Module 11 Flashcards
44 Anesthesia for Laparoscopic and Robotic Surgeries
KEY POINTS
- Small incisions, decreased postoperative pain, and lower surgical complication rates are some of the benefits of laparoscopy over _______(1).
- _______(2) and position-related physiologic changes are a significant disadvantage, to the anesthesiologist.
- Risk of perioperative complications may be significant in patients with body mass index > _______(3) and obesity-related comorbidities.
- Advances in _______(4) have expanded its application to multiple subspecialties.
- Access to the patient during robotic-assisted surgery may be seriously limited during an intraoperative _______(5) or airway emergency.
- Severe _______(6) and acidosis from absorbed carbon dioxide can lead to reduced inotropy, dysrhythmias, and arterial vasodilation.
- High intra-abdominal pressures during _______(7) can severely impair venous return and cardiac filling.
- Endobronchial intubation can occur during diaphragmatic displacement into the thorax and _______(8) positioning.
- Renal blood flow, glomerular filtration, and urine output are _______(9) during pneumoperitoneum.
- laparotomy
- Pneumoperitoneum
- 40 kg/m²
- robotic-assisted laparoscopic surgery
- cardiopulmonary
- hypercarbia
- hypovolemia
- Trendelenburg
- reduced
Key Points cont.
- The assessment of neuromuscular blockade during laparoscopic surgery remains highly _______(1).
- Major vascular injuries occur rarely during _______(2) and are associated with significant morbidity and mortality.
- Severe hypotension during pneumoperitoneum should be treated with _______(3), and possible conversion to an open procedure.
- Risk factors for complications of subcutaneous emphysema include operative times more than _______(4), lower BMI, high intra-abdominal pressure, and _______(5) surgery.
- Tension capnothorax is a life-threatening condition that requires a high index of suspicion and immediate action from the operating room _______(6).
- Perioperative use of preemptive multimodal strategies and postoperative nausea and vomiting prophylaxis are integral components for optimal patient recovery after _______(7) surgery.
- subjective
- abdominal entry
- desufflation
- 200 minutes
- Nissen fundoplication
- team
- laparoscopic
Definitions
Laparoscopic surgery:
- Minimally invasive surgical technique where specialized tubes are inserted for surgical _______(1)
- Small skin incisions are made, approximately 1 cm in length, to facilitate insertion of rigid tubes, called _______(2).
Laparotomy:
- surgical incision to Open the abdominal _______(3)
- Performed to examine the abdominal _______(4)
Introduction
- Improved surgical _______(5)
- reduced postoperative _______(6)
- faster return to _______(7)
- lower surgical-related complications continue to make laparoscopy
Fast Track Programs:
- facilitated the expansion of laparoscopy into _______(8) facilities
- maximize the benefits of minimally invasive surgery has improved surgical _______(9)
- large number of surgeries that once required prolonged hospital stays are now performed in outpatient surgery centers and _______(10) facilities
- access
- trocars
- cavity
- organs
- cosmesis
- pain
- work
- noninpatient
- outcomes
- short-stay
Venous Gas Embolism (VGE) During Laparoscopic Surgery @ 1:07:57
- Definition and Clinical Significance
o VGE occurs when CO2 gas bubbles enter the venous system and travel to the right heart, causing obstruction of venous return and potentially right ventricular _______(1).
o Although a severe complication, symptomatic VGE is infrequent in laparoscopic _______(2). - Prevalence Observed with Monitoring
o Intraoperative TEE monitoring shows subclinical VGE in a significant percentage of laparoscopic surgeries, with a reported range from 20% in radical prostatectomies to almost _______(3) in total hysterectomies. - Causes of VGE
o Direct cause: Misplacement of the _______(4) needle into a vein or organ can introduce CO2 directly into the venous system.
o Indirect cause: During laparoscopic surgery, dissection may open vessels, allowing CO2 to enter the venous circulation.
High-Risk Surgical Actions
- Specific surgical actions such as transecting the _______(1) ligament or dissecting the _______(2) ligament during a laparoscopic hysterectomy have been associated with VGE events.
Influence of Patient Positioning
- The position of the patient during surgery can affect the likelihood and severity of CO2 entrainment into the venous system and the right heart chambers.
