Test 2: Laparoscopic & Robotics (1/3) Flashcards
What are some indications for laparoscopic general surgery?
-Diagnosis
-Evaluation Abd Trauma
-Lysis of Adhesions
-Cholecystectomy
-Gastrectomy
-Esophagectomy
-Hernia Repair
-Colectomy
-GERD / Hiatal Hernia Repair
-Myotomy
-Splenectomy
-Adrenalectomy
-Liver Resection
-Bariatrics
-Telemedicine
-Stereo Imaging
What are some indications for laparoscopic gynecologic surgery?
-Diagnosis
-Lysis of Adhesions
-Fallopian Tube
-Fulguration Endometriosis
-Ovarian Cyst
-Hysterectomy
What are some indications for laparoscopic urologic surgery?
-Nephrectomy
-Varicocelectomy
-Prostatectomy
What are some indications for laparoscopic orthopedic surgery?
-Shoulder
-Hip
-Knee
-Ankle
-Wrist
What are some benefits to the use of minimally invasive surgery?
-Smaller incisions
-Less postoperative pain
-Decreased incisional stress response
-Decreased infection risk
-Decreased rate of complications
-Faster recovery
-Decreased length of stay
-Improved overall patient satisfaction
What are some disadvantages to MIS?
-Complications r/t establishment of the pneumoperitoneum
-Positioning Challenges (ventilation/oxygenation, edema/nerve damage, access to patient)
-Need for advanced and specialized training
What are the majority of complications associated with laparoscopic surgery related to?
Initial entry into the abdominal cavity and establishment of the pneumoperitoneum
What are the complications associated with establishment of the pneumoperitoneum?
-Placement of surgical trocars
-Insufflation of gas produces significant physical stress on multiple organ systems
-PONV
-Referred Pain
How does the surgeon create an environment where they can clearly view all intra-abdominal structures and successfully manipulate the instruments required for surgical dissection?
The creation of an artificial pneumoperitoneum.
How do you create a pneumoperitoneum?
The installation of air or gas into the peritoneal cavity under controlled pressure
What are the two entry methods most commonly used for the establishment of the pneumoperitoneum?
-Closed Technique
-Open (Hasson) Procedure
These techniques include direct entry without prior establishment of the pneumoperitoneum and the use of optical entry trocars. The choice of technique is determined by the surgeon.
An appropriate gas, usually ______, is then insufflated through the needle to increase the intraabdominal pressure, lift the abdominal wall, and create a space between it and the underlying organs.
CO2
Why is CO2 the gas of choice?
-Non-toxic
-Nonflammable
-Readily absorbed into the bloodstream (highly blood soluble) with minimal risk of air embolization
-Less hemodynamic effects compared to other nonflammable gases (like Argon)
Which technique involves the use of a spring-loaded needle known as a Veress needle to pierce the abdominal wall at its thinnest point, around the umbilicus?
The Closed Technique
Which technique involves the development of a 1- to 2.5-mm midline vertical incision that begins at the lower border of the umbilicus and extends through the subcutaneous tissue and underlying fascia?
The Open Technique
Limit intra-abdominal pressure to ____ mmHg
15 mmHg
The magnitude of the patient response to the pneumoperitoneum depends on what?
-Degree of intra-abdominal pressure (IAP)
-Length of surgery
-Patient Position
-Periop volume status
-Patient age and presence of co-morbidities (specifically cardiopulmonary)
What hemodynamic changes are associated with the creation of a pneumoperitoneum?
-SNS Stimulation, leading to the release of Renin & Vasopression, and Increased MAP, SVR, and HR (occur regardless of high or low pressure)
-Compression of the intra-abdominal vessels, leading to decreased venous return and decreased Stroke Volume.
The impact of abdominal insufflation can cause a reduction of ____ - ____ % of CO
20-50%
How do you offset reductions in CO (decreased Stroke Volume) created by the impact of abdominal insufflation?
-Adequate perioperative hydration
-Changes in patient position
-Compression stockings to augment venous return
Changes in position appear to have a _____ effect on central pressure than does the _______ itself. (!!!)
Greater; Pneumoperitoneum.
Why are cardiac output and blood pressure more susceptible to gravitational forces under anesthesia?
Compensatory mechanisms to increase heart rate when hypotension occurs are blunted by general anesthetics, rendering cardiac output and blood pressure more susceptible to gravitational forces.
What are the hemodynamic changes associated with Trendelenburg Position (head-down)?
-Increased venous return
-Increase in CVP
-Increase in ICP
-Increase in IOP
Edema of the face, tongue, oropharynx, and eyes
What are the hemodynamic implications associated with Reverse Trendelenburg?
