Test 2: Laparoscopic & Robotics (2/3) Flashcards
What is the reported incidence of injury of all laparoscopic procedures?
0.3-1.0%
More than 50% of all complications occur during what?
Initial entry into the abdomen and insertion of trocars
What are complications associated with entry into the abdomen?
-Intestinal, Urinary Tract, and Vascular Injuries
-CO2 gas embolus
Unfortunately, approximately 30% to 50% of these injuries go undiagnosed intraoperatively, resulting in significant surgical mortality (3.5–5%).
Rates as high as 30% mortality have been reported when major bowel and vascular injuries occur.
What are factors that increase risk of injury?
-body habitus & position
-anatomic anomalies
-prior surgery (adhesions)
-surgical skill
-degree of abdominal elevation during trocar placement
-the volume of gas insufflation
Intestinal injuries occur in 0.3% to 0.5% of operative laparoscopies, and less than ____% of these are recognized at the time of surgery.
50%
Untreated intestinal injuries during laparoscopic surgery can lead to what?
-Peritonitis
-Sepsis
-Respiratory Distress
-Multisystem Organ Failure
What is essential to prevent mortality from bowel injuries?
Early recognition and surgical repair is essential to prevent mortality from bowel injuries.
Which technique is associated with a lower incidence of unrecognized vascular and visceral injury?
Open (Hasson) technique
Injury to the urinary tract occurs in 0.5% to 8.3% of cases, secondary to:
Trauma from instrument manipulation, electrocautery, or laser.
How do they recognize injury to the urinary tract?
-Direct visualization of urine leakage from damaged structures
-Catheterization and instillation of methylene blue dye is used when significant risk of damage is suspected.
Placement of the primary trocar under ________ creates the safest distance between the anterior abdominal wall and underlying abdominal contents in order to minimize injury from trocar insertion.
High pressure (25 mm Hg)
The direct entrainment of air and/or other medical gases, such as carbon dioxide, into the arterial or venous system.
Gas Embolism
The mortality rate of a CO2 gas embolism is ____%
28%
True/False: Massive and/or fatal gas embolisms have been reported during all types of laparoscopic procedures including laparoscopic cholecystectomy, liver resection, and hysterectomy.
True
How does a CO2 Gas Embolism Occur?
-It can occur any time there are open vessels that have an intravascular pressure that is below intraabdominal pressure
-The erroneous placement of a Veress needle or trocar directly into the lumen of an intraabdominal vessel.
True/False: Increasing CVP, such as with the use of PEEP, is effective in reducing the incidence of gas embolism.
False; studies have not shown them to be effective
What is the actual incidence of gas embolism during laparoscopic procedures?
65-100%.
Most cases have minor gas embolisms, associated with cardiopulmonary changes, which resolve spontaneously.
What are the signs and symptoms of those larger, CO2 gas embolisms?
-Acute decrease/loss of EtCO2
-Increase in EtNitrogen
-Hypotension/Hypoxia that cannot be explained by deep anesthesia or hypovolemia
-Dysrhythmias, severe hemodynamic instability, CV collapse
What is the most sensitive diagnostic technique for the detection of gas?
Transesophageal Echocardiography
Where would you visually detect the gas embolism?
Right side of the heart and pulmonary outflow tract
Changes in Doppler sounds will occur with volumes of ____mL/kg of gas.
0.5 mL/kg
When the “classic mill wheel murmur” is audible, what effects are present?
-Tachycardia
-Hypotension
-Cardiac dysrhythmias
-Cyanosis
-ECG changes indicative of R-heart strain
How do you manage a CO2 gas embolism?
-Stop insufflation of Gas
-Stop N2O if being administered
-100% FiO2
-Release the pneumoperitoneum
-Flood surgical field with NS (not rly applicable in laparoscopic surgery)
-Place patient in Left Lateral Decubitis position (Durant Maneuver)
-Aspirate gas via central line if present
-Support hemodynamics with volume and pressors
What is the name for placing the patient in left lateral decubitus position?
Durant Maneuver
Why should adequate hydration should be provided for the patient undergoing laparoscopy?
Low CVP increases the risk of venous gas embolism.
In what ways can gas migrate into the thoracic cavity?
-Congenital defect in the diaphragm
-Embryonic connections between the thoracic and abdominal cavities may open under high pressure
-Perforations in the diaphragm or pleura during upper abdominal laparoscopic procedures (esophageal)
Pneumothorax, pneumomediastinum, and pneumopericardium are rare, but are most common with what type of laparoscopic surgery?
