Types of General Surgery Part III Flashcards
Common laparoscopic GI procedures include:
cholecystectomy- removal of disease gall bladder
herniorrhaphy- defect in muscles of abdominal wall
appendectomy- most common acute surgical procedure of the abdomen- obstruction/inflammation due to lymphoid tissue or fecal matter
Cholecystectomies can be performed due to
cholecystitis, cholelithiasis, cancer
Types of hernias include
inguinal, umbilical, incisional, abdominal, femoral, & diaphragmatic
Cholecystectomies can be performed
laparoscopic versus open
rate of conversion 5-10%
concern is a Sphincter of Oddi spasm
Risk factors for conversion to open for a cholecystectomy includes
acute cholecystitis with thickened gallbladder wall previous upper abdominal surgery male gender advanced age obesity bleeding bile duct injury
Potential cholecystectomy complications include
bleeding from cystic artery & cystic duct liver laceration
pneumothorax
Considerations for cholecystectomy include
preoperative antibiotics are controversial
DVT prophylaxis
Positioning for cholecystectomy include
surgeon on patient’s left (supine) or between patient’s legs (lithotomy)
Reverse Trendelenburg, left tilt (right side up)
Herniorrhaphy is performed
outpatient, elective surgery
open versus laparoscopic
If a hernia is not reduced,
there is potential for incarceration which makes it an urgent surgery
Strangulated hernia is
an emergency surgery, GA–> can lead to necrotic bowel requiring bowel resection
Anesthetic considerations for hernia surgery include
avoid strain (smooth emergence)
anesthetic choice: GA, local, or regional (T8)
EBL~50 mL
postop pain is 4-6
LA infiltration of ilioinguinal and iliohypogastric nerves
bradycardia due to peritoneal retraction
GI lab diagnostics include
esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP), colonoscopy
Appendectomies are performed for
appendicitis (presenting as pain, anorexia)
mortality 1% (2% if perforated)
incidence of 6% of population
The anesthetic technique utilized for appendectomies includes
GA (RSI?), OGT, avoid N20, give antibiotics
Considerations for appendectomy include
fluid & electrolyte deficits, aspiration precautions, avoid metoclopramide with obstructions, skeletal muscle relaxation
Colonoscopies are done to
view the lining of the rectum and colon- cancer screening, treatment of polyps
Potential complications of colonoscopy & EGD include
perforation, bleeding, desaturation, and laryngospasm (due to spontaneous breathing as it is a room air general)
Considerations for colonoscopy include
colon prep, clear liquid diet
- left lateral decubitus
- usually heavy sedation or GA
Considerations/positioning for EGD includes
supine or lateral decubitus
conscious sedation/topical, GA
When performing an EGD, there is
shared airway/limited access
mouth-piece inserted by endoscopist to prevent biting
may consider GETA (obese, risk factors)
if there is any food that is found when endoscope is inserted then it needs to be aborted
Indications for esophageal surgery include
GERD, CA, hiatal hernia, motility disorders
Patient symptoms indicating need for esophageal surgery include
dysphagia, heartburn, hoarse voice, & chest pain
ERCP is performed to
diagnose and treat pancreatic and biliary disorders
Complications of ERCP include
perforation, bleeding, laryngospasm, and desaturation
Surgical considerations for ERCP include
GETA or sedation, length is 30 minutes to several hours, use of contrast dye
left lateral decubitus/prone (may change during procedure)
A Nissen fundoplication is
when the fundus is wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
can be laparoscopic or transthoracic (open) approach
surgical time: 3-4 hours
Considerations for a Nissen fundoplication include
54-60 French esophageal dilator (Bougie), NG tube 12-24 hours postop, pneumatic compression stockings, smooth extubation
Medications that should be given for Nissen fundoplication include
H2 blockers, metoclopramide (2-4 hours preop), antibiotic, and antiemetics
Nissen fundoplication are performed via
GETA
induction include: position, RSI w/ cricoid pressure
lithotomy and reverse Trendelenburg positioning
Indications for esophagectomy include
ETOH, tobacco, chemo/radiation
Anesthetic considerations for esophagectomy are
surgical approach, invasive monitors, double-lumen tube, & postop pain management
An esophagectomy is when
