Laprascopic and robotic assisted surgery- part II Flashcards
The following types of surgeries can be performed laprascopically
gastric, colonic, splenic, hepatic, gallbladder, gynecologic, and urologic
Relative contraindications to laparoscopic surgery includes:
increased ICP hypovolemia Severe CV disease Severe respiratory disease dense adhesions V/P shunt or peritoneal jugular shunt (LaVeen)- found in abdomen
Advantages to laparoscopic surgery includes
lower pain scores and opioid requirement, earlier ambulation and return to normal activities, lower incidence of post-operative ileus, faster recovery, shorter LOS, lower cost, decreased stress response, reduced postoperative pulmonary dysfunction
Disadvantages to laparoscopic surgery include
impaired visualization, expensive equipment, requires specific surgical skill, limited range of motion, altered depth perception, no tactile sensation, increased PONV, referred pain
Laparoscopic surgery can be used for
diagnostic and surgical intervention
Laparoscopic surgery uses
insufflation of the abdomen (carbon dioxide), views of abdominal contents through small incisions, use of small instruments through trocars, camera projects images on monitor screen, minimally invasive surgery
A pneumoperitoneum can be created using
carbon dioxide (most common)
inert gases
or gasless laparoscopy (better for hemodynamically unstable patients but not commonly used)
As compared to air, helium, oxygen, or nitrous oxide,
CO2 is more soluble in blood
CO2 pneumoperitoneum is
non-combustible
colorless, odorless, inexpensive
eliminated via respiration
easily absorbed by the tissue (high blood solubility) with rapid elimination
The most important aspect regarding insufflation is
the need to communicate with the surgeon if the patient cannot tolerate due to pulm or CV issues
What are the respiratory effects of pneumoperitoneum?
reduced FRC, reduced compliance, increased ventilatory pressures, barotrauma, atelectasis
What are the CV effects of pneumoperitoneum?
sympathetic stimulation= HTN, tachycardia
impaired venous return= hypotension
vagal stimulation= arrhythmias, bradycardia
What are the renal effects of pneumoperitoneum?
reduced renal perfusion, activation of RAAS, increased ADH
What are the gastric effects of pneumoperitoneum?
increased intra-abdominal pressure, risk of gastric regurgitation, splanchnic ischemia, embolus, extra-peritoneal spread of CO2
The physiologic effects of pneumoperitoneum include decreased
Cardiopulmonary function, cardiac output, venous return, FRC, VC, and renal function
The physiologic effects of pneumoperitoneum include increased
PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd (dead space), regurgitation/aspiration
To manage the pulmonary changes with pneumoperitoneum, we can
degree degree of trendelenburg, modify ventilatory settings (pressure control), use PEEP with caution, consider increasing volatile, consider bronchodilators
To manage the CV changes of pneumoperitoneum, we can
do slow, gradual abdominal insufflations, vent abdomen if IAP >20 mmHg, evaluate intravascular volume, consider treatment for preexisting cardiac dysfunction
To manage the renal changes of pneumoperitoneum, we can
closely monitor UOP, administer IVF boluses, consider diuretics, maintain IAP <15 mmHg
To manage the cerebral changes of pneumoperitoneum, we can
decrease degree of trendelenburg (adjust head up), vent abdomen if IAP >20 mmHg
The best way to avoid CV compromise with laparoscopic surgery is
IAP <15 mmHg
Invasive arterial lines should be used for patients undergoing laparoscopic surgery with
ASA III-IV, or abnormal PaCO2/EtCO2 gradient, for BP/serial ABGs
The typical surgical type for laparoscopic surgery is
GA with cuffed ETT
RA has been used- need high block T4-5 (SNS denervation) more difficult to compensate for CV/resp changes
The type of ventilation used for laparoscopic surgery is
controlled ventilation
increased MV and PIP often required
adjust RR, Vt 6-8 mL/kg, PEEP 5-10 cmH20
Goals: EtCO2= 35 mmHg, PIP, low 30s cm H20
The benefit of doing a general with ETT for laparoscopic surgery is
secure airway
control of ventilation
The benefit of using an LMA for laparoscopic surgery is
spontaneous ventilation, lower incidence of sore throat, lower pain scores, less analgesics, less PONV
-unable to secure airway (aspiration risk), control ventilation, administer muscle relaxation
When positioning for laparoscopic surgery, it is important to
prevent nerve injury- common peroneal nerve (lithotomy), & brachial plexus (shoulder braces, arm position)
tilt not to exceed 15-20 degrees
make changes slowly
recheck ETT position after every position change
fluid replacement in Trendeleburg (edema)
Conversion to an open procedure consists of
supine position
new fluid plan due to increased 3rd space losses
new pain management plan
new ventilator settings- reduce rate, increase Vt
For the maintenance of anesthesia for laparoscopic surgery, it is important to
avoid nitrous oxide (could expand bowel lumen)
consider propofol-based TIVA if PONV, balance techniques with volatile agent, opioids, TIVA; muscle relaxation?, careful monitoring of pulmonary and hemodynamic status, watch for ETT during position changes
Describe the pathophysiology of a gas embolism.
