Lap/Robotic Surgery Flashcards
Some subspecialties for laparoscopic surgery?
general, urology, gyno
Some subspecialties for robotic surgery?
thoracic, cardiac, GI, urology
Robotic instruments have how many degrees of freedom?
7
Contraindications to laparoscopic surgery (8)?
diaphragmatic hernia, acute or recent MI, severe pulmonary disease, VP shunt, CHF or cardiac valve disease, hx of CVA/cerebral aneurysm, increased ICP, glaucoma
Contraindications to robotic surgery (2)?
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
Type of surgical technique where Veress needle pierces abdominal wall at its thinnest point?
closed
Is closed placement of Veress needle done under direct vision?
no
Type of incision that is a midline vertical incision and is placed under direct vision?
open
Downside to open incision for placement of trocar?
it takes longer
Maintain IAP pressure
15 mm
Why is CO2 the gas of choice for pneumoperitoneum?
noncombustible and more soluble in blood, rapidly returned from periphery, eliminated by lungs, increases safety margin and decreases risk of gas embolism
What does hypercapnia do to myocardial contractility?
increases it
What causes the decreased venous return in pneumoperitoneum?
pooling of blood in the legs, caval compression, increased venous resistance
Increased intraabdominal pressure decreases or increases inotropy?
decreases
Does CO decrease or increase d/t increased intraabdominal pressure caused by pneumoperitoneum?
decrease
What does increased intraabdominal pressure do to intrathoracic pressure?
increases it
What type of effect does increased intrathoracic pressure have on neurohumoral factors?
increases release of catecholamines and vasopressin
Stimulation of peritoneal receptor does what?
increases release of catecholamines and vasopressin
Does increased intraabdominal pressure decrease/increase SVR?
increase
Three components of Da Vinci Surgical System?
1- control console 2-patient side cart (robotic arms) 3-equipment tower
What type of ANS output from CO2 absorption and neuroendocrine response to pneumoperitoneum?
sympathetic
SVR increases by what percentage from CO2 absorption/pneumoperitoenum?
20%
What does SV do in response to pneumoperitoneum?
decrease (decrease in venous return)
What does compression of the arterial vasculature do to myocardial wall tension and myocardial O2 demand?
increases the wall tension and increases the demand (ischemia and ST changes)
Why does preload decrease with increased IAP?
compression of venous capacitance vessels
What contrasts the decreased preload caused by compression of the venous capacitance vessels in pneumoperitoneum?
compression of liver and spleen increases intravascular volume
If inflation pressures are
increases it d/t increased venous return
What happens to CO/BP when inflation pressures are >15 mm and why?
decreases, decreases, d/t decreased venous return
What does hypercapnia do to myocardial contractility
decreases it
What does hypercapnia and respiratory acidosis do to pulmonary vasculature?
pulmonary vasoconstriction
What is one nerve complication you have to worry about with steep T burg positioning?
increased IOP leading to ischemic optic neuropathy
3 things that increase intraocular pressure?
hypotension, increased ETCO2, increased duration of surgery (>2-4 hours)
What happen to CBF and ICP with increased intraocular pressure?
they increase
What causes increased SVR and MAP?
hypercarbia, neuroendocrine response (increased catecholamines, vasopressin, and cortisol), compression of aorta
What does pneumoperitoneum do to CI and cardiac filling volumes?
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)
CO2 absorption reaches a plateau w/in how many minutes of initiation?
10-15 min
What does pushing the diaphragm cephaulad do to the FRC and TLC?
decrease
What two effects does decreased TLC have? And how do you counteract that?
atelectasis and increased airway pressure (PIP); increase the MV
CO2 absorption is greater during intra or extraperitoneal?
extraperitoneal
What happens to lung volume and compliance with lap and robotic procedures?
decrease and decrease
ETCO2 under or overestimates arterial CO2?
under
Signs of VQ mismatch and intrapulmonary shunting?
decreased O2 sats and increased airway pressure
Decreased FRC has what 2 effects?
increased VQ mismatch and increased alveolar arterial oxygen gradient
Decreased lung compliance and increased resistance has what 2 pulmonary effects?
increased pleural pressures and airway pressures
How does elevated diaphragm adversely effect ETT placement?
shortens distance from ETT to carina and makes it likely for endobronchial intubation
What effects does pneumoperitoneum have on kidneys?
increases creatinine clearance and decreases UO
Why is UO not a reliable guide to renal ftn during pneumoperitoneum?
pneumoperitoneum causes increased ADH, renal vasoconstriction, and hypercarbia which induces sympathetic response and renal vasoconstriction which further reduces RBF
IAP of what is safe with renal disease?
Neuroendocrine response to pneumoperitoneum causes what effect in renal system?
increased ADH, renal vasoconstriction and hypercarbia which decrease renal blood flow
What happens to hepatic blood flow with pneumoperitoneum and why?
it decreases d/t venous compression and causes hypotension
Why is there an increased risk for DVT with pneumoperitoneum?
increased lower extremity venous stasis esp in T burg and lithotomy
When would use of LMA be okay with pneumoperitoneum?
shorter pelvic procedures
When could local or regional anesthesia for lap procedures be used?
shorter, lower IAP, minimal head down tilt
Which LMA is recommended for lap (short) procedures and why?
proseal; can use higher peak pressures and get CO2 down w/out leaking around seal
Rule of 15s is?
Which surgery requires paralysis- laparoscopic or robotic?
robotic
Why is use of N2O controversial in lap and robotic surgery?
diffuses in to bowel lumen, may cause increased PONV,
Only avoid N2O if?
high risk for PONV
How much do you need to increase MV for lap/robotic surgery?