the majority of thoracic esophagus and nearby lymph nodes are removed, stomach is moved up and attached to the remaining portion of the esophagus
The surgical approach for an esophagectomy includes
RSI b/c the esophagus is being removed
depends on patient condition, portion to be removed, surgeon skill/preference
Pt’s should be given gastrokinetics such as Reglan & avoid over-sedation preoperatively
Very sick patients- malnourished, pulm complications, wheezing, dyspnea
Complications of esophagectomy include
vocal cord paralysis, vocal cord palsy, wound infection, risk for fire
Gastrostomy is indicated for
dysphagia, high risk or active aspiration
Gastrostomy is when
an opening is created through the skin and the stomach wall to provide nutritional support or GI compression
The approach & anesthesia type for a gastrostomy is
laparoscopic, percutaneous (PEG) or open
surgical time < 1 hour
Anesthesia type: GA (RSI) or LA + sedation
A total gastrectomy is performed for
lesions in the upper 1/3rd of the stomach
A partial gastrectomy is performed for lesions in
the lower 2/3rd of the stomach
Anesthetic considerations for gastrectomy include
stable or acutely ill/malnourished correct hypovolemia & anemia chemo/radiation cross matched blood available full stomach/NGT invasive monitoring warming Extubate- needs to be smooth (fully awake)
Complications of gastrectomy include
hemorrhage, peritonitis, PE, pneumothorax, anticipate fluid shifts
Intestinal surgery is performed for
diverticulitis, cancer, Crohn’s disease, and ulcerative colitis
Intestinal surgery includes
small bowel resection, colectomy, colonoscopy
For patient’s undergoing intestinal surgery, they will have a
bowel prep and might be dry, hypovolemic, & have electrolyte disturbances
Indications for a small bowel resection include
obstruction, cancer, diverticulum, Crohn’s disease
A small bowel resection is when
healthy bowel is anastomosed or ileostomy created
Small bowel resection considerations
bowel prep (hypokalemia, hypovolemia), surgical time: 2-4 hours, EBL <500 mL, preop EKG, CBC, electrolytes, T&S
Postoperative complications for small bowel resection include
pulmonary effusion, anastomotic leak, short bowel syndrome, sepsis, small bowel necrosis
Anesthetic considerations for small bowel obstruction include
aspiration precautions, RSI with cricoid pressure if obstruction is present, NG tube, foley catheter, avoid metoclopramide, consider epidural for postop pain management, large third space fluid loss (10-15 mL/kg/hr), hypothermia
A colectomy is the
removal of part/all of the colon
can be open or laparoscopic
Considerations with colectomy include
bowel preparation clear liquids 1 to 2 days preoperatively volume & electrolyte depleted preoperative electrolytes IV/PO antibiotics Preop thoracic epidural for postop pain corticosteroid supplements
The liver is highly vascular and total blood flow is
1.5 L/min
80% blood flow supplied by portal vein
20% hepatic artery
The liver is the only organ
capable of regenerating functional parenchyma within 24 hours of resection
-70% total liver mass can be regenerated in animal models
The liver has
metabolic and hematologic roles
four lobes: left, right, quadrate, caudate or eight segments
Preop H&P for liver resection includes
bruising, anorexia or weight changes, N/V or pain with fatty meals, pruritus or fatigue, abdominal distension/ascites, GI bleeding, scleral icterus, hepatomegaly or splenomegaly, palmar erythema, gynecomastia, asterixis, spider angiomata, petechiae, & ecchymosis
Preop workup for a liver resection includes
CT or MRI for tumor location, 12-lead EKG/echocardiogram, CXR
lab studies: CBC, PT/PTT/bleeding time, chemistry profile, LFTs
Optimization of the liver resection patient includes
correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities (esp K+), malnutrition, anemia, esophageal varices, & hepatic encephalopathy
For patients undergoing liver resection, we assume
full stomach (ascites, decreased gastric & intestinal motility)- H-2 receptor blocker, metoclopramide, sodium citrate
In regards to sedative pre-medication for the liver resection patient,
titrate to effect, altered pharmacodynamics or pharmacokinetics
In regards to PT or INR & platelets for the liver resection platelet,
consider platelet infusion if <100,000 cells/microliter
PT or INR- parental Vitamin K, recombinant factor VII (FFP in emergency)
Monitoring for patients with liver resections include
