Laparoscopic and Robotic Assisted Surgery Flashcards
Laparoscopic surgery
used for diagnostic and surgical intervention
insufflation of abdomen with CO2
view abdominal contents thru small incision
using small instruments through trocars
minimally invasive
Advantages of laparoscopic surgery
lower pain scores and opioids earlier ambulation and return to normal activities lower incidence of postop ileus faster recovery and shorter LOS decreased stress response
Disadvantages of laparoscopic surgery
impaired visualization expensive equipment requires specific surgical skill limited ROM altered depth perception no tactile sensation increased PONV referred pain
Relative contraindications of laparoscopic surgery
increased ICP hypovolemia VP shunt or peritoneal jugular shunt severe CV disease severe respiratory disease dense adhesions
CO2 pneumoperitoneum
insufflation of the abdomen with carbon dioxide (more soluble)
easily absorbed by the tissue with rapid elimination
non-combustible
inexpensive
How is the CO2 eliminated from the CO2 pneumoperitoneum?
via respiration
effects of CO2 insufflation
sympathetic stimulation (HTN, tachy)
impaired venous return (HoTN)
vagal stimulation (arrhythmia, bradycardia)
reduced FRC, compliance, increased pressures, barotrauma, atelectasis
reduced renal perfusion, activation of RAAS, increased ADH
increased intra-abdominal pressure, risk of regurg, splanchnic ischemia, embolus, extraperitoneal spread of CO2
physiologic effects of pneumoperitoneum
increased: PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd, regurg/aspiration
decreased: cardiopulmonary function, cardiac output, venous return, FRC, VC, renal function
anesthetic considerations for laparoscopic surgery
GA with cuffed ETT
controlled ventilation (increased MV and PIP, Vt 6-8 mL/kg)
if use regional- need high block (T4-5)
Ventilation goals for laparoscopic surgery
EtCO2 35 mmHg
PIP low 30s cmH2O
advantages of LMA proseal
spontaneous ventilation
lower incidence of sore throat
lower pain scores, less pain meds, less PONV
disadvantages of LMA proseal
aspiration risk d/t cannot secure airway
can’t control ventilation
can’t give muscle relaxation
Conversion to open procedure considerations
supine position, new fluid plan (increased 3rd space loss), new pain management plan, new vent settings (reduce rate/increase Vt)
Laparoscopic surgery complications
vascular injury, GI injury, cardiac dysrhythmias, increased vagal tone, BP changes, SQ emphysema, capnothorax, capnomediastinum, capnopericardium (diaphragm defect, plural tear, bullae rupture), CO2 embolism
Gas embolism pathophysiology
depends on size of bubbles and rate of entrainment vapor lock in vena cava and RA obstruction to venous return acute RV HTN circulatory collapse
Diagnosis of gas embolism in the ideal world
TEE
swan ganz catheter
precordial doppler
Diagnosis of gas embolism in the real world
pulse ox = hypoxemia esophageal stethoscope = hear Millwheel sound sudden EtCO2 decrease aspiration of gas from CVP HoTN bronchospasm increased PIP
Treatment of gas embolism
stop insufflation and desufflate steep Trendelenburg and left lateral decubitus D/C Nitrous oxide and give 100%FiO2 hyperventilate place CVP CPR consider CPB
advantages of robotic assisted laparoscopy
3D view depth perception intuitive movements increased precision magnification increased free movement
disadvantages of robotic assisted laparoscopy
massive system limited working space limited patient access limited instrument availability expensive maintenance costs longer setup
What to prep for robotic surgery
have 2 peripheral IVs consider arterial line limit IVF initially positioning padding
Cholecystectomy
removal of diseased gall bladder d/t cholecystitis, cholelithiasis, cancer
can be open or laparoscopic
Herniorrhaphy
defect in muscles of abdominal wall needing repair
can be open or laparoscopic
if incarcerated- urgent
if strangulated - emergent
Appendectomy
removal of appendix d/t obstruction/inflammation d/t lymphoid tissue or fecal matter
avoid N2O
give antibiotics
place OGT, probably need to do RSI
Risk factors for conversion to open during lap cholecystectomy
acute cholecystitis w/ thick gallbladder wall previous upper abdominal surgery males advanced age obesity bleeding bile duct injury
Colonoscopy
to view the lining of the rectum and colon for cancer screening and treatment of polyps
patients need colon prep and clear liquid diet
in left lateral decubitus position
potential complications of colonoscopy
perforation, bleeding, desaturation, laryngospasm
