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N931 Advanced Principles > Week 1 Abdominal General Surgery > Flashcards

Week 1 Abdominal General Surgery Flashcards

1
Q

Name the surgical areas that embody General Surgery

A 
Esophagus
Stomach
Intestine/Colon
Liver
Gallbladder
Pancreas
Thyroid
Skin
Hernias
Breasts
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2
Q

Common GI Associated Problems (8)

A 
Fluid and Electrolytes
Anemia
Cancer
Obesity
GERD
Pain
N/V
Ascites
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3
Q

Three techniques for General Surgery

A

General Anesthesia
Regional Anesthesia
MAC/IV Sedation

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4
Q

Advantages of General Anesthesia

A

allows paralysis
more safely allows positioning extremes
more reliable
lower failure rate

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5
Q

Disadvantages of General Anesthesia

A

increased stress response
known full stomach (aspiration risk)
more postoperative nausea and sedation

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6
Q

Advantages of Regional Anesthesia

A

requires lower insufflation pressures, patient breathes spontaneously, decreased stress response, faster recovery period

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7
Q

Disadvantages of Regional Anesthesia

A

Occasional failure, sympathectomy

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8
Q

Describe MAC/Intravenous sedation

A

combined with local anesthesia
Patient breaths spontaneously
patient comfort levels

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9
Q

Considerations for Anesthetic Management of General Surgery (10)

A 
choice of anesthetic
routine monitors 
foley catheter
cuffed ET
pneumoperitoneum
evacuation of gastric contents
positioning
smooth emergence/ extubation
anti-emetics
pain management
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10
Q

What is laparoscopic surgery used for?

A

diagnostic and surgical intervention

Minimally invasive

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11
Q

What do they insufflate the abdomen with?

A

CO2

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12
Q

Describe the view of laparoscopic and how

A

views abdominal contents through small incisions via small instruments through trocars
Camera will project image on monitor screen

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13
Q

Types of Laparoscopic Surgery (7)

A 
gastric
colonic
splenic
hepatic
gallbladder
gynecologic
urologic
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14
Q

What are the advantages to laparoscopic surgery compared to open surgery? (7)

A

lower pain scores and opioid requirement
earlier ambulation and return to normal activities
lower incidence of post-operative ileus
usually faster recovery, shorter hospital stays
reduced post-operative pulmonary/diaphragmatic dysfunction: quicker return to preop pulm function
less stress response & less wound complications
lower cost (usually)

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15
Q

What are the disadvantages of laparoscopic technique? (8)

A 
impaired visualization
expensive equipment
requires specific surgical skill
limited range of motion
altered depth perception
no tactile sensation
increased PONV
referred pain
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16
Q

What are the relative contraindications of laparoscopic surgery? (6)

A 
increased ICP
severe CV disease
severe respiratory disease
dense adhesions
Bi-directional V/P shunt or peritoneojugular shunt
hypovolemia
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17
Q

What are the two entry methods of entering laparoscopically?

A

closed technique and/or open technique

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18
Q

Describe the closed technique

A

involves the spring-loaded needle known as the veress needle to pierce the abdominal wall at its thinnest point
then insufflation occurs
the trocar is blindly inserted or under direct vision to allow surgeon to pass instruments into abdominal cavity

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19
Q

Describe the open technique

A

development of a 1-2.5mm midline vertical incision that begins at the lower border of the umbilicus and extends through the subcutaneous tissue and underlying fascia
Once surgeon in abdominal cavity, trocar can be placed by direct site and sutured in place. Gas then is insufflated into the side port of the hasson trocar

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20
Q

Three types of gas that can be utilized for pneumoperitoneum

A

carbon dioxide
inert gases
gasless laparoscopy

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21
Q

Why is CO2 mostly chosen for pneumoperitoneum?

A

more soluble in blood then air, helium, oxygen or nitrous oxide
easily absorbed by the tissues (high blood solubility) with rapid elimination
eliminated through respiration
non-combustible
colorless, odorless, inexpensive

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22
Q

What the cardiovascular effects of CO2 insufflation?

A

HTN and Tachycardia from sympathetic stimulation
Hypotension from impaired venous return
Arrhythmia, bradycardia from vagal stimulation

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23
Q

What are the respiratory effect of CO2 insufflation?