20-30%
3 changes in pulmonary function from pneumoperitoneum?
decreased lung compliance, decreased LV, and increased PIP
LPV in lap/robotic surgeries uses volume or pressure controlled vent?
pressure
What vent parameter improves arterial O2 during prolonged pneumoperitoneum?
PEEP 5-10
Are recruitment maneuvers recommended for lap and robotic surgery?
yes-before and after surgery
What limits use of recruitment maneuvers?
HD instability
What’s effective in improving lung compliance, O2, and ventilation for pneumoperitoneum?
recruitment maneuvers
How is one way to do a recruitment maneuver?
PEEP 10 and intermittent positive airway pressure at 40 for 40 seconds
What does keeping ETCO2 35-45 do and how?
improve tissue oxygenation; it improves CO by vasodilation and shifting the oxyhemoglobin curve to the right
What does shifting oxyhemoglobin to the right do?
increases O2 off loading
How many IVs necessary for robotic surgery?
2
When should you use cerebral oximetry?
prolonged steep head up or down or high risk undergoing long procedures
Fluid management for lap/robotic?
20-40 mL/kg
Major elective surgical procedures such as robotic prostatectomy or hysterectomy should have what type of fluid management?
fluid minimization
What do you have to worry ab with steep head down and lots of fluid admin?
increased pharygeal, facial, laryngeal edema and ION
What parameters should you use to guide fluid management with lap/robotic surgeries?
SV, systolic or pulse pressure variation
What can hyperventilation do in regards to fluid requirements during pneumoperitoneum?
interefere and influence fluid requirements
4 multimodal ways to decrease PONV?
4mg Decadron, 4 mg Zofran, hydration, Scopolamine patch before surgery
Shoulder pain after lap/robotic surgery d/t what?
diaphragmatic irritation
What position alleviates shoulder pain?
supine bc CO2 rises
Primarily what type of pain does one experience after laparoscopic surgeries?
visceral/deep, not parietal/incisional
What are some factors that can influence shoulder pain after surgery?
duration of procedure, degree of IAP, inflation pressures, and volume of subdiaphragmatic gas
3 positives of infusing lidocaine locally in to incisions?
decrease pain, increase bowel ftn, and decrease hospital stay
Peak airway pressures should be less than what in lap/robotic?
35
Inflation pressures/IAP should be less than?
15
What can induce a tachyarrhythmia during lap/robotic?
hypercapnia,
2 signs of endobronchial pneumoperitoneum?
decreased PaO2 and increased PP
What is the most commonly used double sided tube in thoracic robotic surgery?
left
CO2 insufflation should be maintained at what during robotic thoracic surgery with a double lumen tube?
10-15
What intervention can you do to decrease intraabdominal pressure?
insert OG to decompress stomach
What can you do to reduce bladder injuries?
have pt void prior to surgery or insert foley
Heat loss in lap surgeries comes mainly from?
convection
What should you do if there is blood in aspiration from Veress needle?
prepare to give blood!
Which access technique is associated with less unrecognizable vascular and visceral injury?
open
Most common respiratory complication during laparoscopy?
SQ emphysema
2 predictors of SQ emphysema?
operative time >200 min, 6 + surgical ports
S/s SQ emphysema?
sudden rise in ETCO2 (>25% or occurs >30 min after abdomen insufflated with CO2), increase PP
Treatment of SQ emphysema?
hyperventilation or release pneumoperitoneum
Does SQ emphysema usually resolve after abdomen deflated?
yes
3 s/s pneumothorax?
increased PP, decreased SaO2, decreased BP
What causes pneumothorax in lap/robotic surgeries?
movement of gas thru weak areas and defects in diaphragm
S/s gas embolism?
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
Cause of gas embolism?
misplaced Veress needle or trocar
What is something that can decrease the risk of venous gas embolism?
adequate hydration bc low CVP increases risk of air embolism
Management of venous gas embolism?
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
Left lateral decubitus also called?
Durant’s maneuver
Difference between capnothorax and pneumothorax?
ETCO2 increases with capnothorax and decreases with pneumothorax
Does O2 sat change with SQ emphysema? What happens to ETCO2?
no; increases
What type of injury do you have to be careful about preventing in robotic procedures?
corneal abrasions
Tucking arms can damage what nerve?
ulnar
Retractors can damage what nerve?
radial
What neurological effects does pneumoperitoneum have?
increased ICP and cerebral blood flow
What GI effects does pneumoperitoneum have?
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
What renal effects does pneumoperitoneum have?
decreased renal artery and vein blood flow, decreased medullary and cortical blood flow
What cardiovascular effects does pneumoperitoneum have?
decreased venous return may result in lower extremity edema, decrease in CI by up to 50% esp when pt in reverse T burg
What respiratory effects does pneumoperitoneum have?
decreased pulmonary compliance by 30-50%, decreased FRC, increased peak airway pressures and plateau pressures
CO during pneumoperitoneum is dependent upon what?
IAP
IAP
Increases it d/t increased venous return
What is the most common type of robotic surgery?
GI
Why does IAP> 15 decrease CO and BP?
Decreased venous return
What does increased IAP do to preload and afterload?
Decrease and increase
Complication manifested as sudden rise in EtCO2 and increased PP
SQ emphysema
Complication manifested as increased PP, decreased SaO2, And decreased BP
Pneumothorax
Decreased ETCO2 and hypoxemia and hypotension
Gas embolism
Facial, pharyngeal, and laryngeal edema can lead to what?
Upper airway obstruction and laryngospasm