EXAM QUESTION: Detection and Management of Venous CO2 Gas Embolism
- Detection
o Clinical signs include:
- Acute _______(3) hr?
- Cardiac _______(4)
- QRS complex? _______(5)
- _______(6) bp?
- _______(7) o2?
- Decreased end-tidal CO2
o Physical exam may reveal:
- _______(8) color?
- “Mill wheel” _______(9) on auscultation
o Most sensitive detection method? _______(10)
Management
- Immediate Actions:
- ____A pneumoperitoneum and decompress abdomen
- Initiate advanced cardiac life support if cardiac arrest occurs
- Administer rapid IV fluids for hypotension
- Employ hyperventilation and 100% O2 to accelerate CO2 removal
- Positioning:
- Place patient in _______(1) and left lateral _______(2) positions to reduce right ventricular air lock severity
Answers: VGE
1. failure
2. procedures
3. 100%
4. Veress
Answers: detection
1. round
2. broad
3. tachycardia
4. arrhythmias
5. widening
6. Hypotension
7. Hypoxemia
8. Cyanosis
9. murmur
10. Transesophageal echocardiography (TEE)
Answers: mngmt
A. Terminate
1. Trendelenburg
2. decubitus
Airway Edema: @ 1:09:38
- Causes:
o Prolonged steep Trendelenburg position
o Large volume fluid resuscitation
o Occurs during procedures like robotic _______(1) - Risks:
o Induces facial and pharyngo-laryngeal edema
o Can lead to postoperative airway _______(2) - Prevention during Recovery:
o Positioning patient in____A. sitting to facilitate edema reversal - Assessment before Extubation:
o ____B test may be considered
o Limited definition of its efficacy in ruling out significant laryngeal edema intraoperatively - Management Strategy:
o If severe airway edema is a concern, plan for:- Continued intubation
- Postoperative ventilatory _______(3)
Venous Thrombosis:
- Activation of Coagulation Cascade:
o CO2 pneumoperitoneum potentially activates the _______(1). - Venous Outflow Obstruction:
o Occurs during CO2 _______(2). - Prevalence:
o Although low, deep venous thrombosis (DVT) and pulmonary embolism (PE) risks are considered _______(3) with laparoscopic surgery.
Postoperative Management - Laparoscropy
Postoperative Nausea and Vomiting (PONV):
- Increased Risk with Laparoscopy:
o Laparoscopic patients have a higher PONV risk compared to _______(1) procedures.
- Procedure-Specific Risks:
o _______(2) stands out as the highest independent predictor for PONV.
o The nature of laparoscopic surgery follows as a significant predictor.
Answers: AE
1. prostatectomy
2. compromise
3. support
A. Recumbernt
B. Cuff leak
Answers: VT
1. coagulation cascade
2. pneumoperitoneum
3. increased
Answers: postop
1. nonlaparoscopic
2. Cholecystectomy
Worst Result of Pneumoperitoneum: CV Arrest
- A significant source of intraoperative and postoperative issues during laparoscopy stems from the creation of _______(1)
- Patient may be _______(2)
o NPO
o Bowel Prep
- May already have cardiac _______(3)
- May not tolerate position _______(4)
o Steep Reverse Trend
Answers:
1. pneumoperitoneum
2. Dehydrated
3. compromise
4. Change
Capnothorax @ 1:06:25
- Pathophysiology:
o Definition: _______(1) refers to CO2 gas accumulation in the pleural space.
o Mechanism:- CO2 during insufflation may dissect from the peritoneum into the mediastinum and along the pleura.
- Uncontrolled thoracic cavity pressurization can cause _______(2), increasing intrathoracic pressure and causing mediastinal shift and venous return decline, leading to right ventricular _______(3). –> life-threatening
- Anatomic Considerations:
o Connection Points:- Diaphragmatic defects like the _____A hiatus, _______(4) hiatus, and _____B opening allow abdominal-thoracic connectivity.
- Risk Factors:
o Similar to Subcutaneous Emphysema:- Procedures near the _______(5) elevate the risk of capnothorax.
o Procedural Risks: - Higher during diaphragm-adjacent surgeries (e.g.,___C).
