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6901 > Lap/Robotic Surgery > Flashcards

Lap/Robotic Surgery Flashcards

1
Q

Some subspecialties for laparoscopic surgery?

A

general, urology, gyno

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2
Q

Some subspecialties for robotic surgery?

A

thoracic, cardiac, GI, urology

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3
Q

Robotic instruments have how many degrees of freedom?

A

7

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4
Q

Contraindications to laparoscopic surgery (8)?

A

diaphragmatic hernia, acute or recent MI, severe pulmonary disease, VP shunt, CHF or cardiac valve disease, hx of CVA/cerebral aneurysm, increased ICP, glaucoma

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5
Q

Contraindications to robotic surgery (2)?

A

poor PFT in robotic cardiac surgery bc single lung vent may be poorly tolerated; if prolonged T burg required in pts w hx of cerebral aneurysm

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6
Q

Type of surgical technique where Veress needle pierces abdominal wall at its thinnest point?

A

closed

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7
Q

Is closed placement of Veress needle done under direct vision?

A

no

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8
Q

Type of incision that is a midline vertical incision and is placed under direct vision?

A

open

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9
Q

Downside to open incision for placement of trocar?

A

it takes longer

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10
Q

Maintain IAP pressure

A

15 mm

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11
Q

Why is CO2 the gas of choice for pneumoperitoneum?

A

noncombustible and more soluble in blood, rapidly returned from periphery, eliminated by lungs, increases safety margin and decreases risk of gas embolism

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12
Q

What does hypercapnia do to myocardial contractility?

A

increases it

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13
Q

What causes the decreased venous return in pneumoperitoneum?

A

pooling of blood in the legs, caval compression, increased venous resistance

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14
Q

Increased intraabdominal pressure decreases or increases inotropy?

A

decreases

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15
Q

Does CO decrease or increase d/t increased intraabdominal pressure caused by pneumoperitoneum?

A

decrease

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16
Q

What does increased intraabdominal pressure do to intrathoracic pressure?

A

increases it

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17
Q

What type of effect does increased intrathoracic pressure have on neurohumoral factors?

A

increases release of catecholamines and vasopressin

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18
Q

Stimulation of peritoneal receptor does what?

A

increases release of catecholamines and vasopressin

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19
Q

Does increased intraabdominal pressure decrease/increase SVR?

A

increase

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20
Q

Three components of Da Vinci Surgical System?

A

1- control console 2-patient side cart (robotic arms) 3-equipment tower

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21
Q

What type of ANS output from CO2 absorption and neuroendocrine response to pneumoperitoneum?

A

sympathetic

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22
Q

SVR increases by what percentage from CO2 absorption/pneumoperitoenum?

A

20%

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23
Q

What does SV do in response to pneumoperitoneum?

A

decrease (decrease in venous return)

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24
Q

What does compression of the arterial vasculature do to myocardial wall tension and myocardial O2 demand?

A

increases the wall tension and increases the demand (ischemia and ST changes)

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25
Q

Why does preload decrease with increased IAP?

A

compression of venous capacitance vessels

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26
Q

What contrasts the decreased preload caused by compression of the venous capacitance vessels in pneumoperitoneum?

A

compression of liver and spleen increases intravascular volume

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27
Q

If inflation pressures are

A

increases it d/t increased venous return

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28
Q

What happens to CO/BP when inflation pressures are >15 mm and why?

A

decreases, decreases, d/t decreased venous return

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29
Q

What does hypercapnia do to myocardial contractility

A

decreases it

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30
Q

What does hypercapnia and respiratory acidosis do to pulmonary vasculature?

A

pulmonary vasoconstriction

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31
Q

What is one nerve complication you have to worry about with steep T burg positioning?

A

increased IOP leading to ischemic optic neuropathy

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32
Q

3 things that increase intraocular pressure?

A

hypotension, increased ETCO2, increased duration of surgery (>2-4 hours)

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33
Q

What happen to CBF and ICP with increased intraocular pressure?

A

they increase

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34
Q

What causes increased SVR and MAP?

A

hypercarbia, neuroendocrine response (increased catecholamines, vasopressin, and cortisol), compression of aorta

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35
Q

What does pneumoperitoneum do to CI and cardiac filling volumes?

A

variable to both- CI is decreased or no change d/t increased afterload, decreased venous return, and cardiac filling. cardiac filling is increased or no change bc of compression of intra abdominal compression (liver and spleen)

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36
Q

CO2 absorption reaches a plateau w/in how many minutes of initiation?

A

10-15 min

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37
Q

What does pushing the diaphragm cephaulad do to the FRC and TLC?

A

decrease

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38
Q

What two effects does decreased TLC have? And how do you counteract that?

A

atelectasis and increased airway pressure (PIP); increase the MV

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39
Q

CO2 absorption is greater during intra or extraperitoneal?