A

decreased FRC, compliance, increased ventilatory pressures, barotrauma, atelesctasis

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24
Q

What are the renal effects of CO2 insufflation?

A

reduced renal perfusion

activation of RAAS, increased anti-diuretic hormone

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25
Q

What are the abdominal/gastric effects of CO2 insufflation?

A

increased intra-abdominal pressures, increased risk of gastric regurgitation, splanchic ischemia, carbon dioxide embolus, extra-peritoneal spread of carbon dioxide

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26
Q

What is physiologically increased in pneumoperitoneum? (11)

A 
PaCO2
ETCO2
PAP (peak airway pressure)
MAP (mean arterial pressure)
SVR (systemic vascular resistance)
HR 
CVP
IAP
ICP
Vd
Risk of regurgitation and aspiration
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27
Q

What is physiologically decreased with pneumoperitoneum? (7)

A 
Cardiopulmonary function
Cardiac output
Venous Return
Functional residual capacity
vital capacity
renal function
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28
Q

How do you clinically manage pulmonary physiologic changes with pneumoperiteneum?

A

Position changes (decrease degree of trendelenberg)
Modify ventilator settings (pressure control)
Use PEEP with caution
Consider increasing volatile
Consider bronchodilators

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29
Q

How do you clinically manage cardiac physiologic changes with pneumoperiteneum?

A

slow, gradual abdominal insufflations
vent abdomen if IAP > 20mmHg
Evaluate intravascular volume (consider IVF bolus)
Consider treatment for pre-existing cardiac dysfunction

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30
Q

How do you clinically manage renal/hepatic physiologic changes with pneumoperiteneum?

A

Closely monitor hourly UOP
Administer IVF boluses
Consider diuretics
Maintain IAP <15mmHg

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31
Q

How do you clinically manage cerebral blood flow changes with pneumoperiteneum?

A

decrease degree of trendelenberg (adjust head up)

vent abdomen if IAP > 20mmHg

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32
Q

Anesthesia Implications for Laparoscopic Surgery (Respiratory)

A

GA with cuffed ET tube for controlled ventilation
increased minute ventilation and positive inspiratory pressure often required
adjust respiratory rate, tidal volume and PEEP

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33
Q

Describe regional anesthesia and laparoscopic surgery

A

has been used
risky!
need to have a high block T4-T5 (SNS denervation) more difficult to compensate for CV, ventilatory changes, shoulder & distention pain completely alleviated

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34
Q

How do you avoid CV compromise in laparoscopic surgery?

A

avoid intra-abdominal pressure > 15mmHg

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35
Q

When do you need invasive monitoring with a laparoscopic case?

A

ASA 3-5 and/or abnormal gradient PaCO: ETCO2

Allows for blood gas and BP measurements

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36
Q

What are the anesthesia implications for using an LMA during a laparoscopic procedure

A

spontaneous ventilation
lower incidence of sore throat
lower pain scores, less analgesic medications, less PONV
unable to administer muscle relaxation

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37
Q

Important Positioning TA’s for Laparoscopic Surgery

A

prevent nerve injury
tilt not to exceed 15-20 degrees
make changes slowly
recheck ETT position after every position change
consider less aggressive fluid replacement in head down position

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38
Q

What are the common nerves damaged in laparoscopic surgery?

A 
common peroneal nerve (lithotomy)
brachial plexus (shoulder braces, etc)
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39
Q

Anesthetic Considerations for the Maintenance phase of laparoscopic surgery

A

balanced techniques appropriately using volatile agent, opioids, or TIVA (no N2O)
consider TIVA if PONV
Continue muscle relaxation
Monitor hemodynamic and pulmonary status
Watch for endobronchial intubation during position changes

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40
Q

What are considerations when converting from laparoscopic to an open procedure

A

supine position
new fluid plan (3rd space losses will increase)
new pain management plan (opioid requirements will change)
new ventilator settings- may need to increase rate and tidal volume

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41
Q

Where can vascular intraoperative injuries can occur during an lapaproscopic procedure?

