Module 4 Flashcards
what is important to document from patients history before surgery?
- anesthesia problems
- prosthetics
- implants
- radiation sites/ports
- prior surgery
- lung/heart history
What medications is good to know?
- steroids/immunosuppresseive drugs (stress steroids?)
- lung/heart meds
- anticoagulants (dc at least three days before)
NSAIDs (don’t need to DC aspirin before lap surgery)
PE should include
VS, chest/cardiac exam, abdominal exam (incisions, scars, hernias, masses, organomegaly…)
ASA classifications
- no physiologic/biochemical/psychiatric disturvances
- mild/mod systemic disease
- severe systemic disease that limits activity
- severe systemic disturbances that limit the patient and are life threatening with and without surgery
- moribund patient, little chance of survival, surgery as last resort
what ASA classes may not be candidates for lap surgery?
4 and 5
due to cardiopulmonary requirements of pneumoperitoneum, like decreased venous return and diaphragmatic excursions and need for hyperventilation
what needs to go into informed consent?
enough information on condition, proposed treatment and alternatives, expected benefits
includes need for GETA and possible need for open surgery
what do you need to do for obese pts?
trochcar insertion: perpendicular to abdominal wall, may need longer ones (>100mm)
- consider placement of spinal needle first to define intraop penetration point
tricks to placing trochars in thin patients
- elevate abdominal wall
- place verses needle away from middle one near coastal margin
- use open approach or optiview
**these also help if patient has had previous abdominal surgery
absolute CIs to lap surgery
- inability to tolerat laparotomy
- hypovolemic shock
- lack of proper surgeon training
- lack of institutional support
relative CIs to lap surg
- inability to tolerate GETA
- long standing peritonitis
- large abdominal/pelvic mass
- massive incarcerate ventral/inguinal hernias
- severe CP disease/intolerance of proper positioning
preop precautions:
1. visceral arterial aneurysm
2. scars
3. hx of peritonitis
4. umbilical abnormalities
5. hepatosplenomegaly
6. hepatic cirrhosis
7. presence of intestinal obstruction
8. pregnancy
9. thin
- risk of injury with trocar placement
- adhesions
3, adhesions - avoid blind techniques of initial access at umbilicus (ensure no mesh)
- risk of injury or poo exposure
- bleeding or post op ascites
- increased risk of enterotomy, limits vision
- careful of uterus
- less space
relative CIs to: cchole
GB cancer
portal HTN
cirrhosis
acute cholecystitis
mirizzi syndrome
relative CIs to: appy
phlegmon
large abscess
relative CIs to: colon resection
large fixed mass
dense adhesions
massive bowel dilation
T4 tumors
relative CIs to: emergency lap
long standing peritonitis
hemodynamic instability partially correctable with resuscitation
massive bowel dilation