Esophageal
True/False: Pneumothorax caused by CO2 insufflation may rapidly resolve spontaneously without intervention.
True
What kind of pneumothorax requires surgical decompression and chest tube placement?
One resulting from barotrauma, such as a ruptured bleb.
What are risk factors associated with the development of pneumothorax during laparoscopy?
-laparoscopic esophageal surgery
-operative times over 200 minutes
-end-tidal CO2 greater than 50 mm Hg
-operator inexperience
What are the S/sx of Pneumothorax?
-Increased PIP
-Decreased O2 sat
-Absence of breath sounds
-Hypotension & tachycardia
-CV Collapse
How does subcutaneous emphysema occur?
-trocar or Veress needle misplacement in subcutaneous tissue or
-the result of high intraabdominal pressure and movement of gas through defects in the peritoneum
Incidence is the same regardless of entry technique.
Most cases of subcutaneous emphysema are clinically insignificant and resolve ________.
Spontaneously.
The development of subcutaneous emphysema is associated with the development of what complications? (Severe cases)
-Severe hypercarbia
-Decreased chest compliance
-Hemodynamic instability
What are the ideal gas properties for laparoscopy?
-Colorlessness
-lack of flammability (electrocautery)
-physiologic inertness
-excretion via a pulmonary route
Why can’t you use N2O or air for laparoscopy?
Support combustion (can’t use with electrocautery)
Why can’t you use Helium for laparoscopy?
Helium is not highly insoluble and raises issues about safety in the presence of a significant gas embolism.
Why is CO2 the closest to “ideal” gas for laparoscopy?
-Readily available & inexpensive
-Does not support combustion
-Rapidly absorbed from the vascular space
-Readily excreted by the Respiratory System
What are the “cons” of using CO2 as the gas?
-Prolonged CO2 absorption can cause hypercarbia and respiratory acidosis
-Known peritoneal and diaphragmatic irritant
How does CO2 manifest as a peritoneal and diaphragmatic irritant? (!!!!)
Postoperative shoulder pain
What is the most common anesthetic technique used during diagnostic and surgical laparoscopy?
General Anesthesia
Why is GA the preferred anesthetic technique for laparoscopy?
-Control of ventilation
-Management of patient discomfort associated with creation of pneumoperitoneum
-Manage changes in position such as steep T-burg
True/False: You should always use an LMA for laparoscopic surgery.
False: this remains controversial. Most often the airway is secured with a cuffed endotracheal tube.
What are the ventilator changes associated with anesthesia for laparoscopy?
-Increase Minute Ventilation by 15-35% to offset CO2 absorption
-Maintain EtCO2 between 35-45 mmHg
-Pressure control ventilation
-PEEP
-Intraop recruitment maneuvers
What is important to know regarding NMB and laparoscopic surgery?
Controversial.
-Deep blockade associated with inadequate reversal and postop respiratory depression
-N2O may contribute to bowel distention and increased incidence of PONV.
-If using NMB, keep it 1-2 twitches.
What are the benefits of using RA with Laparoscopy?
-Reduction in stress response
-Early ambulation with lower DVT rates
-Postop pain control
What are the disadvantages of using RA with Laparoscopy?
-High sensory levels required, leading to hypotension and patient discomfort due to SNS blockade
-Shoulder pain r/t diaphragmatic irritation is not well managed by RA.
-May prove to be difficult due to pneumoperitoneum and positioning.
The incidence of PONV in the laparoscopic population has been reported to be as high as 72% and is known to be associated with:
-surgical wound dehiscence
-aspiration
-unanticipated hospital admission
What is the standard of care for prevention of PONV?
Multimodal therapy using antiemetics that target different receptors.
The use of total intravenous anesthesia (TIVA) and a combination of antiemetics has been reported to decrease the incidence of PONV to less than _____%.
-Avoid N2O
10%
How do you manage postop pain in laparoscopy patients?
Multimodal approach:
-Opioids
-NSAIDs (Celecoxic and/or Ketorolac, Acetaminophen)
-Corticosteroids (Glucocorticoids)
-Local Anesthetics (used in surgical incisions and port sites)
-TAP blocks for robotic-assisted procedures
Using a multimodal approach to pain management causes what?
-Improved patient satisfaction
-Decreased opioid requirements
-Decreased incidence of postop complications like PONV and unplanned hospital admission
What should you do before extubating your patient after laparoscopic surgery?
-Assess for subcut air and facial/airway edema
-Ensure air leak around ETT prior to extubation