A

d/t trocar insertion/veress needle

aorta, ICV, iliac vessels, cystic/ hepatic arteries, retroperitoneal hematoma

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42
Q

What cardiac intra-operative complications can occur during a lapaproscopic procedure

A

dysrhythmias, hybercarbia, increased vagal tone with peritoneal traction, BP changes

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43
Q

What are some intraoperative complications from laparoscopic surgery?

A

SQ emphysema
capnothorax, capnomediastinum, capnopericardium
CO2 embolism

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44
Q

How does capnothorax, capomediastinum, capnopericardium occur?

A

diaphragm defect, pleural tear, bullae rupture

High degree of suspicion can be lifesaving

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45
Q

How does an CO2 embolism occur?

A

direct needle placement in vessel, gas insufflation into abdominal organ

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46
Q

Pathophysiology of a Gas Embolism

A 
depends on size of bubbles and rate of entrainment
vapor lock in vena cava and right atrium
obstruction to venous return
acute RV HTN = paradoxical embolism
circulatory collapse
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47
Q

Diagnostic Tools for a Gas Embolism

A 
pulse oximetry
esophogeal stethoscope- millwheel sound
sudden ETCO2 decrease
aspiration of gas from CVP
hypotension
bronchospasm
increased PIPs
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48
Q

Treatment of Gas Embolism

A 
stop insufflation and desufflate
place into steep trendelenberg/ left lateral decubitus
discontinue N2O 
administer 100% FiO2
hyperventilate
Place CVP
CPR
Consider CPB
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49
Q

Subcutaneous Emphysema

A

Accidental insufflation of extraperitoneum
be aware of increases in PaCO2 after plateau has been reached
not a contraindication for extubation
can track to thorax and mediastinum (capnothorax or capnomediastinum)

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50
Q

What are common laparoscopic GI procedures?

A

cholecystectomy
herniorrhapy
appendectomy

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51
Q

What is a cholecystectomy?

A

removal of a diseased gallbladder

can be due to cholecystitis, cholelithiasis, cancer

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52
Q

What is herniorrhapy?

A

defect in muscles of the abdominal wall (inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic)

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53
Q

What is the most common surgical procedure of the abdomen?

A

appendectomy

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54
Q

What causes the need for an appendectomy?

A

obstruction with inflammation by lymphoid tissue or fecal matter

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55
Q

Risk factors of converting a cholecystectomy from lap to open (7)

A 
acute cholecystitis with thickened gallbladder wall
previous upper abdominal surgery
male gender
advanced age
obesity
bleeding
bile duct injury
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56
Q

How is a cholecystectomy performed?

A

laparoscopic or open

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57
Q

Potential complications of a cholecystectomy

A

bleeding from cystic artery and cystic liver laceration

pnemothorax

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58
Q

Pre and Post-Operative Cholecystectomy considerations

A

Preoperative antibiotics controversial

DVT prophylaxis

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59
Q

How is a patient positioned for a cholecystectomy?

A

surgeon on patients left (supine) or between patient’s legs (lithotomy)
reverse trendelenberg, left tilt/right side up

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60
Q

What are symptoms of a spasm of the sphincter of Oddi?

A

recurrent attacks of upper right quadrant or epigastric abdominal pain
Non-colicky and steady pain
can be aggravated by foods, especially fatty foods

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61
Q

What can treat a sphincter of oddi spasm?

A

glucagon

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62
Q

Herniorrhapy Anesthetic considerations

A

outpatient, elective surgery
open or laparoscopic
potential for incarceration if not reduced
avoid strain
general, local, or regional (TB) anesthesia

63
Q

What is an incarcerated hernia?

A

part of the intestine or abdominal tissue that becomes trapped in the sac of a hernia
They can cause intestinal obstruction or strangulation and infarction, resulting in a high incidence of infection, hernia recurrence and operative mortality esp in older patients
URGENT SURGERY

64
Q

What is an strangulated hernia?

A 
emergency surgery (requires general anesthesia) can lead to necrotic bowel requiring bowel resection
higher morbidity and mortality
65
Q

Can a patient cough after a herniorrhapy?

A

discuss with surgeon

66
Q

What is the EBL of herniorrhapy?

A

about 50ml

67
Q

What happens if an appendectomy perforates?

A

septic shock

peritonitis

68
Q

What are some anesthetic implications of an appendectomy?