- Potential mechanical injury to the diaphragm (e.g., trocar entry).
- Rarely, congenital pleurodiaphragmatic channels.
- Procedures near the _______(5) elevate the risk of capnothorax.
Early Clinical Signs:
- _______(1): lungs?
- Palpable in the upper torso.
- Respiratory Changes:
- Severe hypercarbia, altered ECG axis, and amplitude.
- Physical Examination:
- Diminished breath sounds and chest excursion, either bilaterally or unilaterally.
Acute Presentation of Tension Capnothorax: (3 Hells)
- High _______(2), ______A, severe _______(3).
- Life-threatening, challenging intraoperative diagnosis.
Diagnostic Approaches:
- Intraoperative Suspicion:
- Requires high suspicion and prompt communication with the surgical team.
- Postoperative Imaging:
- Useful for confirmation; _______(4) for assessing lung pathology, including pneumothorax.
Management Strategies:
- Immediate Actions:
- Primary treatment is immediate _______(1).
- CO2 Reabsorption:
- _______A to expedite CO2 removal.
- ______B to mitigate the abdomen-thorax pressure gradient.
Observation and Supportive Therapy:
- Observation:
- Adequate for patients with minimal physiologic impact.
- Cardiac Concerns:
- Patients with preexisting cardiac dysfunction may require additional support.
Emergency Interventions:
- Needle decompression or chest tube placement for severe cases.
- Consideration for laparoscopy termination and** conversion to open surgery** if instability persists.
Answers: patho
1. Capnothorax
2. tension capnothorax
3. compression
A. aortic
4. esophageal
B. Caval
5. diaphragm
C. Nissen fundoplication
Answers: signs
1. Subcutaneous Emphysema
2. peak airway pressures
A. Hypoxia
3. hypotension
4. transthoracic echocardiography
Answers: mngmt
A. Hyperventilation
B. Positive End-Expiratory Pressure (PEEP)
1. peritoneal desufflation
Patient’s age and comorbidities can greatly affect the severity of pneumoperitoneum related changes observed by clinicians
In robotic surgery, _______(1) operative time and limited _______(2) to the patient, due to prominent robotic equipment, can further complicate management of urgent conditions.
- long
- access
Table 44-2 Disadvantages of Laparoscopy Surgery
Patient-specific
- Risk of _______(1)
- Referred pain from _______(2)
- _______(3) Issues (Especially Trendelenburg Hysterectomy)
- _______(4) Emphysema
Surgeon-specific
- Highly-specialized _______(5)
- _______(6) issues
- Limited _______(7) sense
- Longer _______(8) times
- Complex _______(9) and setup
- Use in _______(10) or scar tissue more challenging
Anesthesiologist-specific
- Pneumoperitoneum-induced _______(11) response
- _______(12)
- Mechanical _______(13) challenges
- Extraperitoneal CO₂-related _______(14)
- Limited access to patient (_______(15) surgery)
Answers:
1. PONV (Postoperative Nausea and Vomiting)
2. CO₂
3. Ventilation
4. Subcutaneous
5. training
6. Ergonomics
7. tactile
8. operating
9. equipment
10. reoperation
11. stress
12. Positioning
13. ventilatory
14. complications
15. robotic
Table 44-1 Benefits of Laparoscopic Surgery
Patient-specific
- Improved cosmetic _______(1)
- Shorter recovery _______(2)
- Earlier return to _______(3)
- Faster return to normal _______(4)
- Lower _______(5)
Surgeon-specific
- Lower medical _______(6)
- Better clinical _______(7)
- Earlier return of bowel _______(8)
- Lower postoperative _______(9)
Anesthesiologist-specific
- Decreased Incisional Stress _______(10)
- Little/No Opioid _______(11)
- Decreased Post-Op _______(12)
- Minimal Fluid _______(13)
- Minimal decline in Post-op respiratory _______(14)
o They don’t have that pain that prevents coughing, deep breathing, etc.
