Test 2 Laproscopy and Robotic Surgery Flashcards
what surgery was the first to be done laproscopically?
cholecystectomy
common surgeries where laparoscopic and robotic techniques are used
- general surgery
- gynecologic surgeries
- urologic
- orthopedic - specifically arthroscopy
benefits to minimally invasive surgery?
- smaller incisions
- less postop pain
- decreased incisional stress response 4. decreased rate of complications
- faster recovery
- decreased LOS
- overall improved pt satisifaction
Disadvantages of minimally invasive surgeries
- sequela of pneumoperitoneum
- positioning challenges
- need for specialized training
laparoscopic surgery requires the creation of an artificial pneumoperitoneum, this done by?
instillation of air/gas into a cavity under controlled pressure
what are the two most commonly used entry methods in lap surgery to create a pneumoperitoneum
- closed technique
- open (hasson) technique
what gas is used to insufflate the peritoneal cavity during lap surgery to allow visualization of the organs
CO2
why is CO2 the gas of choice for insufflation during laproscopic surgery?
- non toxic
- nonflammable
- readily absorbed into the blood stream with minimal risk of air embolization
- produces less hemodynamic effects than other nonflammable gases (argon)
during laparosocpic surgery, when insufflating CO2 for creation of pneumoperitoneum, the intra-abdominal pressure needs to be limited to ________ mmHg
15
describe the closed technique for creating pneumoperitoneum during lap surgery
use spring loaded needle - veress needle to pierce abdominal wall at thinnest point around the umbilicus
describe the open technique to create a pneumoperitoneum during laparoscopic surgery
make 1 - 2.5 mm midline vertical incision that begins at the lower boarder of the umbilicus and extends through the subQ tissue and underlying fascia
what part of laparoscopic surgery is responsible for the large majority of complications that occur?
creation of the pneumoperitoneum
the creation of a pneumoperitoneum for laparoscopic surgery causes increased intrabdominal pressure, what effect does this have on CV/hemodynamics?
- increase: SVR, MAP, and HR
- decrease: SV
physiological effects of pneumoperitoneum depend on what factors?
- degree of intra-abdominal pressure 2. length of surgery
- patient position
- perioperative volume status
- patient age
- presence of co-morbidities, esp cardiopulmonary ones.
CV effects of pneumoperitoneum (for laparoscopic surgery)
- variable effects on cardiac filling pressures
- CO reduction of 20-50%
- SV reduction secondary to increased IAP
- CO2 absorption can cause myocardial depression/arrhythmias
- has effect on cardiac conduction system
how can you decrease CO reduction with pneumoperitoneum?
adequate fluid load and compression stockings prior to surgery
how can you ensure stroke volume is not reduced with pneumoperitoneum (for lap surgery)?
- adequate perioperative hydration
- changes in patient position
- application of compression stockings
what has the greater effect on cardiac filling pressures during laparoscopic surgery - the pneumoperitoneum or positioning?
positioning
during laproscopic surgery, what position will increase CVP, ICP, IOP and cause head/airway edema?
trendelenburg
during laparoscopic surgery, what position will reduced cardiac preload; therefore, reducing CO
reverse trendelenburg
with creation of pneumoperitoneum for laparoscopic surgery, CO2 absorption that makes PaCO2 > 60, will cause what effect on the CV system?
myocardial depression and arrhythmias
with creation of pneumoperitoneum, CO2 absorption –> PaCO2 45-60, will have what effect on the CV system?
little CV effect
high pressure insufflation of pneumoperitoneum can lead to what cardiac conduction changes?
- prolong QT dispersion = ventricular instability –> increased arrhythmias and cardiac effects
- bradycardia
how does laparoscopic surgery/pneumoperitoneum affect the respiratory lung mechanics?
- decrease compliance
- decrease FVC
- decrease FEV1
- decrease FRC
- increase PIP
how does the pneumoperitoneum/laparoscopic surgery affect gas exchange?
- increases PaCO2 and EtCO2
- subcutaneous tracking of CO2 d/t misplaced trocars
- V/Q mismatch
- hypoxemia
if a patient is undergoing laparoscopic surgery, and their EtCO2 starts to rise, what action must you take to offset the hypercarbia?
increase minute ventilation
hypercarbia with laparoscopic surgery will hit its peak at ~ ________ minutes
40
maximum absorption of CO2 with laparoscopic surgery occurs when IAP is __________ mmHg
10
laparoscopic surgery, can cause displacement of abdominal structures which can have what effects on the respiratory system?