depends on size of bubbles & rate of entrainment
vapor lock in vena cava & RA, obstruction to venous return, acute RV hypertension=paradoxical embolism-> circulatory collapse
Intraoperative complications of laparoscopic surgery includes
vascular injury, GI injury, cardiac, SQ emphysema, CO2 embolism
GI injuries present during laparoscopic surgery include
bowel, liver, spleen, mesenteric
Vascular injury during laparoscopic surgery is a result of
trocar insertion and can result in injury to the aorta, IVC, iliac vessels, cystic/hepatic arteries, retroperitoneal hematoma
Cardiac issues that present during laparoscopic surgery include
dysrhythmias, increased vagal tone, BP changes
CO2 embolism can be a result of
direct needle placement in vessel, gas insufflation into abdominal organ
SQ emphysema is a result of
extra-peritoneal insufflation
Capnothorax, capnomediastinum, and capnopericardium can be a result of
diaphragm defect, plural tear, bullae rupture
Diagnosis of a gas embolism is via:
ideal world: TEE, Swan Ganz catheter, precordial doppler
Real world: pulse oximetry (hypoxemia), esophageal stethoscope-Millwheel sound, sudden EtCO2 decrease, aspiration of gas from CVP, hypotension, bronchospasm, increased PIP
Treatment of a gas embolism is:
stop insufflation and desufflate steep Trendelenburg and left lateral decubitus D/C nitrous oxide and give 100% FiO2 Hyperventilate Place CVP CPR Consider CPB
Subcutaneous emphysema is a result of ____ & can be identified by
accidental insufflation of extraperitoneum
be aware of increases in PaCO2 after plateau has been reached
Subcutaneous emphysema is NOT
a contraindication for extubation
it can track to thorax & mediastinum and result in capnothorax or capnomediastinum
Emergence and postop considerations for laparoscopic surgery is (regrading pain)
intra-abdominal incisions and should pain result due to irritation of diaphragm and/or visceral pain from biliary spasm
Opioids + NSAID+ Tylenol + dexamethasone + local infiltration (incisional & intraperitoneal)
______ occurs in 40-75% of laparoscopic surgeries
PONV
Robotic assisted surgery is
a minimally invasive surgery using “robotics”
control console, patient side cart (robotic arms), and equipment tower with screens
Advantages to robotic assisted laparoscopy include
3-D view, improved depth perception & intuitive movements, increased precision 10-15x, magnification, free movement
Disadvantages to robotic assisted laparoscopy include
massive system, limited working space, limited patient access, limited instrument availability, expensive, maintenance costs, longer setup
Preparation for robotic surgery includes
2 peripheral IVs
consider arterial line
limit IVF initially (d/t Trendelenburg position)
Positioning- Trendelenburg, lateral, flexion
Limited access to the patient
Padding- robotic can lay arms on patient
concern for sliding