A 
fluid and electrolyte deficits
aspiration precautions
antibiotics
avoid reglan with obstruction
skeletal muscle relaxant
69
Q

Where is pain detected after a laparoscopic procedure?

A

procedures are associated with intra-abdominal, incisional, and shoulder pain (d/t irritation of diaphragm, and/or visceral pain from biliary spasms)

70
Q

What are a good post operative pharmacological pain managements?

A 
opioids 
NSAIDs
acetaminophen
dexamethasone
local anesthetic infiltration (incisional and intraperitoneal)
71
Q

What are the three parts of a robotic laparoscopic technique?

A

control console
patient side card (robotic arms)
equipment tower (screens)

72
Q

Advantages of Robotic Laparoscopy

A 
3 dimensional view
depth perception
intutitive movements
increased precision 10-15x magnification
increased free movement
73
Q

Disadvantages of Robotic Laparoscopy

A 
Massive system
limited working space
limited patient access
limited instrument availability
maintenance cost
74
Q

Preparation for robotic surgery includes:

A 
2 peripheral IVs
consider arterial line
limit IVF initially
trendelenburg/lateral/flexion
Limited patient access
Padding
75
Q

Types of GI Lab Diagnostic Tests include

A

esophagogastroduodenoscopy
endoscopic retrograde cholangiopancreatography
colonoscopy

76
Q

What is a endoscopic retrograde cholangiopancreatography

A

procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts
used to diagnose and treat pancreatic and biliary disorders
contrast dye used

77
Q

What is the purpose of an EGD/Colonoscopy?

A

diagnostic/therapeutic

minimally invasive

78
Q

How can a EGD/Colonoscopy be performed?

A

conscious sedation, topical/ general anesthesia

79
Q

Considerations for an EGD include

A

sharing the airway/ limited access
mouth piece inserted by endoscopist to prevent biting on scope
supplemental oxygen
may consider GETA if obese

80
Q

What are the potential complications of EGD/colonoscopy?

A

perforation
bleeding
desaturation/laryngospasm

81
Q

What is the purpose of a colonoscopy?

A

views lining of rectum and colon
cancer screening
treatment of polyps

82
Q

What are potential complications of a colonoscopy?

A

perforation
bleeding
desaturation/laryngospasm

83
Q

Anesthetic considerations for Colonoscopy?

A

colon prep, clear liquid diet
left lateral decubitus
usually heavy sedation or general

84
Q

Describe the ERCP procedure

A

left lateral or prone; positioned changed during procedure

length 30 minutes- several hours

85
Q

Complications of ERCP

A

perforation
bleeding
laryngospasm
desaturation

86
Q

Indications for esophageal surgery

A

GERD
Cancer
Histal Hernia
Motility disorders

87
Q

Patient symptoms for Esophageal surgery

A

dysphagia
heartburn
hoarse voice
chest pain

88
Q

What a nissen fundoplication?

A

can be performed laparoscopically or open (transthoracic)
3-4 hours
fundus is wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter

89
Q

Describe the anesthesia plan for a nissen fundoplication

A

GETA (cuffed tube)
position, rapid sequence cricoid pressure for induction
H2 blockers, reglan, antibiotics, antiemetics
Position includes: lithotomy and reverse trendelenburg
Needs a smooth extubation

90
Q

What is an esophagectomy?

A

when majority of the thoracic esophagus and nearby lymph nodes are removed
stomach is moved up and attahed to the remaining portion of the esophagus

91
Q

Why would a patient need a esophagectomy?

A

tobacco/ETOH

concomitant chemo/radiation

92
Q

Anesthetic considerations for Esophagectomy

A

surgical approach
invasive monitors
double lumen tube
post-op pain management

93
Q

What does the surgical approach of an esophagectomy depend on?

A

patient condition, portion to be removed and surgeon skill/ preference

94
Q

What is a gastrostomy?

A

creates an opening through the skin and the stomach wall to provide nutritioinal support or GI decrompression

95
Q

Indications for gastrostomy?

A

dysphagia, high risk or active aspiration

96
Q

How is a gastrostomy performed?

A

laparoscopic, percutaneous (PEG) or open

97
Q

What is the surgical time for a gastrostomy?