- atelectasis
- possiblity for endobronchial intubation
________________ is necessary to maintain normocarbia in the anesthetized patient undergoing laparoscopic surgery with CO2 pneumoperitoneum
controlled mechanical ventilation
what vent settings do you want when your patient is undergoing laparoscopic surgery with pneumoperitoneum
- increase minute ventilation by 20-30%
- pressure control
lung protection strategies on the ventilator with laparoscopic surgery with pneumoperitoneum
- 6-8 mL
- 6-8 cmH20 PEEP
- intraoperative recruitment maneuvers q30min
T/F: mild pulmonary dysfunction is normal after laparoscopic surgery with pneumoperitoneum
TRUE
post-op laparoscopic surgery patients will have a slight ______________ breathing pattern d/t residual effects of anesthesia, pain, and diaphragmatic dysfunction
restrictive
who is at increased risk of respiratory decompensation with laparoscopic surgery
- pts with marginal cardiopulmonary function
- COPD
- Morbidly obese
renal effects with laparoscopic surgery
- transient increase Cr clearance
- decreased UOP
- increased release of ADH, aldosterone, and renin
- renal vasoconstriction
- decreased renal blood flow
hepatic and splanchnic effects of laparoscopic surgery/pneumoperitoneum
- decreased liver and splanchnic blood flow
- 50% of pts will have increased liver enzymes
immunologic effects of laparoscopic surgery + pneumoperitoneum
- negative effect on local immune response
- altered levels of proinflammatory cytokines and angiogenic factors
- potential cancer cell growth
complications with laparoscopic surgery occurs in _____-_____%
0.3 - 1
more than 50% of all laparoscopic surgery complications occur when?
during entry into the abdomen and insertion of trocars
what percentage of abdominal entry/trocar insertion injuries go unrecognized/undiagnosed ?
30-50%
entry related complications with laparoscopic surgery involve: __________, ____________, ____________, and ____________
intestinal tract; urinary tract; vascular injuries; CO2 gas embolism
with laparoscopic insertion injury that causes major bowel or vascular injury, the mortality rate is ___________%
30
risk factors that increase the risk of laparoscopy complications/injuries
- body habitus and position
- anatomic anomalies
- prior surgery
- surgeon skill
- degree of abdominal elevation during trocar placement
- volume of gas insufflation
> _____________% of intestinal injuries with laparoscopic surgery are unrecognized intraoperatively
50
patients who experience intestinal injury during laparoscopic surgery, that goes unrecognized can result in?
- peritonitis
- sepsis
- respiratory distress
- Multisystem organ failure
what technique is associated with lower incidence of unrecognized vascular and visceral injury during laparoscopic surgery
open (Hasson) entry
injury to the intestines during laparoscopic surgery occurs in __________% of surgeries
0.3-0.5
urinary tract injuries during laparoscopic surgery occur in ____________% of surgeries
0.5-0.8
urinary tract injuries during laparoscopic surgery typically occur secondary to ?
- trauma from instrument manipulation
- electrocautery
- laser
how can you decrease the risk of urinary tract injuries during laparoscopic surgery?
insert foley catheter and instill methylene blue dye
T/F: urinary tract injuries are easily recognized during laparoscopic surgery
true (will have urine leakage from damaged structure)
placement of primary trocar under ________ creates the safest distance between the anterior abdominal wall and underlying abdominal contents to minimize injury from placement
high pressure - 25 mmHg
what is a complication that occurs during laparoscopic surgery that involves the direct entrainment of air/medical gas into the arterial/venous system
CO2 gas embolisms
T/F: CO2 gas embolism during laparoscopic surgery is rare, but has a mortality rate of 28%
TRUE
the erroneous placement of a veress needle/trocar directly into intrabdominal vessel can cause what complication
CO2 embolisms
CO2 embolism with laparoscopic surgery can occur anytime there are open vessels that have ______________ < ___________
intravascular pressure < intraabdominal pressure
T/F: most laparoscopic cases have minor CO2 gas embolisms which cause cardiopulmonary changes, but they resolve spontaneously
TRUE
s/sx of significant gas embolism during laparoscopic surgery in the anesthetized patient:
- acute decrease/loss of EtCO2 and Increase in EtN2
- Hypotension and/or hypoxia that is unexplained
- tachycardia
- dysrhythmias
- severe hemodynamic instability
- CV collapse
Dx of CO2 gas embolism during laparoscopic surgery
- TEE
- doppler mill wheel murmur (w/ 0.5 mL/kg of gas - late sign)
what is the most sensitive diagnostic tool for dx a CO2 gas embolism with laparoscopic surgery
TEE
CO2 gas embolism management during laparoscopic surgery
- D/C insufflation
- D/C N2O
- 100% FiO2
- flood surgical field with saline to halt gas entrainment
- left lateral position
- gas aspiration via central line if in place
- support hemodynamics with volume and vasopressors
T/F: high CVP increases the risk of venous gas embolisms
false; low CVP increases the risk
pneumomediastinum/thorax/pericardium is rare, but occurs most commonly during laparoscopic _____________ surgery
esophageal
a rare, but serious complication with laparoscopic surgery is _________________________ that occurs d/t migration of gas into adjacent body cavities
pneumomediastinum/thorax/pericardium
how does a pneumomediastinum/thorax/pericardium occur with laparoscopic surgery
gas can enter the thoracic cavity through:
1. congenital defects in the diaphragm 2. embryonic connections btween thorax and abdomen
3. perforation in the diaphragm or pleura
T/F: pneumothorax caused by CO2 insufflation during laparoscopic surgery is usually self resolving
TRUE
if during laparoscopic surgery, a pneumothorax occurs from barotrauma (like ruptured pulmonary bleb), how should it be treated?
