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N931 Advanced Principles of Anesthesia I > Laparoscopic and Robotic Assisted Surgery > Flashcards

Laparoscopic and Robotic Assisted Surgery Flashcards

1
Q

Laparoscopic surgery

A

used for diagnostic and surgical intervention
insufflation of abdomen with CO2
view abdominal contents thru small incision
using small instruments through trocars
minimally invasive

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2
Q

Advantages of laparoscopic surgery

A 
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
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3
Q

Disadvantages of laparoscopic surgery

A 
impaired visualization
expensive equipment
requires specific surgical skill
limited ROM
altered depth perception
no tactile sensation
increased PONV
referred pain
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4
Q

Relative contraindications of laparoscopic surgery

A 
increased ICP
hypovolemia
VP shunt or peritoneal jugular shunt
severe CV disease
severe respiratory disease
dense adhesions
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5
Q

CO2 pneumoperitoneum

A

insufflation of the abdomen with carbon dioxide (more soluble)
easily absorbed by the tissue with rapid elimination
non-combustible
inexpensive

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6
Q

How is the CO2 eliminated from the CO2 pneumoperitoneum?

A

via respiration

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7
Q

effects of CO2 insufflation

A

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

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8
Q

physiologic effects of pneumoperitoneum

A

increased: PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd, regurg/aspiration
decreased: cardiopulmonary function, cardiac output, venous return, FRC, VC, renal function

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9
Q

anesthetic considerations for laparoscopic surgery

A

GA with cuffed ETT
controlled ventilation (increased MV and PIP, Vt 6-8 mL/kg)
if use regional- need high block (T4-5)

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10
Q

Ventilation goals for laparoscopic surgery

A

EtCO2 35 mmHg

PIP low 30s cmH2O

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11
Q

advantages of LMA proseal

A

spontaneous ventilation
lower incidence of sore throat
lower pain scores, less pain meds, less PONV

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12
Q

disadvantages of LMA proseal

A

aspiration risk d/t cannot secure airway
can’t control ventilation
can’t give muscle relaxation

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13
Q

Conversion to open procedure considerations

A

supine position, new fluid plan (increased 3rd space loss), new pain management plan, new vent settings (reduce rate/increase Vt)

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14
Q

Laparoscopic surgery complications

A

vascular injury, GI injury, cardiac dysrhythmias, increased vagal tone, BP changes, SQ emphysema, capnothorax, capnomediastinum, capnopericardium (diaphragm defect, plural tear, bullae rupture), CO2 embolism

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15
Q

Gas embolism pathophysiology

A 
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
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16
Q

Diagnosis of gas embolism in the ideal world

A

TEE
swan ganz catheter
precordial doppler

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17
Q

Diagnosis of gas embolism in the real world

A 
pulse ox = hypoxemia
esophageal stethoscope = hear Millwheel sound
sudden EtCO2 decrease
aspiration of gas from CVP
HoTN
bronchospasm
increased PIP
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18
Q

Treatment of gas embolism

A 
stop insufflation and desufflate
steep Trendelenburg and left lateral decubitus
D/C Nitrous oxide and give 100%FiO2
hyperventilate
place CVP
CPR
consider CPB
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19
Q

advantages of robotic assisted laparoscopy

A 
3D view
depth perception intuitive movements
increased precision
magnification increased
free movement
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20
Q

disadvantages of robotic assisted laparoscopy

A 
massive system
limited working space
limited patient access
limited instrument availability
expensive 
maintenance costs
longer setup
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21
Q

What to prep for robotic surgery

A 
have 2 peripheral IVs
consider arterial line
limit IVF initially
positioning
padding
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22
Q

Cholecystectomy

A

removal of diseased gall bladder d/t cholecystitis, cholelithiasis, cancer
can be open or laparoscopic

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23
Q

Herniorrhaphy

A

defect in muscles of abdominal wall needing repair
can be open or laparoscopic
if incarcerated- urgent
if strangulated - emergent

24
Q

Appendectomy

A

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

25
Q

Risk factors for conversion to open during lap cholecystectomy

A 
acute cholecystitis w/ thick gallbladder wall
previous upper abdominal surgery
males
advanced age
obesity
bleeding
bile duct injury
26
Q

Colonoscopy

A

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

27
Q

potential complications of colonoscopy

A

perforation, bleeding, desaturation, laryngospasm

28
Q

ERCP

A

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

29
Q

complications of ERCP

A

perforation, bleeding, laryngospasm, desaturation

30
Q

indications for esophageal surgery

A

GERD, cancer, hiatal hernia, motility disorders

31
Q

Nissen fundoplication

A

fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
can be laparoscopic or transthoracic (open)
takes about 3-4 hours

32
Q

Nissen fundoplication considerations

A

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

33
Q

esophagectomy

A

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

34
Q

gastrostomy

A

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

35
Q

gastrectomy anesthetic considerations

A 
stable or acutely ill/malnourished
correct hypovolemia and anemia
chemo/radiation
cross matched blood available
full stomach/NGT
invasive monitoring
warming
36
Q

small bowel resection

A

indicated for obstruction, cancer, diverticulum, crohn’s
given a bowel prep
surgical time 2-4 hours

37
Q

anesthetic considerations for small bowel resection

A

aspiration precautions, RSI w/ cricoid pressure, NGT, foley catheter, avoid reglan, consider epidural, large 3rd space fluid loss, hypothermiaa

38
Q

colectomy

A 
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
39
Q

Liver anatomy and physiology

A

4 lobes, 8 segments
has metabolic and hematologic roles
highly vascular: total blood flow 1.5 L/min mostly by portal vein

40
Q

liver resection preop workup

A

CT or MRI for tumor location
12 lead ekg/echo
cxr
labs: CBC, PT/PTT/bleeding time, chemistry, LFTs

41
Q

liver resection preop optimization

A

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

42
Q

Benzo effects for liver resection patients

A

increased cerebral uptake
decreased clearance
prolonged half life

43
Q

Dexmedetomidine effecs for liver resection patients

A

decreased clearance and prolonged half life

44
Q

Propofol effects for liver resection patients

A

recovery times may be longer after infusions

drug of choice for those with encephalopathy

45
Q

opioids in liver disease

A

fentanyl: plasma clearance is decreased

46
Q

NMB in liver disease

A

prolongs elimination of vec, roc, panc = increased DOA
can use cisat
succinylcholine may be prolonged

47
Q

catecholamine effects in liver disease

A

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

48
Q

liver resection complications

A

intraop: hemorrhage, coagulopathy, hypocalcemia, hypoglycemia, VAE, pulmonary disturbances
postop: bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure

49
Q

splenectomy

A

open or laparoscopically

only treatment for hereditary spherocytosis and cancers of spleen

50
Q

bariatric surgery

A

reserved for BMI >40 or >35 with related comorbidities not well controlled by medical therapy

51
Q

what is the greatest cause of periop 30 day mortality after bariatric surgery

A

pulmonary emboli

52
Q

advantages of laparoscopic bariatric surgery

A

less postop pain, lower morbidity, faster recovery, less fluid 3rd spacing, decreased wound infection, smaller incisions

53
Q

disadvantages of laparoscopic bariatric surgery

A

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

54
Q

implantable gastric stimulator

A

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

55
Q

anesthetic considerations for implantable gastric stimulator

A

avoid N/V
valsalva may dislodge electrodes
ecg interference

N931 Advanced Principles of Anesthesia I (6 decks)

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