base decisions of severity of liver disease and type of surgery
2 LARGE BORE IVS- all but the most minor procedures b/c blood loss is unpredictable
A-line- BP & lab data
TEG to guide blood product administration
Foley catheter
OGT/NGT- be careful
TEE? (risky)
+/- CVP or PA (if pHTN)-multiple complex hemodynamic abnormalities
CVP or PA can be used in liver resections to assess
hypovolemia, abdominal compartment syndrome, distributive shock, CHF
For liver resection patients, benzodiazepines have
increased cerebral uptake
decreased clearance
prolonged half-life
For liver resection patients, dexmedetomidine has
decreased clearance and prolonged half-life
For liver resection patients, propofol has
longer recovery times after infusions
drug of choice with encephalopathy
single dose= similar response as normal patients
For liver resection patients, etomidate, ketamine, and methohexital have
unchanged elimination half-life in most studies
Intraoperative management of the liver resection patient includes
GETA- RSI or awake intubation- sevoflurane/isoflurane are agents of choice
fluids- no evidence colloids are better than crystalloids for resuscitation
altered pharmacokinetics
consider epidural for postop pain control
local/MAC- adequate sedation is essential to minimize SNS stimulation & resultant decreases in hepatic flow & O2 delivery- titrate carefully
NMB and liver disease causes
increased volume of distribution that may require a higher initial dose
cirrhosis/advanced liver disease prolongs elimination of vec, roc, panc, and mivacurium= increased DOA
cisatricurium & atricurium are not dependent on hepatic elimination and can be used without adjustment
Succinylcholine & liver disease
decreased cholinesterase levels,
succinylcholine effects may be prolonged
Morphine & liver disease
prolonged half-life, exaggerated sedative & respiratory-depressant effects
Meperidine & liver disease
may experience neuro-toxicity from accumulation of normeperidine
Fentanyl and liver disease
plasma clearance is decreased- exaggerated effects
Remifentanil & liver disease
elimination unaltered
Alfentanil & liver disease
elimination half-life doubled–> enhanced effects
Intraoperative fluid management for the liver patient includes
limiting fluid pre-resection–> CVP < 5 cmH2O increases risk of venous air embolism
Portal triad clamping
post-resection- restore to euvolemia
volume loading–> distension of vessels with difficulty controlling blood loss
Patients with biliary obstruction are
particularly intolerant of blood loss
For hypotensive liver patients, consider
increased doses or addition of non adrenergic vasoconstrictor (vasopressin) to support BP
For patients with liver disease, there is an impaired ability to translocate
blood from pulmonary and splanchnic blood reservoirs to systemic circulation
For liver disease patients, there is a decreased response to catecholamines because
of circulating vasodilators such as bile acids & glucagon
Intraoperative complications of liver resection include
hemorrhage, coagulopathy hypocalcemia hypoglycemia VAE pulmonary disturbances
Post-operative complications of liver resection include
bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure
The spleen is part of the
lymphatic system
filters foreign substances from the blood and removes blood cells
regulates blood flow to the liver and sometimes stores blood cells (sequestration)- healthy adults 30% of platelets are sequestered in the spleen
The spleen is a highly
vascular organ of 300mL/min
Preop anesthetic considerations for splenectomy include
evaluate underlying disease process and implications
chemotherapy & ITP
Intraoperative anesthetic considerations for splenectomy include
asepsis, large-bore venous access, warming measures, epidural for post-op pain
Complications of splenectomy include
atelectasis, pneumothorax, infection, hemorrhage & VAE
Splenectomy is the only treatment for
hereditary spherocystosis and cancers of spleen
other indications for removal: trauma, abscesses, idiopathic thrombocytopenic purpura, Hodgkin’s staging, splenic artery rupture (pregnancy)
Bariatric surgery is reserved for patients with
BMI >40 kg/m2
BMI >35 kg/m2 with related comorbidities not well controlled by medical therapy
The greatest cause of perioperative 30 day mortality for bariatric surgery is
pulmonary emobli
Bariatric surgery is a
surgical alteration of the small intestine or stomach to promote weight loss