A

extraperitoneal

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40
Q

What happens to lung volume and compliance with lap and robotic procedures?

A

decrease and decrease

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41
Q

ETCO2 under or overestimates arterial CO2?

A

under

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42
Q

Signs of VQ mismatch and intrapulmonary shunting?

A

decreased O2 sats and increased airway pressure

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43
Q

Decreased FRC has what 2 effects?

A

increased VQ mismatch and increased alveolar arterial oxygen gradient

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44
Q

Decreased lung compliance and increased resistance has what 2 pulmonary effects?

A

increased pleural pressures and airway pressures

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45
Q

How does elevated diaphragm adversely effect ETT placement?

A

shortens distance from ETT to carina and makes it likely for endobronchial intubation

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46
Q

What effects does pneumoperitoneum have on kidneys?

A

increases creatinine clearance and decreases UO

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47
Q

Why is UO not a reliable guide to renal ftn during pneumoperitoneum?

A

pneumoperitoneum causes increased ADH, renal vasoconstriction, and hypercarbia which induces sympathetic response and renal vasoconstriction which further reduces RBF

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48
Q

IAP of what is safe with renal disease?

A
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49
Q

Neuroendocrine response to pneumoperitoneum causes what effect in renal system?

A

increased ADH, renal vasoconstriction and hypercarbia which decrease renal blood flow

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50
Q

What happens to hepatic blood flow with pneumoperitoneum and why?

A

it decreases d/t venous compression and causes hypotension

51
Q

Why is there an increased risk for DVT with pneumoperitoneum?

A

increased lower extremity venous stasis esp in T burg and lithotomy

52
Q

When would use of LMA be okay with pneumoperitoneum?

A

shorter pelvic procedures

53
Q

When could local or regional anesthesia for lap procedures be used?

A

shorter, lower IAP, minimal head down tilt

54
Q

Which LMA is recommended for lap (short) procedures and why?

A

proseal; can use higher peak pressures and get CO2 down w/out leaking around seal

55
Q

Rule of 15s is?

A
56
Q

Which surgery requires paralysis- laparoscopic or robotic?

A

robotic

57
Q

Why is use of N2O controversial in lap and robotic surgery?

A

diffuses in to bowel lumen, may cause increased PONV,

58
Q

Only avoid N2O if?

A

high risk for PONV

59
Q

How much do you need to increase MV for lap/robotic surgery?

A

20-30%

60
Q

3 changes in pulmonary function from pneumoperitoneum?

A

decreased lung compliance, decreased LV, and increased PIP

61
Q

LPV in lap/robotic surgeries uses volume or pressure controlled vent?

A

pressure

62
Q

What vent parameter improves arterial O2 during prolonged pneumoperitoneum?

A

PEEP 5-10

63
Q

Are recruitment maneuvers recommended for lap and robotic surgery?

A

yes-before and after surgery

64
Q

What limits use of recruitment maneuvers?

A

HD instability

65
Q

What’s effective in improving lung compliance, O2, and ventilation for pneumoperitoneum?

A

recruitment maneuvers

66
Q

How is one way to do a recruitment maneuver?

A

PEEP 10 and intermittent positive airway pressure at 40 for 40 seconds

67
Q

What does keeping ETCO2 35-45 do and how?

A

improve tissue oxygenation; it improves CO by vasodilation and shifting the oxyhemoglobin curve to the right

68
Q

What does shifting oxyhemoglobin to the right do?

A

increases O2 off loading

69
Q

How many IVs necessary for robotic surgery?

A

2

70
Q

When should you use cerebral oximetry?

A

prolonged steep head up or down or high risk undergoing long procedures

71
Q

Fluid management for lap/robotic?

A

20-40 mL/kg

72
Q

Major elective surgical procedures such as robotic prostatectomy or hysterectomy should have what type of fluid management?

A

fluid minimization

73
Q

What do you have to worry ab with steep head down and lots of fluid admin?

A

increased pharygeal, facial, laryngeal edema and ION

74
Q

What parameters should you use to guide fluid management with lap/robotic surgeries?

A

SV, systolic or pulse pressure variation

75
Q

What can hyperventilation do in regards to fluid requirements during pneumoperitoneum?

A

interefere and influence fluid requirements

76
Q

4 multimodal ways to decrease PONV?

A

4mg Decadron, 4 mg Zofran, hydration, Scopolamine patch before surgery

77
Q

Shoulder pain after lap/robotic surgery d/t what?

A

diaphragmatic irritation

78
Q

What position alleviates shoulder pain?

A

supine bc CO2 rises

79
Q

Primarily what type of pain does one experience after laparoscopic surgeries?

A

visceral/deep, not parietal/incisional

80
Q

What are some factors that can influence shoulder pain after surgery?