surgical needle decompression followed by chest tube placement
risk factors for pneumothorax w/ laparoscopic surgery
- esophageal surgery
- surgery time > 200 minutes
- EtCO2 > 50 mmHg
- operator inexperience
s/sx of pneumothorax (with lap surgery)
- increased PIP
- decreased O2 sat
- absence of breath sounds
- hypotension
- tachycardia
- CV collapse
___________________ is a frequent manifestation of pneumoperitoneum d/t gas entry into fat tissue
Subcutaneous emphysema
subcutaneous emphysema with pneumoperitoneum will usually resolve itself within __________ hours
24
what has been associated with causing subQ emphysema in patients undergoing laparoscopic surgery with pneumoperitoneum
- misplacement of veress needle/trocar into subQ 2. high intraabdominal pressures and movement of gas through peritoneal defects
severe cases of subQ emphysema, secondary to pneumoperitoneum have been associated with the development of what?
- severe hypercarbia
- decreased chest compliance
- hemodynamic instability
what properties would be required for an ideal gas in the creation and maintenance of pneumoperitoneum
- colorless
- inflammable
- physiologically inert
- pulmonary excretion
why can N2O and air not be used as gas for creation and maintenance of pneumoperitoneum?
support combustion and cannot be used in the presence of electrocautery (which is essential for lap)
why can helium not be used as gas for the creation and maintenance of pneumoperitoneum
highly insoluble which raises issues in safety in the presence of significant gas embolism
pros of CO2 as “ideal gas” for creation and maintenance of pneumoperitoneum?
- readily available and inexpensive
- does not support combustion
- high solubility
- pulmonary excretion
cons of CO2 as “ideal gas” for creation and maintenance of pneumoperitoneum
- prolonged CO2 can cause hypercarbia and respiratory acidosis
- is a peritoneal/diaphragmatic irritant
CO2 use with pneumoperitoneum is a peritoneal/diaphragmatic irritant that has been associated with causative factor in the development of ____________________
postoperative shoulder pain
what type of anesthetic technique can be used with laparoscopic surgery
local, regional, and general
what is the most common anesthetic technique used with laparoscopy?
general
with laparoscopic surgery, on the ventilator, ________________ is increased by 15-30% to offset ___________
minute ventilation; CO2 absorption
what ventilator mode is most effective during laparoscopic surgery
pressure control
neuraxial anesthesia (SAB and epidural) are usually reserved for laparoscopic ______________ procedures
pelvic
pros of neuraxial anesthesia (SAB and epidural) with laparoscopic surgery
- decreased stress response
- early ambulation with lower DVT rates
- effective post op pain control
disadvantages of neuraxial anesthesia with laparoscopic surgeries
- high sensory levels required which may result in: pain, hypotension, and respiratory compromise
- can be difficult d/t pneumoperitoneum and positioning
PONV with laparoscopic surgery is VERY high (72%); therefore, how should you approach this?
- different drugs with different targets 2. Consider TIVA
emergence and postoperative concerns of patients undergoing laparoscopic surgery?
- assess for SubQ air
- assess for facial/airway edema (check cuff leak)
- multimodal PONV
- multimodal pain management
what multimodal pain approach should you take postoperatively for patients undergoing laparoscopic surgery?