Answers:
1. results
2. time
3. work
4. activities
5. costs
6. risk
7. outcomes
8. function
9. complications
10. Response
11. Requirement
12. Pain
13. Shift
14. Function
Insufflation
- CO2 has a desirable safety _______(1)
- CO2 is highly soluble in _______(2)
o Rapid pulmonary _______(3)
o Minimizes the consequences of inadvertent extraperitoneal or intravascular _______(4) - CO2:
o Nonflammable
o Non-oxidizing
o safe to use during _______(5).
Answers:
1. profile
2. blood
3. removal
4. insufflation
5. electrocautery
Intraperitoneal insufflation (cont.)
- established by creating a small subumbilical _______(1)
- Insert Veress _______(2)
- Tubing connected to the Veress stopcock to deliver low-flow rates of _______(3)
o until adequate abdominal distention is achieved - Maximal preset intra-abdominal pressures (IAP) above _______(4) mmHg should be avoided
o Anything Higher than THAT:
- CO2-related _______(5)
- significant _______(6) instability
* If this Happens: _______(7) before trying to treat with Drugs
Answers:
1. incision
2. needle
3. CO2
4. 15
5. complications
6. cardiopulmonaru
7. Stop insufflation
Patient positioning during laparoscopic surgery (She goes back to this smh)
- Steep _______(16) (i.e., “head up”)
o exposes upper abdominal structures, such as in gastric bypass surgery
o Head up position → increased _______(1), decreased _______(2). and _______(3), blood pooling _______(4) - Steep _______(17) position (i.e., “head down”)
o Expose lower abdominal structures, such as in uterine or _______(5) surgery
o Head down position → increased _______(6) return, and _______(7) filling - The lateral jackknife position
o used to expose the retroperitoneal space during radical _______(8) surgery. - Leftward tilting
o exposes the _______(9) - Rightward tilting
o exposes the left _______(10) - Lithotomy
o dependent on the need for genital, urologic access.
Concerns
- _______(11) Injury
- Falling off the _______(12)
- _______(13) Issues
- Cardiac Output
o _______(14) changes, Afterload increases
- Fluid _______(15)
Answers:
1. SVR (Systemic Vascular Resistance)
2. CO (Cardiac Output)
3. CI (Cardiac Index)
4. extremity
5. prostate
6. venous
7. cardiac
8. nephrectomy
9. appendix
10. colon
11. Nerve
12. Bed
13. Ventilation
14. SVR
15. Shifts
16. reverse Trendelenburg
17. Trendelenburg
Ambulatory Laparoscopic Gastric Bypass surgery
- Unplanned Admission rates were _______(1)
- Unplanned Readmission rate _______(2)
- Henry Ford (Bariatric Center of Excellence)= <_______(3)
- Almost always due to _______(4)
o Metabolism Issues - Appropriate patient presurgical screening is ideal for:
o optimizing good surgical results
o avoiding unexpected complications - Patients with a BMI of less than _______(5) and well-optimized comorbid conditions, such as type II diabetes, heart disease, and obstructive sleep apnea, may have acceptable risk for ambulatory surgery
o Inspire: Hard and Fast at 35, 30 for anything Big - Concerns for greater risk of perioperative complications exist for patients with BMI greater than _______(6) and poorly managed obesity-related _______(7).
Answers:
1. 16%
2. 1.82%
3. 5%
4. Dehydration
5. 40 kg/m2
6. 40 kg/m2
7. comorbidities
Robotic Laparoscopic Surgery
- First popularized in urology for radical prostatectomies, robotic-assisted surgery
- Has since gained ground in other fields, in part, due to reports of improved surgical outcomes
o Open Prostatectomy: Used to cause high _______(1),
■ Now done robotically
STORY TIME: 2…-23:45
[Redacted]
Table 44-3 Examples of Robotic-assisted Laparoscopic Surgery
Cardiac
- Coronary artery _______(2), valvuloplasty
Thoracic
- Lung _______(3), esophagectomy
Gastrointestinal
- Fundoplication, colectomy, gastrectomy, _______(4)
Urologic
- Radical cystectomy, pyeloplasty, _______(5)
Gynecologic, Oncologic
- Hysterectomy, lymph node dissection, _______(6)
Answers:
1. blood loss
2. bypass
3. resection
4. hepatectomy
5. prostatectomy
6. oophorectomy