A

duration of procedure, degree of IAP, inflation pressures, and volume of subdiaphragmatic gas

81
Q

3 positives of infusing lidocaine locally in to incisions?

A

decrease pain, increase bowel ftn, and decrease hospital stay

82
Q

Peak airway pressures should be less than what in lap/robotic?

A

35

83
Q

Inflation pressures/IAP should be less than?

A

15

84
Q

What can induce a tachyarrhythmia during lap/robotic?

A

hypercapnia,

85
Q

2 signs of endobronchial pneumoperitoneum?

A

decreased PaO2 and increased PP

86
Q

What is the most commonly used double sided tube in thoracic robotic surgery?

A

left

87
Q

CO2 insufflation should be maintained at what during robotic thoracic surgery with a double lumen tube?

A

10-15

88
Q

What intervention can you do to decrease intraabdominal pressure?

A

insert OG to decompress stomach

89
Q

What can you do to reduce bladder injuries?

A

have pt void prior to surgery or insert foley

90
Q

Heat loss in lap surgeries comes mainly from?

A

convection

91
Q

What should you do if there is blood in aspiration from Veress needle?

A

prepare to give blood!

92
Q

Which access technique is associated with less unrecognizable vascular and visceral injury?

A

open

93
Q

Most common respiratory complication during laparoscopy?

A

SQ emphysema

94
Q

2 predictors of SQ emphysema?

A

operative time >200 min, 6 + surgical ports

95
Q

S/s SQ emphysema?

A

sudden rise in ETCO2 (>25% or occurs >30 min after abdomen insufflated with CO2), increase PP

96
Q

Treatment of SQ emphysema?

A

hyperventilation or release pneumoperitoneum

97
Q

Does SQ emphysema usually resolve after abdomen deflated?

A

yes

98
Q

3 s/s pneumothorax?

A

increased PP, decreased SaO2, decreased BP

99
Q

What causes pneumothorax in lap/robotic surgeries?

A

movement of gas thru weak areas and defects in diaphragm

100
Q

S/s gas embolism?

A

decreased ETCO2, hypoexemia, mill wheel murmur, cyanosis, pulmonary edema, increased ET N2O, arrhythmias, increased PAP, r vent failure, decreased pul venous return, decreased l preload, decreased CO

101
Q

Cause of gas embolism?

A

misplaced Veress needle or trocar

102
Q

What is something that can decrease the risk of venous gas embolism?

A

adequate hydration bc low CVP increases risk of air embolism

103
Q

Management of venous gas embolism?

A

halt insufllation of pneumoperitoneum and release it, off with N2O, surgeon flood the field, place in left lateral decubitus, aspirate CVP if placed, volume, and pressors

104
Q

Left lateral decubitus also called?

A

Durant’s maneuver

105
Q

Difference between capnothorax and pneumothorax?

A

ETCO2 increases with capnothorax and decreases with pneumothorax

106
Q

Does O2 sat change with SQ emphysema? What happens to ETCO2?

A

no; increases

107
Q

What type of injury do you have to be careful about preventing in robotic procedures?

A

corneal abrasions

108
Q

Tucking arms can damage what nerve?

A

ulnar

109
Q

Retractors can damage what nerve?

A

radial

110
Q

What neurological effects does pneumoperitoneum have?

A

increased ICP and cerebral blood flow

111
Q

What GI effects does pneumoperitoneum have?

A

decreased portal and hepatic vein flow, decreased total hepatic blood flow and flow thru hepatic microcirculation, no change in hepatic artery flow, decreased gastric pH, mesenteric blood flow, and microcirculation blood flow

112
Q

What renal effects does pneumoperitoneum have?

A

decreased renal artery and vein blood flow, decreased medullary and cortical blood flow

113
Q

What cardiovascular effects does pneumoperitoneum have?

A

decreased venous return may result in lower extremity edema, decrease in CI by up to 50% esp when pt in reverse T burg

114
Q

What respiratory effects does pneumoperitoneum have?

A

decreased pulmonary compliance by 30-50%, decreased FRC, increased peak airway pressures and plateau pressures

115
Q

CO during pneumoperitoneum is dependent upon what?

A

IAP

116
Q

IAP

A

Increases it d/t increased venous return

117
Q

What is the most common type of robotic surgery?

A

GI

118
Q

Why does IAP> 15 decrease CO and BP?

A

Decreased venous return

119
Q

What does increased IAP do to preload and afterload?

A

Decrease and increase

120
Q

Complication manifested as sudden rise in EtCO2 and increased PP

A

SQ emphysema

121
Q

Complication manifested as increased PP, decreased SaO2, And decreased BP

A

Pneumothorax

122
Q

Decreased ETCO2 and hypoxemia and hypotension

A

Gas embolism

123
Q

Facial, pharyngeal, and laryngeal edema can lead to what?

A

Upper airway obstruction and laryngospasm

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