ERCP
endoscopic retrograde cholangiopancreatography
diagnose and treat pancreatic and biliary disorders
use contrast dye
placed in left lateral decubitus/prone
can be 30 minutes to several hours
complications of ERCP
perforation, bleeding, laryngospasm, desaturation
indications for esophageal surgery
GERD, cancer, hiatal hernia, motility disorders
Nissen fundoplication
fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
can be laparoscopic or transthoracic (open)
takes about 3-4 hours
Nissen fundoplication considerations
RSI with cricoid pressure
medications: H2 blockers, metoclopramide, antibiotic, antiemetics
lithotomy and reverse trendelenburg positioning
54-60 French esophageal dilator (Bougie)
NGT kept in place postop
pneumatic compression stockings
esophagectomy
majority of the thoracic esophagus and lymph nodes removed and the stomach is moved up and attached to the remaining portion of the esophagus
use double lumen tube
gastrostomy
create an opening through the skin and the stomach wall to provide nutritional support or GI compression
done laparoscopic, percutaneous or open
<1 hour surgical time
gastrectomy anesthetic considerations
stable or acutely ill/malnourished correct hypovolemia and anemia chemo/radiation cross matched blood available full stomach/NGT invasive monitoring warming
small bowel resection
indicated for obstruction, cancer, diverticulum, crohn’s
given a bowel prep
surgical time 2-4 hours
anesthetic considerations for small bowel resection
aspiration precautions, RSI w/ cricoid pressure, NGT, foley catheter, avoid reglan, consider epidural, large 3rd space fluid loss, hypothermiaa
colectomy
removal of part/all of the colon open or laparoscopic given bowel prep and clear liquid diet 1-2 days preop depleted electrolytes and volume antibiotics thoracic epidural corticosteroids
Liver anatomy and physiology
4 lobes, 8 segments
has metabolic and hematologic roles
highly vascular: total blood flow 1.5 L/min mostly by portal vein
liver resection preop workup
CT or MRI for tumor location
12 lead ekg/echo
cxr
labs: CBC, PT/PTT/bleeding time, chemistry, LFTs
liver resection preop optimization
correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities, malnutrition, anemia, esophageal varices, hepatic encephalopathy
vitamin K, recombinant factor VII, FFP if emergency
plt transfusion if <100,000
assume full stomach - H2 receptor blocker, reglan, sodium citrate
Benzo effects for liver resection patients
increased cerebral uptake
decreased clearance
prolonged half life
Dexmedetomidine effecs for liver resection patients
decreased clearance and prolonged half life
Propofol effects for liver resection patients
recovery times may be longer after infusions
drug of choice for those with encephalopathy
opioids in liver disease
fentanyl: plasma clearance is decreased
NMB in liver disease
prolongs elimination of vec, roc, panc = increased DOA
can use cisat
succinylcholine may be prolonged
catecholamine effects in liver disease
decreased response d/t circulating vasodilators such as bile acids and glucagon
impaired ability to translocate blood from pulmonary and splanchnic blood reservoirs to systemic circulation
consider increased doses or addition of non adrenergic vasoconstrictor to support BP
liver resection complications
intraop: hemorrhage, coagulopathy, hypocalcemia, hypoglycemia, VAE, pulmonary disturbances
postop: bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure
splenectomy
open or laparoscopically
only treatment for hereditary spherocytosis and cancers of spleen
bariatric surgery
reserved for BMI >40 or >35 with related comorbidities not well controlled by medical therapy
what is the greatest cause of periop 30 day mortality after bariatric surgery
pulmonary emboli
advantages of laparoscopic bariatric surgery
less postop pain, lower morbidity, faster recovery, less fluid 3rd spacing, decreased wound infection, smaller incisions
disadvantages of laparoscopic bariatric surgery
complete NMB is important, positioning requirements increase fall risk, high risk for right main stem intubation, incidence of rhabdomyolysis in obsese pts higher compared with open procedure
implantable gastric stimulator
laparoscopic placement
2 lead electrodes on greater curvature of stomach
SQ electric pulse generator implanted on abdominal wall
stimulates gastric smooth muscle, decreases peristalsis
makes patient feel less hungry
anesthetic considerations for implantable gastric stimulator
avoid N/V
valsalva may dislodge electrodes
ecg interference
