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AP 1 > Test 2: Laparoscopic & Robotics (1/3) > Flashcards

Test 2: Laparoscopic & Robotics (1/3) Flashcards

1
Q

What are some indications for laparoscopic general surgery?

A

-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

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2
Q

What are some indications for laparoscopic gynecologic surgery?

A

-Diagnosis
-Lysis of Adhesions
-Fallopian Tube
-Fulguration Endometriosis
-Ovarian Cyst
-Hysterectomy

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3
Q

What are some indications for laparoscopic urologic surgery?

A

-Nephrectomy
-Varicocelectomy
-Prostatectomy

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4
Q

What are some indications for laparoscopic orthopedic surgery?

A

-Shoulder
-Hip
-Knee
-Ankle
-Wrist

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5
Q

What are some benefits to the use of minimally invasive surgery?

A

-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

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6
Q

What are some disadvantages to MIS?

A

-Complications r/t establishment of the pneumoperitoneum
-Positioning Challenges (ventilation/oxygenation, edema/nerve damage, access to patient)
-Need for advanced and specialized training

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7
Q

What are the majority of complications associated with laparoscopic surgery related to?

A

Initial entry into the abdominal cavity and establishment of the pneumoperitoneum

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8
Q

What are the complications associated with establishment of the pneumoperitoneum?

A

-Placement of surgical trocars
-Insufflation of gas produces significant physical stress on multiple organ systems
-PONV
-Referred Pain

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9
Q

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?

A

The creation of an artificial pneumoperitoneum.

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10
Q

How do you create a pneumoperitoneum?

A

The installation of air or gas into the peritoneal cavity under controlled pressure

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11
Q

What are the two entry methods most commonly used for the establishment of the pneumoperitoneum?

A

-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.

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12
Q

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.

A

CO2

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13
Q

Why is CO2 the gas of choice?

A

-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)

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14
Q

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?

A

The Closed Technique

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15
Q

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?

A

The Open Technique

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16
Q

Limit intra-abdominal pressure to ____ mmHg

A

15 mmHg

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17
Q

The magnitude of the patient response to the pneumoperitoneum depends on what?

A

-Degree of intra-abdominal pressure (IAP)
-Length of surgery
-Patient Position
-Periop volume status
-Patient age and presence of co-morbidities (specifically cardiopulmonary)

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18
Q

What hemodynamic changes are associated with the creation of a pneumoperitoneum?

A

-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.

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19
Q

The impact of abdominal insufflation can cause a reduction of ____ - ____ % of CO

A

20-50%

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20
Q

How do you offset reductions in CO (decreased Stroke Volume) created by the impact of abdominal insufflation?

A

-Adequate perioperative hydration
-Changes in patient position
-Compression stockings to augment venous return

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21
Q

Changes in position appear to have a _____ effect on central pressure than does the _______ itself. (!!!)

A

Greater; Pneumoperitoneum.

22
Q

Why are cardiac output and blood pressure more susceptible to gravitational forces under anesthesia?

A

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.

23
Q

What are the hemodynamic changes associated with Trendelenburg Position (head-down)?

A

-Increased venous return
-Increase in CVP
-Increase in ICP
-Increase in IOP

Edema of the face, tongue, oropharynx, and eyes

24
Q

What are the hemodynamic implications associated with Reverse Trendelenburg?

A

Reduced cardiac preload, which will decrease cardiac output.

25
Q

Mild hypercarbia (PaCO2 45-60) has _____ CV effects.

A

Little

26
Q

Severe hypercarbia (PaCO2 >60) yields:

A

Myocardial depression and arrhythmias

27
Q

What are the changes to the Cardiac Conduction System associated with the pneumoperitoneum? (occur even in healthy patients)

A

-Significantly prolonged QT Dispersion (Ventricular Instability)
-Increased risk of arrhythmias and cardiac effects
-Brady cardia can occur due to PNS innervation, insufflation, and positioning.

28
Q

Elderly patients exhibit _____ increases in CVP and decreases in MAP compared to younger, healthier patients

A

Greater
Elderly have more exaggerated hemodynamic responses

29
Q

Increases in intra-abdominal pressure shift the diaphragm _______, affecting lung mechanics.

A

Cephalad

30
Q

What are the Pulmonary Parameters that are affected by Insufflation of the Abdomen?

A

-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

31
Q

How does Insufflation of the Abdomen affect Gas Exchange?

A

-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

32
Q

How do you offset the increased PaCO2 and EtCO2 associated with CO2 Pneumoperitoneum?

A

Increased Minute Ventilation.

33
Q

Maximum absorption of CO 2 is noted with an intra-abdominal pressure of _____ mmHg.

A

10 mmHg

34
Q

Misplaced trocars involves the risk of what other major concern during the creation of the pneumoperitoneum?

A

Subcutaneous tracking of CO2.

35
Q

Activation of the ____ offsets the impact of atelectasis on gas exchange by redistributing perfusion away from collapsed lung units.

A

Hypoxic Pulmonary Vasoconstriction (HPV) Reflex

However, many anesthetics attenuate HPV, specifically inhalation agents in a dose-dependent manner.

36
Q

What occurs as a result of a shortening of the distance from the tip of the endotracheal tube to the carina?

A

Endobronchial intubation

37
Q

A ____ -_____% increase in minute ventilation is necessary to maintain prepneumoperitoneum levels and prevent respiratory acidosis.

A

20-30%

38
Q

How would you increase Minute Ventilation?

A

-Increasing Tidal Volume is preferred rather than increasing RR.

39
Q

Which ventilator mode is more effective in maintaining arterial pH?

A

Pressure Control Mode

40
Q

What are the benefits of pressure control mode?

A

-Pts are easier to ventilate
-Significantly lower maximum peak airway pressures
-Increased mean airway pressures

41
Q

What are lung protective strategies related to ventilation?

A

-Tidal volumes of 6-8 mL/kg of predicted body weight
-6- 8 cmH2O PEEP
-Intraoperative recruitment maneuvers q 30 min

42
Q

What are the benefits of using lung protective ventilation?

A

-Decreased Postop Pulmonary Complications
-Decreased need for postop intubation
-Decreased LOS

43
Q

What patient population is at increased risk of decompensation when faced with the stress introduced by increases in intraabdominal pressure and CO 2 insufflation?

A

Patients with marginal cardiopulmonary function.

44
Q

True/False: Patients with COPD are at increased risk of developing postoperative complications after laparoscopic procedures.

A

True

45
Q

Morbidly obese patients are at risk for what pulmonary complication with laparoscopic surgery?

A

V/Q Mismatch - difficulty with ventilation/oxygenation

46
Q

What are the mild pulmonary dysfunctions noted postoperatively?

A

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.

47
Q

What are the renal effects associated with Laparoscopic Surgery?

A

-Transient increases in creatinine clearance
-Decreases in UOP
-Release of ADH, RAAS

48
Q

How does the pneumoperitoneum contribute to reduced renal blood flow?

A

Respiratory acidosis from the pneumoperitoneum induces an SNS response and renal vasoconstriction, further diminishing renal blood flow.

49
Q

What is the effect of increased IAP on the Hepatic and Splanchnic systems?

A

-Marked decreases in splanchnic and liver perfusion, as well as intestinal ischemia
-50% of patients demonstrate elevated liver enzymes

50
Q

How does the CO 2 pneumoperitoneum affect the Immune System?

A

-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

AP 1 (32 decks)

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