Laparoscopy, C37 P223-226

Question 1

What is laparoscopy?

P223

Answer 1

Minimally invasive surgical technique
using gas to insufflate the peritoneum
and instruments manipulated through
ports introduced through small incisions
with video camera guidance

Question 2

What gas is used and why?

P223

Answer 2

CO(2) because of better solubility in blood
and, thus, less risk of gas embolism;
noncombustible

Question 3

Which operations are
performed with the
laparoscope?
P223

Answer 3

Frequently—cholecystectomy;
    appendectomy; inguinal hernia
    repair; ventral hernia repair, Nissen
    fundoplication
Infrequently—bowel resection,
    colostomy, surgery for PUD (PGV,
    perforation), colectomy, splenectomy,
    adrenalectomy

Question 4

What are the
contraindications?
P224

Answer 4

Absolute—hypovolemic shock, severe
cardiac decompensation
Relative—extensive intraperitoneal
adhesions, diaphragmatic hernia, COPD

Question 5

What are the associated
complications?
P224

Answer 5

Pneumothorax, bleeding, perforating
injuries, infection, intestinal injuries,
solid organ injury, major vascular injury,
CO2 embolus, bladder injury, hernia at
larger trocar sites, DVT

Question 6

What are the classic findings
with a CO(2) gas embolus?
P224

Answer 6

Triad:
1. Hypotension
2. Decreased end tidal CO(2) (low flow
    to lung)
3. Mill-wheel murmur

Question 7

What prophylactic measure
should every patient get
when they are going to have
a laparoscopic procedure?
P224

Answer 7

SCD boots—Sequential Compression
Device (and most add an OGT to
decompress the stomach; Foley catheter
is usually used for pelvic procedures)

Question 8

What are the
cardiovascular effects of a
pneumoperitoneum?
P224

Answer 8

Increased afterload and decreased
preload (but the CVP and PCWP are
deceivingly elevated!)

Question 9

What is the effect of CO(2)
insufflation on end tidal
CO(2) levels?
P224

Answer 9

Increased as a result of absorption of
CO(2) into the bloodstream; the body
compensates with increased ventilation
and blows the extra CO(2) off and thus
there is no acidosis

Question 10

What are the advantages
over laparotomy?
P224

Answer 10

Shorter hospitalization, less pain and

scarring, lower cost, decreased ileus

Question 11

What is the Veress needle?

P224

Answer 11

Needle with spring-loaded, retractable,
blunt inner-protective tube that
protrudes from the needle end when it
enters peritoneal cavity; used for blind
entrance and then insufflation of CO(2)
through the Veress needle

Question 12

How can it be verified that
the Veress needle is in the
peritoneum?
P224

Answer 12

Syringe of saline; saline should flow freely
without pressure through the needle
“drop test”

Question 13

If the Veress needle is not in
the peritoneal cavity, what
happens to the CO(2) flow/
pressure?
P225

Answer 13

Flow decreases and pressure is high

Question 14

What is the Hasson technique?

P225

Answer 14

No Veress needle—cut down and place

trocar under direct visualization

Question 15

What is the cause of postlaparoscopic
shoulder pain?
P225

Answer 15

Referred pain from CO(2) on diaphragm

and diaphragm stretch

Question 16

What is a laparoscopicassisted
procedure?
P225

Answer 16

Laparoscopic dissection; then, part of the
procedure is performed through an open
incision

Question 17

What is FRED®?

P225

Answer 17

Fog Reduction Elimination Device:
sponge with antifog solution used to coat
the camera lens

Question 18

Give some tips for “driving”
the camera during
laparoscopy.
P225

Answer 18

1. Keep the camera centered on the
    action
2. Watch all trocars as they enter the
    peritoneal cavity (and the tissues
    beyond, so they can be avoided!)
3. Watch all instruments as they come
    through the trocars (unless directed
    otherwise)
4. Ask if you want to come out and
    clean and re-FRED the lens
5. Look outside the body at the trocars
    and instrument angles to reorient
    yourself
6. Keep the camera oriented at all
    times (i.e., up and down); usually the
    camera cord is on the bottom of the
    camera—orient yourself to the camera
    before entering the abdomen
7. You may clean the camera lens at
    times by lightly touching the lens to
    the liver or peritoneum
8. Never let the camera lens come into
    contact with the bowel because the
    camera may get very hot and you can
    burn a hole in the bowel or burn the
    drapes!
9. Put your helmet on (i.e., expect to
    get yelled at!)
10. Never act agitated when the surgeons
    are a little abrupt (e.g., “Center—
    center the camera!”)
11. Always watch the trocars as they are
    removed from the abdominal wall
    for bleeding from the site and view
    the layers of the abdominal wall,
    looking for bleeding as you pull the
    camera trocar out at the end of the
    case

Question 19

At what length must you
close trocar sites?
P226

Answer 19

> 5 mm should be closed

Question 20

How do you get the spleen
out through a trocar site after
a laparoscopic splenectomy?
P226

Answer 20

Morcellation in a bag, then remove

piecemeal

Question 21

What is an IOC?

P226

Answer 21

IntraOperative Cholangiogram (done
during a lap chole to evaluate the
common bile duct anatomy and to look
for any retained duct stone)

Question 22

What is the safest time for
laparoscopy during
pregnancy?
P226

Answer 22

Second trimester