Bariatric surgery types include
malabsorptive procedures: jejuno-ileal bypass and biliopancreatic diversion
restrictive procedures: gastroplasty (VBG) and adjustable gastric banding (AGB)
combined restrictive and minimal malabsorptive Roux-en-Y gastric bypass
Advantages to laparoscopic bariatric surgery include
less postop pain, lower morbidity, faster recovery, less fluid 3rd spacing, decreased wound infection, and smaller incisions
Disadvantages to laparoscopic bariatric surgery include
complete NMB is important, positioning requirements increase fall risk, high risk for right main-stem intubation (d/t diaphragmatic shift), incidence of rhabdomyolysis in obese pts higher compared with open procedure
For patients undergoing laparoscopic bariatric surgery, the anesthetists may need to
facilitate the proper placement of an intragastric balloon
prior to gastric diversion, ensure all endogastric devices are removed (avoid stapling in place or transection)
after gastric pouch in place, avoid blind NG insertion
Preoperative considerations of the obese patient include
DVT prophylaxis–> encourage early ambulation
airway assessment= neck circumference most important factor
OSA/OHS increase risk difficult airway- consider preop ABG
IM injections unreliable- thickness overlying adipose tissue
pre-medications- anxiolysis and aspiration pneumonitis precautions
Anesthetic considerations for the implantable gastric stimulator include
avoid N& V
valsalva may dislodge electrodes
ECG interference
Implantable gastric stimulator is supposed to
make patient feel less hungry
stimulate gastric smooth muscle, decrease peristalsis
SQ electric pulse generator implanted on abdominal wall
2 lead electrodes on greater curvature of stomach
Monitoring considerations of the obese patient include
monitors- appropriate sized BP cuff (forearm measurements overestimates BP)
IV & arterial line access may be challenging
Consider CVP or PAP catheter- significant CV or pulm disease or when large fluid shifts are expected
Positioning considerations of the obese patient include
Regular OR table max weight~~200 kg
high incidence of pressure sores and nerve injuries
“stacking” or “ramped” position for intubation to align ear with sternum
The most important induction consideration for the obese patient is
pre-oxygenation= most important step
-decreased FRC, increased O2 consumption, +/- higher incidence of difficult airway
Induction considerations for the obese patient includes
induction drug dosing altered, consider awake intubation with minimal sedative-hypnotics, RSI?, may need two person mask ventilation/extra help, breath sounds may be difficult to auscultate, PEEP can be helpful intraop, routine use of reverse trendelenburg
Prevention of thromboembolism for the obese patient includes
LMW heparin- limits postop pain management options
preop aspirin & warfarin to INR 2.3
Decreased the risk via preoperative exercise, antithrombotic drugs, stocking prophylaxis, nonpolycythemic Hct, increased CO, early ambulation
The intraoperative fluid balance for obese patients takes into consideration that
they experience greater blood loss compared with non-obese patients secondary to technical difficulties/need for extensive dissection
For obese patients, there is a risk of
acute tubular necrosis with inadequate fluid replacement in bariatric surgery
There is a decreased ability to compensate for blood loss in obese patients and thus,
there is early threshold for replacement with colloids/blood products
For placement of regional anesthesia in obese patients, ____ & _____ has been used
ultrasound & fluoroscopy
Local anesthetic doses in the obese patient are
reduced by 20-25% due to epidural vascular engorgement and decreased epidural space
The subarachnoid block height in obese patients can be
unpredictable- high spinal is possible
For regional anesthesia in obese patients,
avoidance of intubation challenges vs. technically challenging landmark ID should be weight
central neuraxial blockade easier in lumbar region
longer needles may be required
Postop pain management for the obese patient includes
epidural anesthesia
PCA with opioid (multi-modal w/ opioid sparing should be attempted)
LA infiltration of incisicion site
non-opioid analgesics/adjuvants
obesity risk factor for postop hypoxemia- consider monitored bed/ICU+ CPAP postop, semi-recumbent position for first 48-72 hours