A

less then 1 hour

98
Q

What anesthesia can be used for a gastrostomy?

A

general anesthesia (rapid sequence induction) or local anesthesia and sedation

99
Q

What is a gastrectomy?

A

partial or total removal of stomach

100
Q

Indications for a gastrectomy?

A

peptic ulcers, gastric perforation, cancer, benign tumors/ polyps

101
Q

What do you have to watch for post-gastrectomy?

A

gastric dumping syndrome, vitamin B12 deficiency, iron deficiency anemia and poor calcium absorption

102
Q

Anesthetic considerations for abdominal surgery

A 
stable or acutely ill/malnourished
correct hypovolemia & anemia
chemo/radiation
cross matched blood available
full stomach/NGT
invasive monitoring
warming
extubate?
103
Q

What organs include intestinal surgery?

A

small bowel resection, colectomy, colonscopy

104
Q

Indications for intestinal surgery include:

A

diverticulitis
cancer
crohn’s disease
ulcerative colitis

105
Q

Considerations for Intestinal surgery include:

A

bowel preparation

postoperative colostomy, ileostomy

106
Q

Indications for a small bowel resection

A

obstruction
cancer
diverticulum, crohn’s disease

107
Q

Surgical time for a small bowel resection

A

2-4 hours

108
Q

EBL for small bowel resection

A

< 500ml

109
Q

Pre-operative considerations for small bowel resection

A 
bowel prep (hypokalemia, hypovolemia)
Pre-op EKG, CBC, electrolytes, type and screen
110
Q

Small Bowel Anesthetic considerations

A 
aspiration precautions
RSI with cricoid pressure
NGT & Foley
NO REGLAN
consider epidural for post op pain
large third space fluid loss (10-15ml/hr)
hypothermia
111
Q

Post-operative Complications for Small bowel resection include

A

pulmonary effusion, anastomotic leak, short bowel syndrome, sepsis, small bowel necrosis

112
Q

Colectomy is

A

removing all or part of the colon

113
Q

Colectomy can be performed

A

open or laparoscopic

114
Q

Pre-op for Colectomy

A

bowel preparation
clear liquids 1-2 days prior
volume and electrolyte depleted
IV and oral antibiotics

115
Q

Post-operative pain for colectomies can have

A

thoracic epidural

116
Q

What are the four lobes of the liver?

A

left right quadrate and caudate

117
Q

What is the role of the liver?

A

metabolic and hematologic roles

118
Q

Name characteristics of the liver

A

eight segments
only organ capable of regenerating functional parenchyma within 24 hours of resection
highly vascular about 1.5:/min

119
Q

Where does majority of deoxygenated blood from the liver empty into?

A

portal vein 80%

120
Q

What supplies the liver with oxygenated blood?

A

20%

hepatic artery

121
Q

For a liver resection, what do history do you want to ask pre-operatively?

A 
bruising
GI bleeding
palmary erythema
spider angiomata, petechiae ecchymosis
anorexia or weight changes
N/V or pain with fatty meals
abdominal distention/ ascites
hepatomegaly or splenomgealy
scleral icterus 
gynecomsatia
asterixis
pruritus or fatigue
122
Q

What do you include in the pre-op workup for a liver resection?

A

CT or MRI of tumor location
12-lead EKG/echocardiogram
CXR
CBC, PT/PTT, bleeding time, chemistry profile, LFTs

123
Q

Monitoring for Liver Resection

A 
large bore IVs
A-line for BP and laboratory data
May or may not have CVP or PA (if pulm HTN)
TEG
Foley
OGT/NGT
TEE?
124
Q

How do you optimize our liver resection patient pre-operatively?