- ERAS (enhanced recovery after major surgery)
- NSAIDs
- Glucocorticoids
- local anesthesia
anesthetic technique with laparoscopic cholecystectomy
GETA with NMB
what position is the patient in during laparoscopic cholecystectomy?
- reverse trendelenburg 2. left tilt
what laparoscopic techniques can be used for cholecystectomy?
- traditional 2. robotic assisted
anesthetic technique with laparoscopic appendectomy?
GETA with NMB
positioning with laparoscopic appendectomy
- trendelenburg
- L tilt
- L arm tucked at side
anesthesia considerations with laparoscopic appendectomy
- hemodynamic stability - tachycardia 2. volume status
- febrile?
laparoscopic techniques with appendectomy
traditional & robotic assisted
indication of laparoscopic nissen fundoplication?
- GERD
- hiatial hernia
- barretts esophagus
anesthetic technique with laparoscopic nissen fundoplication
- GETA with NMB
- RSI and intubation
- PONV prophylaxis
what must the anesthesia provider avoid during laparoscopic nissen fundoplication surgery
NOTHING IN ESOPHAGUS (OGT, esophageal stethoscope, temp probes)
laparoscopic nissen fundoplication surgeries have a high risk for ________________
pneumothorax
positioning with laparoscopic nissen fundoplication
combination of supine and lithotomy
laparoscopic technique with nissen fundoplication
traditional and robotic assisted
indication for a laparoscopic adrenalectomy?
pheochromocytoma
anesthesia considerations with laparoscopic adrenalectomy
- alpha blockade prior to beta
- ABP monitoring
- IV access
- vasoactive meds
anesthetic technique during laparoscopic adrenalectomy
- GETA with NMB
- multimodal pain management
what position will a patient undergoing a laparoscopic adrenalectomy be in
lateral
laparoscopic techniques for adrenalectomy
traditional or robotic assisted
anesthetic technique with laparoscopic hysterectomy
- GETA with NMB
positioning with laparoscopic hysterectomy
- steep trendelenburg
- low lithotomy
- with arms tucked at side
laparoscopic techniques with hysterectomy
- traditional
- robotic assisted
- combo with vaginal/open procedure
anesthetic technique with laparoscopic gastric bypass surgery
GETA with NMB
anesthetic considerations with laparoscopic gastric bypass
- could be difficult airway –> RSI
- placement of esophageal dilator/bougie per surgeon request
- NOTHING IN ESOPHAGUS
- morbidly obese and positioning considerations
- airway/ventilation/oxygenation concerns
- ERAS
- PONV prophylaxis
- Pain management
pros of minimally invasive robotic surgery
- improved patient outcomes
- decreased LOS
- faster recovery
- reduced perioperative blood loss
- reduced postoperative pain
anesthetic implications of robotic assisted surgery
- prolonged surgical times
- spatial restrictions associated with robot
- inability to alter patient position after docking
- physiologic changes associated with extreme positioning
- physiologic consequences associated with pneumoperitoneum
- risk of POVL
- implementation of ERAS
what is the most common position used with minimally invasive robotic surgeries
trendelenburg
positioning considerations with minimally invasive robotic surgery
- prolonged surgery = prolonged pressure
- potential for compression of underlying structures: face and chest 3. patient sliding - 2ndary gravitational forces
how often does patient position need to be assessed during minimally invasive robotic surgery
every 15 minutes
what is the most common robotic assisted procedure?
robotic assisted laparoscopic prostatectomy (RALP)
anesthetic technique with robotic assisted laparoscopic prostatectomy?
GETA with NMB
patient position with robotic assisted laparoscopic prostatectomy (RALP)?
steep trendelenburg + lithotomy
what is the most common nerve damaged during robotic assisted laparoscopic prostatectomy?
common peroneal
risks/complications with RALP ?
- venous air embolisms if insufflation pressure > venous pressure (in presence of active bleeding)
- increased ICP
- POVL
which cardiac surgeries can be done robotically?
- TECAB (total endoscopic coronary artery bypass)
- MVR (mechanical valve replacement) 3. ASD
- Ablation atrial arrhythmias
anesthetic technique during robotic cardiac surgery
GETA with NMB
position with robotic cardiac surgery
modified L or R lateral position
what is the monitoring with required with robotic cardiac surgery
continuous TEE and invasive monitoring
what is challenge for anesthesia providers during robotic cardiac surgeries?
maintained prolonged one lung ventilation