Reduced cardiac preload, which will decrease cardiac output.
Mild hypercarbia (PaCO2 45-60) has _____ CV effects.
Little
Severe hypercarbia (PaCO2 >60) yields:
Myocardial depression and arrhythmias
What are the changes to the Cardiac Conduction System associated with the pneumoperitoneum? (occur even in healthy patients)
-Significantly prolonged QT Dispersion (Ventricular Instability)
-Increased risk of arrhythmias and cardiac effects
-Brady cardia can occur due to PNS innervation, insufflation, and positioning.
Elderly patients exhibit _____ increases in CVP and decreases in MAP compared to younger, healthier patients
Greater
Elderly have more exaggerated hemodynamic responses
Increases in intra-abdominal pressure shift the diaphragm _______, affecting lung mechanics.
Cephalad
What are the Pulmonary Parameters that are affected by Insufflation of the Abdomen?
-Pulmonary compliance decreased by 43%
-Decreased FVC, FEV1, and FRC, creating areas of atelectasis and making ventilation difficult
-Increased PIP
-Positioning may magnify these effects, especially steep Trendelenburg
How does Insufflation of the Abdomen affect Gas Exchange?
-Hypercarbia (Inc PaCO2) requires an increased Minute Ventilation
-Perfusion of non-ventilated alveoli causes the development of pulmonary shunt with impaired oxygenation and CO2 elimination (V/Q mismatch)
-Hypoxemia
How do you offset the increased PaCO2 and EtCO2 associated with CO2 Pneumoperitoneum?
Increased Minute Ventilation.
Maximum absorption of CO 2 is noted with an intra-abdominal pressure of _____ mmHg.
10 mmHg
Misplaced trocars involves the risk of what other major concern during the creation of the pneumoperitoneum?
Subcutaneous tracking of CO2.
Activation of the ____ offsets the impact of atelectasis on gas exchange by redistributing perfusion away from collapsed lung units.
Hypoxic Pulmonary Vasoconstriction (HPV) Reflex
However, many anesthetics attenuate HPV, specifically inhalation agents in a dose-dependent manner.
What occurs as a result of a shortening of the distance from the tip of the endotracheal tube to the carina?
Endobronchial intubation
A ____ -_____% increase in minute ventilation is necessary to maintain prepneumoperitoneum levels and prevent respiratory acidosis.
20-30%
How would you increase Minute Ventilation?
-Increasing Tidal Volume is preferred rather than increasing RR.
Which ventilator mode is more effective in maintaining arterial pH?
Pressure Control Mode
What are the benefits of pressure control mode?
-Pts are easier to ventilate
-Significantly lower maximum peak airway pressures
-Increased mean airway pressures
What are lung protective strategies related to ventilation?
-Tidal volumes of 6-8 mL/kg of predicted body weight
-6- 8 cmH2O PEEP
-Intraoperative recruitment maneuvers q 30 min
What are the benefits of using lung protective ventilation?
-Decreased Postop Pulmonary Complications
-Decreased need for postop intubation
-Decreased LOS
What patient population is at increased risk of decompensation when faced with the stress introduced by increases in intraabdominal pressure and CO 2 insufflation?
Patients with marginal cardiopulmonary function.
True/False: Patients with COPD are at increased risk of developing postoperative complications after laparoscopic procedures.
True
Morbidly obese patients are at risk for what pulmonary complication with laparoscopic surgery?
V/Q Mismatch - difficulty with ventilation/oxygenation
What are the mild pulmonary dysfunctions noted postoperatively?
Slight restrictive breathing pattern r/t anesthesia, pain, diaphragmatic dysfunction (stretching).
-Accumulation of CO2 in bone/muscle in prolonged procedures can take hours to be excreted.
What are the renal effects associated with Laparoscopic Surgery?
-Transient increases in creatinine clearance
-Decreases in UOP
-Release of ADH, RAAS
How does the pneumoperitoneum contribute to reduced renal blood flow?
Respiratory acidosis from the pneumoperitoneum induces an SNS response and renal vasoconstriction, further diminishing renal blood flow.
What is the effect of increased IAP on the Hepatic and Splanchnic systems?
-Marked decreases in splanchnic and liver perfusion, as well as intestinal ischemia
-50% of patients demonstrate elevated liver enzymes
How does the CO 2 pneumoperitoneum affect the Immune System?
-Negative effect on local immune response by altering cytokine levels
-Proinflammatory cytokines and angiogenic factors have been shown to influence neoangiogenesis, adhesion formation, and normal wound healing processes.
-Potential Cancer Cell growth