A

correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities, malnutrition, anemia, esophageal varices and hepatic encephalopathy
consider platelet infusion if < 100,000 cells/microliter
assume full stomach (h2 receptor blocker, metoclopromide, sodium citrate)

125
Q

PT or INR considerations for liver resection

A

parental vitamin K, recombinant factor VIII (FFP in emergency)

126
Q

Anesthetic Management in Liver Resection

A

Local/MAC adequate sedation is essential to minimize SNS stimulation and resultant decrease in hepatic blood flow and O2 delivery- titrate carefully
GETA: RSI or awake intubation
Iso and Sevo agents of choice
Altered pharmacokinetics
Controversial epidural placement for post-op pain

127
Q

Benzodiazepines in Liver Resection Cases

A

increased cerebral uptake
decreased clearance
prolonged E1/2 life

128
Q

Dexmedetomidine in Liver Resection Cases

A

decreased clearance and prolonged 1/2 life

129
Q

Propofol in Liver Resection Cases

A

single dose similar response as normal patients, recovery times may be longer after infusions

130
Q

what is the drug of choice in patients with encephalopathy?

A

propofol

131
Q

What drugs are unchanged in most studies during a liver resection?

A

TPL, etomidate, ketamine, methohexital

132
Q

Morphine and Liver Disease

A

prolonged E1/2 life
increased bioavailibity of oral form
decreased plasma protein binding and exaggerated sedative and respiratory depressant effects

133
Q

Meperidine and Liver Disease

A

50% reduction in clearance and a doubling of the half-life

may experience neuro-toxicity from accumulation of normeperdine

134
Q

Fentanyl and Liver Diseaes

A

plasma clearance is decreased

continous infusions or repeated dosing in cirrhotic patients may produce more exaggerated and pronounced of effect

135
Q

Sufentanil and Liver Disease

A

pharmacokinetics are not significantly altered
some differences seen in E1/2
so infusions are multiple doses could cause prolonged effect

136
Q

Alfentanil and Liver Disease

A

E1/2 Life almost doubled and higher free fractions of the drug are observed, which can lead to a prolonged duration of action and enhanced effects

137
Q

Remifentanil and Liver Disease

A

Elimination unaltered

138
Q

NMB and Liver Disease

A

increase volume of distribution may require a higher initial dose

139
Q

Cirrhosis/Advanced liver disease reduces elimination of whatNMB?

A

vec, roc, pan and mivacurium

increased DOA, especially with repeated doses or infusions

140
Q

What NMB are not dependent on hepatic elimination?

A

Atracurium and cisatracurium

141
Q

What NMB may have a prolonged effect?

A

Succinylcholine

d/t decreased plasma cholinesterase levels

142
Q

How is sugammadex excreted?

A

unchanged in urine

143
Q

Catecholamines in Liver Disease

A

decreased because of circulating vasodilators including bile acids and glucagon
Impaired ability to translocate blood from pulmonary and splanchic blood reservoirs to systemic circulation
consider increased doses or addition of non-adrenergic vasoconstrictor (vasopressin) to support BP

144
Q

What patients are particularly intolerant of blood loss?

A

biliary obstruction

145
Q

Intra-operative fluid management of Liver Resection

A

volume loading can lead to distention of vessels with difficulty controlling blood loss
limiting fluid pre-resection will lead to a CVP less then 5cmH20
portal triad clamping
post resection restore euvolemia

146
Q

Intraoperative Potential Complications of Liver Resection

A 
hemorrhage
coagulopathy
hypocalcemia
hypoglycemia
VAE
pulmonary disturbances
147
Q

Post-operative Potential Complications of Liver Resection

A

bleeding
bile leak
portal vein/ hepatic artery thrombosis
liver failure

148
Q

Characteristics of the Spleen

A

upper left abdomen, just inside the rib cage (9-11th ribs)
part of the lympatic system
filters foreign substances from the blood and removes blood cells
regulates blood flow to the liver and sometimes stores blood cells (sequestration)
highly vascular organ

149
Q

Indications for splenectomy

A 
only treatment for hereditary spheroctosis an cancers of spleen
trauma
abscesses
idiopathic thrombocytopenia purpura
hodgkin's staging
150
Q

Complication of Splenectomy

A

splenic artery rupture (pregnancy)

151
Q

pre-operative anesthetic implications for Splenectomy

A 
underlying disease process and implications
chemotherapy 
ITP
CBC platelets PT PTT
type and cross
152
Q

intraoperative anesthetic implications for Splenectomy

A

asepsis
large bore venous access
warming measures
epidural for post op pain

153
Q

Complications of a splenectomy

A 
Atelectasis
pneumothorax
infection
hemorrhage
VAE

N931 Advanced Principles (14 decks)

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