Laparoscopic and Robotic Assisted Surgery

Question 1

Laparoscopic surgery

Answer 1

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

Question 2

Advantages of laparoscopic surgery

Answer 2

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

Question 3

Disadvantages of laparoscopic surgery

Answer 3

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

Question 4

Relative contraindications of laparoscopic surgery

Answer 4

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

Question 5

CO2 pneumoperitoneum

Answer 5

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

Question 6

How is the CO2 eliminated from the CO2 pneumoperitoneum?

Answer 6

via respiration

Question 7

effects of CO2 insufflation

Answer 7

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

Question 8

physiologic effects of pneumoperitoneum

Answer 8

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

Question 9

anesthetic considerations for laparoscopic surgery

Answer 9

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

Question 10

Ventilation goals for laparoscopic surgery

Answer 10

EtCO2 35 mmHg

PIP low 30s cmH2O

Question 11

advantages of LMA proseal

Answer 11

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

Question 12

disadvantages of LMA proseal

Answer 12

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

Question 13

Conversion to open procedure considerations

Answer 13

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

Question 14

Laparoscopic surgery complications

Answer 14

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

Question 15

Gas embolism pathophysiology

Answer 15

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

Question 16

Diagnosis of gas embolism in the ideal world

Answer 16

TEE
swan ganz catheter
precordial doppler

Question 17

Diagnosis of gas embolism in the real world

Answer 17

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

Question 18

Treatment of gas embolism

Answer 18

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

Question 19

advantages of robotic assisted laparoscopy

Answer 19

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

Question 20

disadvantages of robotic assisted laparoscopy

Answer 20

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

Question 21

What to prep for robotic surgery

Answer 21

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

Question 22

Cholecystectomy

Answer 22

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

Question 23

Herniorrhaphy

Answer 23

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

Question 24

Appendectomy

Answer 24

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

Question 25

Risk factors for conversion to open during lap cholecystectomy

Answer 25

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

Question 26

Colonoscopy

Answer 26

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

Question 27

potential complications of colonoscopy

Answer 27

perforation, bleeding, desaturation, laryngospasm

Question 28

ERCP

Answer 28

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

Question 29

complications of ERCP

Answer 29

perforation, bleeding, laryngospasm, desaturation

Question 30

indications for esophageal surgery

Answer 30

GERD, cancer, hiatal hernia, motility disorders

Question 31

Nissen fundoplication

Answer 31

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

Question 32

Nissen fundoplication considerations

Answer 32

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

Question 33

esophagectomy

Answer 33

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

Question 34

gastrostomy

Answer 34

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

Question 35

gastrectomy anesthetic considerations

Answer 35

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

Question 36

small bowel resection

Answer 36

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

Question 37

anesthetic considerations for small bowel resection

Answer 37

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

Question 38

colectomy

Answer 38

``` 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 ```

Question 39

Liver anatomy and physiology

Answer 39

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

Question 40

liver resection preop workup

Answer 40

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

Question 41

liver resection preop optimization

Answer 41

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

Question 42

Benzo effects for liver resection patients

Answer 42

increased cerebral uptake decreased clearance prolonged half life

Question 43

Dexmedetomidine effecs for liver resection patients

Answer 43

decreased clearance and prolonged half life

Question 44

Propofol effects for liver resection patients

Answer 44

recovery times may be longer after infusions | drug of choice for those with encephalopathy

Question 45

opioids in liver disease

Answer 45

fentanyl: plasma clearance is decreased

Question 46

NMB in liver disease

Answer 46

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

Question 47

catecholamine effects in liver disease

Answer 47

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

Question 48

liver resection complications

Answer 48

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

Question 49

splenectomy

Answer 49

open or laparoscopically | only treatment for hereditary spherocytosis and cancers of spleen

Question 50

bariatric surgery

Answer 50

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

Question 51

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

Answer 51

pulmonary emboli

Question 52

advantages of laparoscopic bariatric surgery

Answer 52

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

Question 53

disadvantages of laparoscopic bariatric surgery

Answer 53

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

Question 54

implantable gastric stimulator

Answer 54

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

Question 55

anesthetic considerations for implantable gastric stimulator

Answer 55

avoid N/V valsalva may dislodge electrodes ecg interference