures)

Question 8

What are the cardiovascular effects of a pneumoperitoneum?

Answer 8

Increased afterload
and

decreased preload

*CVP and PCWP(pulmonary capillary wedge pressure) are deceivingly elevated!

Question 9

What is the effect of CO2 insufflation on end tidal CO2 levels?

Answer 9

Increased as a result of absorption of CO2 into the bloodstream; the body compensates with increased ventilation and blows the extra CO2 off and thus there is no acidosis

Question 10

Advantages of laparoscopy over laparotomy?

Answer 10

Shorter hospitalization, less pain and scarring, lower cost, decreased ileus

Question 11

What is the Veress needle?

Answer 11

Needle with spring-loaded, retractable, blunt inner-protective tube that protrudes from the needle end when it enters peritoneal cavity; used for blind entrance and then insufflation of CO2 through the Veress needle

Question 12

How can it be verified that the Veress needle is in the peritoneum?

Answer 12

Syringe of saline; saline should flow freely without pressure through the needle “drop test”

Question 13

If the Veress needle is not in the peritoneal cavity, what happens to the CO2 flow/pressure?

Answer 13

Flow decreases and pressure is high

Question 14

What is the Hasson technique?

Answer 14

No Veress needle-cut down and place trocar under direct visualization

Question 15

What is the cause of post-laparoscopic shoulder pain?

Answer 15

Referred pain from CO2 on diaphragm and diaphragm stretch

Question 16

What is a laparoscopic-assisted procedure?

Answer 16

Laparoscopic dissection; then, part of the procedure is performed through an open incision

Question 17

What is FRED?

Answer 17

Fog Reduction Elimination Device: sponge with antifog solution used to coat the camera lens

Question 18

Give some tips for “driving” the camera during laparoscopy

Answer 18

1. Keep the camera centered on the action
2. Watch all trocars as they enter the peritoneal cavity (and the tissues beyond, so they can be avoided!)
3. Watch all instruments as they come through the trocars (unless directed otherwise)
4. Ask if you want to come out and clean and re-FRED the lens
5. Look outside the body at the trocars and instrument angles to reorient yourself
6. Keep the camera oriented at all times (ie up and down); usually the camera cord is on the bottom of the camera-orient yourself to the camera before entering the abdomen
7. You may clean the camera lens at times by lightly touching the lens to the liver or peritoneum
8. Never let the camera lens come into contact with the bowel because the camera may get very hot and you can burn a hole in the bowel or burn the drapes!
9. Put your helmet on (ie, expect to get yelled at!)
10. Never act agitated when the surgeons are a little abrupt (eg “center-center the camera!”)
11. Always watch the trocars as they are removed from the abdominal wall for bleeding from the site and view the layers of the abdominal wall, looking for bleeding as you pull the camera trocar out at the end of the case

Question 19

At what length must you close trocar sites?

Answer 19

>5 mm should be closed

Question 20

How do you get the spleen out through a trocar site after a laparoscopic splenectomy?

Answer 20

Morcellation in a bag, then remove piecemeal

Question 21

What is an IOC?

Answer 21

IntraOperative Cholangiogram done during a lap chole to evaluate the common bile duct anatomy and to look for any retained duct stone)

Question 22

What is the safest time for laparoscopy during pregnancy?

Answer 22

Second trimester